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The purpose of this paper is to examine the outcomes and evolution over a five‐year period of a Swedish university hospital quality improvement program in light of enduring uncertainty regarding the effectiveness of such programs in healthcare and how best to evaluate it.

The paper takes the form of a case study, using data collected as part of the program, including quality indicators from clinical improvement projects and participants' program evaluations.

Overall, 58 percent of the program's projects (39/67) demonstrated success. A greater proportion of projects led by female doctors demonstrated success (91 percent, n=11) than projects led by male doctors (51 percent, n=55). Facilitators at the hospital continuously adapted the improvement methods to the local context. A lack of dedicated time for improvement efforts was the participants' biggest difficulty. The dominant benefits included an increased ability to see the “bigger picture” and the improvements achieved for patients and employees.

Quality measurement, which is important for conducting and evaluating improvement efforts, was weak with limited reliability. Nevertheless, the present study adds evidence about the effectiveness of healthcare improvement programs. Gender differences in improvement team leadership merit further study. Improvement program evaluation should assess the extent to which improvement methods are locally adapted and applied.

This case study reports the outcomes of all improvement projects undertaken in one healthcare organization over a five‐year period and provides in‐depth insight into an improvement program's changeable nature.

The purpose of this paper is to explain how different emergency services adopt and adapt the same hospital-wide lean-inspired intervention and how this is reflected in hospital process performance data.

A multiple case study based on a realistic evaluation approach to identify mechanisms for how lean impacts process performance and services’ capability to learn and continually improve. Four years of process performance data were collected from seven emergency services at a Swedish University Hospital: ear, nose and throat (ENT) (two), pediatrics (two), gynecology, internal medicine, and surgery. Performance patterns were linked with qualitative data collected through realist interviews.

The complexity of the care process influenced how improvement in access to care was achieved. For less complex care processes (ENT and gynecology), large and sustained improvement was mainly the result of a better match between capacity and demand. For medicine, surgery, and pediatrics, which exhibit greater care process complexity, sustainable, or continual improvement were constrained because the changes implemented were insufficient in addressing the higher degree of complexity.

The variation in process performance and sustainability of results indicate that lean efforts should be carefully adapted to the complexity of the care process and to the educational commitment of healthcare organizations. Ultimately, the ability to adapt lean to a particular context of application depends on the development of routines that effectively support learning from daily practices.