Abstract
To identify the potential organisational barriers to the lean management in healthcare organisations. Seven electronic databases were systematically searched for published studies relating to the challenges in lean implementation in healthcare systems. In total 412 articles were reviewed to select 23 studies which met the inclusion criteria and quality appraisal criteria. Research papers were selected following a screening process using the PRISMA tool. McMaster university framework was employed to access the quality of these selected papers. This process was to ensure appropriateness of the literature selected for this study. A thematic analysis was conducted on the results extracted from the research papers reviewed. Thematic analysis of the selected 23 studies revealed potential organisational barriers for implementing lean in healthcare organisations. Factors such as poor knowledge and perception of lean, management practices, organisational structure, employee resistance and poor collaboration are responsible for failures in lean implementation. Multiple barriers accounted for the challenging application of lean in healthcare. Successful lean implementation requires overcoming the functional and professional silos in healthcare organisations to reach common understanding and right perception of lean in healthcare. Furthermore, physicians and other clinicians are very important stakeholders, therefore healthcare organisations should encourage their leadership and involvement in lean implementation initiatives to improve the outcome of lean in healthcare. Lean management has the potential to improve efficiency and effectiveness of healthcare services, but lean principles, terminology and methods need to be adapted to healthcare settings for best outcomes.
Plain Language Summary
This systematic review aimed at understanding the potential organisational barriers to the implementation of lean practices in healthcare. Lean approach has been successful in other industries for more than fifty years, but the application of lean in healthcare domain is still novice with limited empirical research on its validity and effectiveness in healthcare. To maximise the potential for success of lean, it is highly essential to anticipate and realize the challenges to lean initiatives in healthcare settings. Multiple factors accounted for the challenging application of lean in healthcare. Nevertheless, these challenges can be overcome by a system wide approach in staff education and training to give a clear understanding of lean principles and its benefits to improve employee perception and acceptance of lean. Altering the lean language for the context of healthcare will allow better permeability into healthcare organisations. Furthermore, physicians and other clinicians are very important stakeholders, therefore healthcare organisations need to encourage their involvement and leadership in lean initiatives and implementation for improved outcomes. Breaking silos by interdepartmental collaboration will facilitate communication and improve efficacy of lean processes throughout organisation. All the above, along with, careful ‘adaptation’ of lean tools and methods to the healthcare context will improve successful implementation of lean in healthcare,
Keywords
Introduction
Healthcare organisations all over the globe are under pressure due to factors like ageing population, rising costs of care, more costly technology and increasing customer expectations for high quality services (Mcintosh et al., 2014). In order to meet this demand, healthcare managers are constantly focusing on methods to reduce operational costs while maintaining or enhancing the quality of service (Antony et al., 2019). Some of the leading health care institutions have therefore adopted a promising management style called ‘Lean management’ (Toussaint & Berry, 2013). Lean is a systematic approach with key focus on identifying value of a process and eliminating any step that does not add value in that process, so that ultimately every step adds value to the entire process (Aherne & Whelton, 2010). In the year 1950, post-World War II, the need to do more in less sparked the birth of Toyota Production system which is now commonly known as ‘Lean Manufacturing’. The National Health Service (NHS) in Great Britain and the Joint Commission institute in the United States of America have also encouraged lean management as a strategy for providing value to their patients while using less resources (Mazzocato et al., 2014). Lean has gained popularity and has become particularly essential in services (Klein et al., 2022). There has been a rapid increase in lean implementation in the past decade by many healthcare organisations reaping benefits like cost reduction as well as quality improvements (Daultani et al., 2015).
Lean in healthcare is still in the early phase of development if compared with its implementation in other industries. Although there is consensus in lean literature for potential of lean healthcare with significant benefits, Proudlove in 2008 stated that there is a lot of undergrowth to clear at hospitals which requires a deeper appreciation of lean for more complex lean implementations (Brandao de Souza, 2009).
The success of lean in healthcare depends on the ability to adapt and not just adopt lean in particular context to achieve continual improvement (Mazzocato et al., 2014). To be clear, healthcare is not similar to manufacturing, therefore lean cannot be directly replicated and relocated to healthcare systems. Some literature does not support extensive use of lean in healthcare due to complexity in adapting lean principles in healthcare and advise against simply duplicating manufacturing-based processes in healthcare (Mcintosh et al., 2014).
According to DeSouza and Pidd, there can be successful translation of lean practices in healthcare domain provided the inherent implementation barriers are identified and worked upon, all the way through the implementation process (Parkhi, 2019). Lean is being implemented since almost 50 years in other industries, but its implementation in healthcare still remains dubious. Hence, this systematic review aims to understand the potential organisational barriers to the lean management in healthcare.
Methods
Different type of studies was located, appraised and synthesised in this systematic review for analysis and identification of organisational barriers to implementation of lean management in healthcare organisations. Research papers were selected following a screening process using the PRISMA tool (PRISMA, 2020).
Data Search Strategy
A thorough and systematic search of databases such as, ‘Business source premiere’, ‘Emerald Management Extra’, ‘Emerald premier: Business, Management and Strategy collection’, ‘Emerald premiere: Health & Social care’, ‘ProQuest’, ‘Elsevier Science direct’, ‘CINAHL’, ‘EBSCOhost’ were used to find journal articles and research papers related to barriers in lean implementation in health care sector. The keywords used were ‘Barriers, Challenges, Obstacles, Difficulties, Problem, and Complications’ for the outcome of research question. Similarly, Mesh terms for lean were, ‘Lean, Lean management, Lean six sigma, Lean manufacturing, Lean production’. Finally, for the term ‘healthcare organisations’, substitutes were, ‘Healthcare Institutes, Health Services, Health sector, Clinics, Healthcare, Hospitals, Healthcare providers’. Additionally, departments within healthcare were also used such, ‘emergency department, pharmacy’ etc. All these keywords were used to search the above-mentioned databases using Boolean operators such as ‘OR, AND or NOT’. Articles were then screened based on their titles. Selected studies were then transferred to document managing application named, ‘Refworks’ for further screening and also to save the searched material.
Data Extraction
All the studies selected for this review were in English language from the past 19 years, including research published between 2005 and 2024 to comprise all recent and relevant literature. Research studies of all countries were selected. All the pertinent empirical studies with quantitative, qualitative and mixed method have been included for this narrative synthesis. Table 1 details the inclusion and exclusion criteria used for data abstraction.
Inclusion and Exclusion Criteria.
Study selection process was undertaken to include all the study papers that met the predetermined inclusion criteria. This was done in two stages. The first step included sifting through titles and abstract of all articles, followed by systematic screening of articles meeting the inclusion criteria. In the second phase of article selection, all the selected papers were further shortlisted by reading the complete text.
Quality Appraisal and Data Analysis
For qualitative systematic reviews such as this, authenticity and trustworthiness are judged instead of validity and reliability (Bettany-Saltikov & McSherry, 2016). To assess the quality of the selected study papers, the McMaster University Quality Assessment Framework was used. This framework is useful for both qualitative and quantitative studies. Very clear guidelines are provided on the way’s quality appraisal is conducted for studies and also provides advice while answering the questions. The framework includes basic terminology and can therefore be used by even students or new researchers (Bettany-Saltikov & McSherry, 2016). This tool comprised of questions on study population, selected participants with consent, study design, confounding factors and data collection methods followed by analyses. The study papers were then rated as weak, moderate or strong. Only moderate to strong study papers have been included for this review (see Table 2).
Report of McMaster Appraisal Ratings per Study.
In the process of data extraction, findings and information that answer the research question were highlighted in the selected papers. A narrative data extraction form was prepared to present findings such as, name of author, year of study, study design, data collection methods and the outcome or key findings. This data was categorised to reflect the perceived barriers in implementation of lean methods in healthcare settings. Table 3 is the data extraction form of this study, depicting the key findings and organisational barriers. Thematic analysis was used to identify key themes from the selected papers. The repeated reading of data extracted from the papers was carried out to identify recurrence themes related to organisational barriers in lean management in healthcare. From these themes final themes were developed iteratively to examine the phenomena studied (Ross, 2012).
Data Extraction Form of the Study.
Results
Total 23 study papers met all the criteria for this systematic review (see Figure 1). Study papers have been included from many countries: UK (5), Finland (2), Sweden (2), Denmark (2), USA (2), Namibia (1), Uruguay (1), Columbia (1), Netherland (1), Brazil (2), Canada (2) and Australia (1). Among the 23 papers, 14 papers had qualitative study design, 6 were mixed method studies and remaining 3 were quantitative study papers. The study population included, chief executive officers, healthcare mangers of all cadre, physicians, nurses and employees from various healthcare settings ranging from large tertiary care hospitals to primary care facilities, emergency departments, clinics, laboratory services etc. All the article findings were then used to create initial common themes which emerged throughout the key findings. Tables 4 to 7 depict thematic analysis of organisational barriers in implementing lean methods.
PRISMA flow diagram.
Theme 1: Poor Perceptions and Knowledge of Lean.
Theme 2: Management Practice.
Theme 3: Organisational Structure.
Theme 4: Employee Resistance and Poor Collaboration.
Hence, final thematic analysis of barriers to lean in healthcare gave us four final themes as below:
1- Poor perception and knowledge of lean
2- Management practices
3- Organisational structure
4- Employee resistance and poor collaboration.
Major Barriers in Lean Implementation in Healthcare Organisations
Poor Perception and Knowledge of Lean
Lack of knowledge and understanding of lean acts as a prominent barrier with 10 studies indicating that employees do not have lean awareness in most healthcare organisations (Grove et al., 2010; Mutingi et al., 2017). ‘Poor understanding of lean principles by the project team, were a barrier to success. The staff were introduced to the top 10 per cent of the “lean iceberg” and were asked to perform tasks’ (Grove et al., 2010). Moreover, three studies argue that employees find it difficult to define and translate key concepts such as, ‘who the customer is?’ or ‘what creates value?’ for the customer (Cheng et al., 2015; Grove et al., 2010; Stanton et al., 2015). This lack of knowledge is also a result of unavailability of professional training to healthcare employees. Six studies have mentioned that no training was given for lean processes and that staff had limited practical experience of lean process in hospital (Aij et al., 2013; Azevedo et al., 2021; Costa et al., 2015; Escuder et al., 2018; D. Hung et al., 2015; Ruiz & Ortiz, 2016). Further to lack of knowledge, a poor perception of lean in healthcare is because lean language evokes negative image of sheading jobs. Also, the manufacturing background acts as a catalyst in reducing acceptance of lean in healthcare (DeSouza & Pidd, 2011; Fine et al., 2009; Grove et al., 2010). Failure in documenting efficiency or faulty data collection techniques are factors responsible for not having strong evidence to support efficacy of lean methods. Seven study papers find this to be a reason for the partial acceptance of lean by physicians and other healthcare employees (DeSouza & Pidd, 2011; Escuder et al., 2018; Hastle et al., 2016; D. Hung et al., 2015, 2017; Jorma et al., 2016; Stanton et al., 2014).
To address this issue management needs to emphasise that lean management in healthcare is about improving patient care not just a cost-cutting exercise. They should highlight the benefits for clinicians and other healthcare employees by clearly articulating key lean management concepts such as value, flow and waste reduction relating them to healthcare practice. Such attempts would enable clinicians to understand that lean can reduce their workload, improve clinical workflows, enhance their quality of work life and eventually lead to better patient outcomes. At this juncture, developing training programmes for clinicians and other healthcare employees is an important organisational intervention. Such training can reduce the fears and concerns that stem from their perceptions regarding implementation of lean management in healthcare (see Abou Hashish & Abdel Aal, 2019; Hihnala et al., 2018; Rosa et al., 2021).
Management Practices
One of the most commonly mentioned factors in this category has been lack of support and commitment from top management. Seven studies have found that management support for lean initiatives is missing and that they lack commitment to lean processual changes (Aij et al., 2013; DeSouza & Pidd, 2011; Escuder et al., 2018; D. Hung et al., 2015; Mutingi et al., 2017; Ruiz & Ortiz, 2016; Saha et al., 2024). One of the participant interviewees from the reviewed studies offered the following justification, ‘The problem is that top management sits in their ivory towers. They trust that everything will work out fine on the work floor. I think there is too much distance between management and their teams because they are always busy’ (Aij et al., 2013). According to Kahm and Ingelsson (2019) healthcare domain needs a reflective managerial change where manager’s actions interact and communicate across their co-workers. However, seven studies described that manager lacked necessary skills and leadership style for successfully carrying out lean initiatives (Costa et al., 2015; DeSouza & Pidd, 2011; Escuder et al., 2018; Grove et al., 2010; Halling & Wijk, 2013; D. Hung et al., 2017; Ruiz & Ortiz, 2016). Other challenges created by the management accounted for lack of time for training and process improvements. Managers reported to have experienced shortage of time for lean process implementation as lean methods increased documentation and reporting of work, leaving them with less time for managerial activities (Hihnala et al., 2018; D. Hung et al., 2015). Further to that, four other studies found that insufficient resources allocated by management also act as an obstacle for lean implementation (Aij et al., 2013; Mutingi et al., 2017; Ruiz & Ortiz, 2016; Stanton et al., 2014). According to Stanton, politics in the hierarchical organisational has a large number of dominant stakeholders which directly influence the availability of resources (Stanton et al., 2014). Although lean processes are perceived as low-cost interventions, an annual budget was suggested by respondents to be necessary for development of improvement activities and staff training (Ruiz & Ortiz, 2016). Lastly, sustenance of lean processes is another problematic issue for management and a challenging area which acts as a barrier to success of lean (Costa et al., 2015; DeSouza & Pidd, 2011; Fine et al., 2009; Kinder & Burgoyne, 2013).
To improve management practices for Lean implementation in healthcare requires strong leadership focusing on employee involvement, continuous improvement and employee empowerment. So, empowering frontline care staff to identify and address problems is essential for successfulness of lean implementation in healthcare. As research shows that lean management flourishes in the on bottom-up improvement in healthcare, management practices are needed to be grounded in organisational cultures where clinicians are given autonomy to participate in decisions on lean initiatives and implementation. Furthermore, as the lean implementation in healthcare often involves many stakeholders with differing interests and priorities, management practices need to value this diversity and manage these stakeholders effectively to achieve potential benefits of lean implementations (see Aij et al., 2013; Antonsen & Bye, 2020; Rosa et al., 2021; van Beers et al., 2022).
Organisational Structure
Organisation structure was found to be another important obstacle to successful lean implementation. The current work structure in healthcare is fragmented into different professional and functional groups giving rise to functional and professional silo imposing barriers to lean initiatives. Eight studies support that organisational silos are responsible for failure of lean processes (Aij et al., 2013; Costa et al., 2015; DeSouza & Pidd, 2011; Escuder et al., 2018; Halling & Wijk, 2013; Kinder & Burgoyne, 2013; Leite et al., 2024; Saha et al., 2024). Functional silos lead to fragmented care, which does not result into complete and total improvement of care provided to patient. Five studies highlighted that, different ways of working without inter-departmental collaboration and limited agreement between different professional groups also leads to sub-optimal improvements and failure of the whole lean initiative (Aij et al., 2013; Cheng et al., 2015; Grove et al., 2010; Halling & Wijk, 2013; Ruiz & Ortiz, 2016). Over this one leader has commented, ‘Sometimes you experience problems outside your circle of influence, and then you are stuck with a problem because you have not established an infrastructure that reflects collaborative work with other departments’ (Aij et al., 2013). In addition to above factors the complexity of work structure in healthcare organisations makes lean implementation more challenging (Costa et al., 2015; Edwards et al., 2011; Grove et al., 2010; Hastle et al., 2016). Unlike the assembly line of a manufacturing unit, healthcare organisations need to tailor their services based on patient’s needs and requirements. Both, the nature of work and different rationalities of different professional groups in healthcare doesn’t allow absorption of lean principles in some areas of healthcare organisation (Edwards et al., 2011) thus acting as an indirect barrier for lean management practices in healthcare setting. In the end, outsourcing in hospitals was also found to make lean implementation more difficult (Costa et al., 2015; Grove et al., 2010).
To improve the fragmented structures discussed above, healthcare organisations need to move to more value stream focussed approach. This value stream approach concentrations on patient journey from admission to discharge instead of focusing on individual professions and departments in healthcare organisations. At this point a patient is viewed as a primary customer and design workflows to meet patient’s needs and preferences. So, in this context healthcare professionals and departments can manage and improve value streams by fostering an atmosphere of cross-disciplinary and cross departmental collaboration. Such approach breaks down silos and creates opportunities for teams in professional groups and departments to make decisions and implement changes within their respective value streams, rather than merely relying on the instructions from top (Eriksson et al., 2016; Holden et al., 2015; Kellner et al., 2024; Lisiecka-Biełanowicz & Biechowska, 2025).
Employee Resistance and Poor Collaboration
Twelve studies found employee resistance to act as barrier to lean management (Aij et al., 2013; Costa et al., 2015; DeSouza & Pidd, 2011; Escuder et al., 2018; Fine et al., 2009; Fournier et al., 2021; Hastle et al., 2016; D. Hung et al., 2015, 2017; Jorma et al., 2016; Leite et al., 2024; Mutingi et al., 2017). Among all the professional groups, doctors and nurses have been reported to be most frequently against lean initiatives or projects (Jorma et al., 2016). A possible explanation for this is that lean has been perceived to be detached from clinical values and practices (Hastle et al., 2016). Besides, some physicians viewed lean initiatives as a potential threat to their authority. Their concern can be understood by the following quote from a physician, ‘I felt very much like, wait a minute here. I’m already being very efficient. I’ve been patted on the back for being efficient and having good patient satisfaction [scores], and now someone else who’s not a physician is coming in to tell me how to do my work’ (D. Hung et al., 2017). Other reasons for staff resistance have been described as, increase in documentation of work and reporting, fatigue over development projects and the will to stay in comfort zone and continue old ways of doing things (Hihnala et al., 2018; Jorma et al., 2016). Three studies also indicate that poor staff involvement and motivation also affect the outcome of lean initiatives. A top-down approach in lean initiatives also explains much of the resistance and decreasing level of workforce involvement in lean process (Hihnala et al., 2018; D. Hung et al., 2017; Kahm & Ingelsson, 2019). Furthermore, healthcare leaders have professional skills but lack motivational skills to coach and engage other employees which negatively affects the success of lean projects (Escuder et al., 2018).
The first step to overcome resistance to lean management is to understand the reasons for resistance. There may be many reasons. For example, clinicians may perceive that lean would target their medical practices or their decision-making autonomy, but they might not articulate these hidden fears and anxieties openly. So, understanding these hidden reasons is crucial for offsetting resistance. As a result, having a dialogue which enable all stakeholders to create collective insights and a common understanding of issues and opportunities in lean is important at this juncture. Schein (1993) argues that the process of dialogue creates a psychologically safe space for all the stakeholders share ideas and knowledge to build shared understanding of issues in organisations and foster creative thought. As a results, this process enables stakeholders from divergent backgrounds with conflicting interests to have a shared understanding about organisational change driven by lean management in healthcare. The end results of such understanding is reduction of employee resistance towards lean management in health with increased collaboration. Transformational leadership is essential to dialogue in healthcare organisations as it enable leaders to challenge assumptions held by professional groups in healthcare through discussions where professional groups and other employees in healthcare organisations feel comfortable and safe expressing their ideas, feelings and criticisms about lean management without fear of negative repercussions (see Fournier et al., 2021).
Discussion
This qualitative systematic review aimed at exploring the possible organisational barriers in lean implementation within healthcare settings. A thorough analysis revealed most significant organisational barriers which limit the successful lean implementations in healthcare.
Based on the results of this review, poor perception and knowledge of lean has been found to be the most commonly discussed barrier in most reviewed studies. Consistent with the finding of this review, Joe (2013) suggests that it is highly essential to educate the healthcare staff about lean principles and methodologies to realise and sustain the benefits achieved in lean implementation. Conversely, training the staff in healthcare is another challenge because very few people in healthcare organisations have well founded knowledge and experience of lean principles, tools and methods of lean production. What complicates things more is when, educators from manufacturing background use unknown terminologies and lack examples from healthcare, making it more difficult to understand ideas and principles of lean (Pokinska, 2010). Also, at the top management level, inadequate business education and supply chain management capabilities among hospital-based buyers have been suggested to be potential barriers. (Burnes, 2001 cited in Parkhi, 2019) The very basic principle of lean is to comprehend value from customer’s standpoint but defining ‘customer’ in healthcare is another problem faced by healthcare employees. This is because ‘customer’ is not a straightforward term in healthcare (Radnor et al., 2012). This uncertain notion of patient as customer and dynamics between different stakeholders acts as an obstacle in lean implementation process (Young & McClean, 2008). Hence staff education and encouragement is needed to overcome this issue. The staff training should be designed for better understanding of lean principles and tools by allowing them to make use of lean tools under supervision and support (Al-Balushi et al., 2014). Similar to the findings of this review, poor perception of lean management techniques has been considered to be a major barrier in acceptance of lean in healthcare. According to Kim et al. (2006), the term lean is misunderstood and some employees think of lean methods, as a way of working themselves out of employment. Hence it is important that the phrase is explained properly in context and application. Another inhibiting factor on the cultural front is the applicability of lean manufacturing methods and concepts to health sector with claims such as, ‘humans are not automobile parts’. This can be overcome by staff training through which, the employees gradually understand the core values of lean which aims to remove waste processes to provide benefits (Pokinska, 2010). Lastly, the lack of evidence about improvements and increased efficiency by lean management techniques creates further problems in lean implementation (Winch & Henderson, 2009). In order to overcome this issue, record keeping and documentation of positive lean outcomes is necessary. Other strategy to promote lean initiatives, is to take support from a successful lean organisation to avoid common mistakes in the early phase of implementation. This will increase reliability on lean thinking due to staff having a successful model of implementation (Spagnol et al., 2013). In all, a poor knowledge about lean and the wrong perception towards lean thinking has been found to act as a profound barrier.
The management practices have been identified as the second theme for this systematic review. In line with this result,
The next theme in discussion is
Finally, the last developed theme for this systematic review is,
Based on the result and discussion, the answer to research question has been obtained. It can thus be stated that major organisational barriers to lean implementation are: (1) Poor perception and knowledge of lean, (2) Management practices, (3) Organisational structure, (4) Employee resistance and poor collaboration.
This qualitative systematic review aimed at exploring the possible organisational barriers in lean implementation within healthcare settings and have found the following four factors: (1) Poor perception and knowledge of lean, (2) Management practices, (3) Organisational structure, (4) Employee non-co-operation and resistance.
Conclusion
This systematic review aimed at understanding the potential organisational barriers to the implementation of lean practices in healthcare. Lean management has been successful in other industries for more than 50 years, but the application of lean in healthcare domain is still novice with limited empirical research on its validity and effectiveness in healthcare. To maximise the potential for success of lean, it is highly essential to anticipate and realise the challenges to lean initiatives in healthcare settings.
Multiple factors accounted for the challenging application of lean in healthcare. Nevertheless, these challenges can be overcome by a system wide approach in staff education and training to give a clear understanding of lean principles and its benefits to improve employee perception and acceptance of lean. Altering the lean language for the context of healthcare will allow better permeability into healthcare organisations. Furthermore, physicians and other clinicians are very important stakeholders, therefore healthcare organisations need to encourage their involvement and leadership in lean initiatives and implementation for improved outcomes. Breaking silos by interdepartmental collaboration will facilitate communication and improve efficacy of lean processes throughout organisation. All the above, along with, careful ‘adaptation’ of lean tools and methods to the healthcare context will improve successful implementation of lean in healthcare.
The study nonetheless, has some limitations; the study population in the selected study papers mostly included top level executives, managers and physicians who are most influential in the organisation. Many frontline staff was not interviewed or surveyed in these study papers, which leaves out their opinion about what makes lean challenging for them. As a result, further study should be carried to understand these barriers from general employee perspectives, giving us insights about the real and root cause of these challenges.
Footnotes
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
Data sharing not applicable to this article as no datasets were generated or analysed during the current study.