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A method to engage salient organisational stakeholders in identifying and ranking measures of healthcare improvement programs is described. The method is illustrated using Executive WalkRounds (EWRs) in a multi-site Australian Health District.

Subject matter experts (SMEs) conducted document analysis, identified potential EWRs measures, created driver diagrams and then eliminated weak measures. Next, a panel of executives skilled in EWRs ranked and ratified the potential measures using a modified Delphi technique.

EWRs measurement selection demonstrated the feasibility of the method. Of the total time to complete the method 79% was contributed by SMEs, 14% by administration personnel and 7% by executives. Document analysis revealed three main EWRs aims. Ten of 28 potential measures were eliminated by the SME review. After repeated Delphi rounds the executive panel achieved consensus (75% cut-off) on seven measures. One outcome, one process and one implementation fidelity metric were selected to measure and monitor the impact of EWRs in the health district.

Perceptions of weak relationships between measures and intended improvements can lead to practitioner scepticism. This work offers a structured method to combine the technical expertise of SMEs with the practical knowledge of healthcare staff in selecting improvement measures.

This research describes and demonstrates a novel method to systematically leverage formal and practical types of expertise to select measures that are strongly linked to local quality improvement goals. The method can be applied in diverse healthcare settings.

This purpose of this paper is to examine the application and outcomes of applying all of the seven lean flows to pathology laboratory remodelling as part of a lean rapid improvement event (RIE).

Longitudinal case study of a lean RIE linking emergency and pathology departments focusing on the systematic application of lean's seven flows to the physical environment.

Following the lean RIE, changes improving patient specimen, technician, supplies and information flows avoided 187 km and eight days of unnecessary walking each year.

The difficulty of making accurate comparisons between time periods in a health care setting is acknowledged.

This research provides evidence that applying lean design concepts in a laboratory can make substantial improvements, particularly if the expertise of the people working in the laboratory is trusted to determine the most appropriate changes. Significant amounts of time and motion were saved by just one, easily quantifiable change.

The laboratory staff is processing increased numbers of time-critical tests, yet report a calmer working environment, without any increase in the pace of work. Laboratory personnel also experienced satisfaction in exercising control over their work environment.

To the best of the authors’ knowledge this is the first comprehensive report applying lean flows to pathology laboratory remodelling and one of the few applications of Lean Systems Thinking between departments and between separate health services organisations.

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.

Positive organizational scholarship in healthcare (POSH) suggests that, to promote widespread improvement within health services, focusing on the good, the excellent, and the brilliant is as important as conventional approaches that focus on the negative, the problems, and the failures. POSH offers different opportunities to learn from and build resilient cultures of safety, innovation, and change. It is not separate from tried and tested approaches to health service improvement – but rather, it approaches this improvement differently. The paper aims to discuss these issues.

POSH, appreciative inquiry (AI) and reflective practice were used to inform an exploratory investigation of what is good, excellent, or brilliant health service management.

The researchers identified new characteristics of good healthcare and what it might take to have brilliant health service management, elucidated and refined POSH, and identified research opportunities that hold potential value for consumers, practitioners, and policymakers.

The secondary data used in this study offered limited contextual information.

This approach is a platform from which to: identify, investigate, and learn about brilliant health service management; and inform theory and practice.

POSH can help to reveal what consumers and practitioners value about health services and how they prefer to engage with these services.

Using POSH, this paper examines what consumers and practitioners value about health services; it also illustrates how brilliance can be theorized into health service management research and practice.

The purpose of this paper is to provide a retrospective analysis of computer simulation’s role in accelerating individual innovation adoption decisions. The process innovation examined is Lean Systems Thinking, and the organizational context is the imaging department of an Australian public hospital.

Intrinsic case study methods including observation, interviews with radiology and emergency personnel about scheduling procedures, mapping patient appointment processes and document analysis were used over three years and then complemented with retrospective interviews with key hospital staff. The multiple data sources and methods were combined in a pragmatic and reflexive manner to explore an extreme case that provides potential to act as an instructive template for effective change.

Computer simulation of process change ideas offered by staff to improve patient-flow accelerated the adoption of the process changes, largely because animated computer simulation permitted experimentation (trialability), provided observable predictions of change results (observability) and minimized perceived risk.

The difficulty of making accurate comparisons between time periods in a health care setting is acknowledged.

This work has implications for policy, practice and theory, particularly for inducing the rapid diffusion of process innovations to address challenges facing health service organizations and national health systems.

The research demonstrates the value of animated computer simulation in presenting the need for change, identifying options, and predicting change outcomes and is the first work to indicate the importance of trialability, observability and risk reduction in individual adoption decisions in health services.

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.

The purpose of this paper is to contribute toward a deeper understanding of the new roles, responsibilities, and job characteristics of employees in Lean healthcare organizations.

The paper is based on three cases studies of healthcare organizations that are regarded as successful examples of Lean applications in the healthcare context. Data were collected by methods including interviews, observations, and document studies.

The implementation of Lean in healthcare settings has had a great influence on the roles, responsibilities, and job characteristics of the employees. The focus has shifted from healthcare professionals, where clinical autonomy and professional skills have been the guarding principles of patient care, to process improvement and teamwork. Different job characteristics may make it difficult to implement certain Lean practices in healthcare. Teamwork and decentralization of authority are examples of Lean practices that could be considered countercultural because of the strong professional culture and uneven power distribution, with doctors as the dominant decision makers.

Teamwork, value flow orientation, and company-wide involvement in CI were associated with positive effects on the organizations’ working environment, staff development, and organizational performance.

In order to succeed with Lean healthcare, it is important to understand and recognize the differences in job characteristics between Lean manufacturing and healthcare. This paper provides insights into how Lean implementation changes the roles, responsibilities, and job characteristics of healthcare staff and the challenges and implications that may follow from this.

The purpose of this paper is to explore the nature and impact of leadership in relation to the local implementation of quality improvement interventions in health care organisations.

Using empirical data from two studies of the implementation of The Productive Ward: Releasing Time to Care™ in English hospitals, the paper explores leadership in relation to local implementation. Data were attained from in-depth interviews with senior managers, middle managers and frontline staff (n=79) in 13 NHS hospital case study sites. Framework Approach was used to explore staff views and to identify themes about leadership.

Four overall themes were identified: different leadership roles at multiple levels of the organisation, experiences of “good and bad” leadership styles, frontline staff having a sense of permission to lead change, leader's actions to spread learning and sustain improvements.

This paper offers useful perspectives in understanding informal, emergent, developmental or shared “new” leadership because it emphasises that health care structures, systems and processes influence and shape interactions between the people who work within them. The framework of leadership processes developed could guide implementing organisations to achieve leadership at multiple levels, use appropriate leadership roles, styles and behaviours at different levels and stages of implementation, value and provide support for meaningful staff empowerment, and enable leader's boundary spanning activities to spread learning and sustain improvements.

As healthcare often is studied in relation to operational rather than socio-technical aspects of Lean such as teamwork, the purpose of this paper is to explore how a Swedish hospital Lean intervention was related to changes in teamwork over time.

Teamwork was measured with the Group Development Questionnaire (GDQ) employee survey during Lean implementation at three units, in 2010 (n=133) and 2011 (n=130). Qualitative data including interviews, observations and document analysis were used to characterize the Lean implementation and context. The expected teamwork change patterns were compared with GDQ data through linear regression analysis.

At Ward-I, Lean implementation was successful and teamwork improved. At Ward-II, Lean was partially implemented and teamwork improved slightly, while both Lean and teamwork deteriorated at the emergency department (ED). The regression analysis was significant at ED (p=0.02) and the Ward-II (p=0.04), but not at Ward-I (p=0.11).

Expected changes in teamwork informed by theory and qualitative data may make it possible to detect the results of a complex change.

Overall, Lean may have some impact on teamwork, if properly implemented. However, this impact may be more prominent in relation to structural and productivity issues of teamwork than group members’ relational issues. Practitioners should note that, with groups struggling with initial stages of group functioning, Lean may be very challenging.

This study focussed specifically on implications of Lean for nurse teamwork in a hospital setting using both qualitative and quantitative data. Importantly, the group functioning at the time when Lean is initiated may affect the implementation of Lean.