case study on material management in hospital

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• Saudi Pharm J
• v.30(12); 2022 Dec

Just-in-time approach in healthcare inventory management: Does it really work?

Bandar balkhi.

a Clinical pharmacy Department, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia

b Pharmacoeconomic Unit, Pharmaceutical Care Service Administration, Armed Forces Hospital - Southern Region (AFHSR), Khamis Mushait, Saudi Arabia

Abdullah Alshahrani

c Department of Emergency Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia

d Global Center for Mass Gathering Medicine, Ministry of Health, Saudi Arabia

Healthcare organizations need to efficiently use their available resources, improve their productivity, reduce operating costs, and provide high-quality services. Just in time (JIT) is an approach that has benefited the healthcare industry in these regards, improving patient outcomes by reducing waste and non-value-adding activities. As such, our main purpose in this study was to discuss the use of JIT systems in healthcare inventory management and highlight their importance, as well as explore the advantages and limitations of JIT systems in healthcare management systems. We also explored supply chain issues in healthcare during the COVID-19 pandemic and provide strategies and recommendations for improvement.

1. Background

The healthcare industry has faced many challenges in improving quality of care and patient satisfaction while reducing costs( Moons et al., 2019 ). Inventory accounts for a large proportion of the costs of healthcare organizations (HCOs) ( Kelle et al., 2012 ). Approximately USD 83 billion is spent in the U.S. on hospital supplies such as disposable gloves and gowns every year( Scanlin, 1997 , Kua-Walker, 2010 ). Furthermore, the amount spent on inventory-related activities such as handling, storage, transport, and restocking inventories is extremely high, accounting for more than one-third of hospital budgets( Dennision et al., 1994 , Kua-Walker, 2010 ). Additionally, U.S. hospitals waste approximately USD 25.4 billion each year on unnecessary supply chain spending( NAVIGANT 2018 ).

Healthcare institutions are responsible for planning, purchasing, managing, handling, tracking, and transporting stock (e.g., medications, medical equipment, and supplies). These activities are critical for their operations. Inventory and supply chain management primarily focuses on improving efficiency, controlling costs, and receiving and distributing the needed supplies on time to provide improved patient care( De Vries 2011 ). Supply chain management is key for organizing workflow and tracking inventory, purchases, orders, and payments. Supply chain management in healthcare settings requires skills in managing costs, inventory forecasting, and space management, while inventory management involves in-depth knowledge of logistics and financial aspects of stock ( Dwivedi and Kothiyal 2012 ). These management systems help to protect organizations from both material and financial losses by maintaining an efficient and accurate record of items and supplies.

Inappropriate inventory management results in substantial losses for healthcare organizations and negatively impacts the quality of patient care( Brandon‐Jones et al., 2014 ). Inadequate management can potentially lead to overstocking, meaning that extra assets are retained in inventory, thereby restricting cash flow and the development of the organization. Conversely, understocking leads to shortages and disturbs the stability of the services provided by the organization( Moons et al., 2019 ). Poor inventory management is one of the largest causes of inefficiency in healthcare, and efficient supply chain management can help hospitals to reduce costs and optimize their operations.

Reducing costs while improving the quality of care is essential in the healthcare industry. Hence, many HCOs are looking for innovative tools that will allow more efficient supply chain practices, helping to reduce costs without affecting the quality of their services ( Lee et al., 2011 , Mathur et al., 2018 ). Many inventory management systems applying just-in-time (JIT) approaches were working well prior to the COVID-19 pandemic; however, the pandemic created unprecedented challenges for these systems. Healthcare supply chains were negatively impacted and there were considerable disruptions to the supply of essential health items such as personal protective equipment (PPE) and ventilators, along with many medications( Chowdhury et al., 2021 ).

2. Objective

Our aim in this study was to provide an overview of techniques that can be used to improve healthcare operations by implementing JIT systems and to discuss their benefits to the healthcare industry . Our findings provide insight into supply chain management by reviewing the relevant literature and exploring the integration of JIT concepts and practices into healthcare systems as a potential cost-saving strategy for healthcare organizations and systems as a whole . Additionally, we describe the use of JIT approaches during the pandemic and the benefits and risks associated with using this method. We outline future implications for JIT systems along with future research directions.

3. JIT systems

JIT is an innovative stock management strategy: a supply–demand system encouraging flow-type production that attempts to precisely match the demand for care with supply( Baum 2006 ). The concept of JIT was originally developed by Toyota Motor Company in Japan, and was then applied in a variety of industries worldwide, including healthcare. JIT systems can quickly respond to demand without the need for excess inventory. In JIT systems, suppliers deliver small quantities of supplies to HCOs as they are needed, which avoids the problem of overstocked inventory and eventually lowers operational costs. JIT is a comprehensive inventory management technique that reduces waste and eliminates non-value-added items( Li 2015 ).

JIT systems restock inventory and place a reorder for future resources when a preset minimum value is reached, using an indicator when more stock is needed to meet the current demand ( Karkowski et al., 2017 ). For each supply category, the order volume is determined to avoid a lack of stock during the time between orders. Differences in demand between different types of supplies are expected, and must be determined using robust software. Some items that must be prioritized, such as life-saving medical and surgical items and other essential items; these are defined, while the items to which JIT can be applied are identified( Kester et al., 2001 ). Therefore, JIT requires the establishment of a monitoring and evaluating system that is able to detect and determine minimal acceptable inventory levels.

In JIT, healthcare organizations and suppliers work together to deliver inventory on time. To successfully run a JIT system, a close relationship must be built between the HCOs and suppliers( Karkowski et al., 2017 ). Without excessive inventory, healthcare organizations will depend on their suppliers. JIT is demanding on suppliers, so having reliable suppliers is an important factor in building the relationship between the HCOs and suppliers. Hospital workflows will be facilitated as HCOs better understand the supplier’s capabilities, and suppliers better understand the HCO’s needs ( Kua-Walker 2010 ).

4. Benefits and risks of JIT systems

4.1. benefits of jit systems.

JIT systems work well in normal settings, providing solutions to many issues faced by other inventory systems as well as many long-term benefits. Overstocking results in waste and lost and damaged items ( Neil, 2004 , Baum, 2006 ). The several benefits of using JIT in healthcare organizations include increased quality and efficiency, and savings in healthcare resources. Applying this method creates a stabilized work schedule and increases productivity.( Siddiqui 2022 ) Therefore, the adoption of JIT by healthcare facilities has been widespread. The most common benefit of using JIT is cost reduction; In United State JIT has resulted in annual savings of approximately USD $3–11 million per hospital, which is around 10 %–17 % in savings ( Scanlin, 1997 , Baum, 2006 ).

In a JIT system, stock is delivered by suppliers when needed, which reduces inventory costs by reducing unused inventory, freeing up money for HCOs to use for other care activities and care facilities( Aptel and Pourjalali 2001 ). JIT provides HCOs with an opportunity to minimize warehouse space, thus reducing inventory holding costs and investment in stock( Baum 2006 ). Other cost reductions include the labor costs required to move and manage supplies; the number of workers can be reduced and some warehouse processes can be automated( NAVIGANT 2018 ). This can also result in improved productivity as employees are able to focus on tasks related to patient care instead of unnecessarily handling inventory ( Neil, 2004 , Kua-Walker, 2010 ).

JIT helps to increase inventory turnover ratios, leading to higher efficiency by preventing products from staying in storage for long periods. In addition, applying JIT saves time; with a smaller inventory, the time spent on ordering, purchasing and managing stock is lowered, which can improve productivity and services. Monitoring and management of inventory can also be improved because of the low number of items in the inventory( Kaswan et al., 2019 ). Close management of smaller stocks reduces the chance of wasting inventory items. Another advantage of the JIT approach includes improved work and operation flows, enhancing overall HCO productivity.( Canel et al., 2000 ) JIT can also improve service quality, leading to increased customer satisfaction( Jackson 2017 ). The JIT approach has several benefits for inventory management in HCOs, but some concerns have been raised due to the nature of the healthcare industry.

4.2. Risks of JIT systems

One of the major concerns with JIT systems is the uncertainty and unpredictability of the volume of hospital work( Neil 2004 ), which can pose a serious risk to hospital operations when the demand unexpectedly increases and the current inventory is insufficient. This may lead to zero stock, which can seriously affect patient care( Baum 2006 ). This is the top reason why HCOs hesitate to use JIT systems. Another issue regards suppliers, particularly for vendors that import items from overseas and may experience disruptions in shipments. To address these issues, stock levels need to be closely monitored and managed.

One solution is to keep a buffer inventory to avoid stock running out. However, this buffer or emergency inventory needs to be balanced to avoid holding a large amount of stock, which would conflict with the main goal of a JIT system, or holding too little stock, which would not resolve the issues or address the risk of shortages. A second solution is to use JIT systems only for general suppliers items that do not directly impact patient care or affect emergency situations like labels, swap, pads, linens, etc ( Doughty et al., 2020 ), ( Kua-Walker 2010 ).This helps to ensure that inventory costs remain low without risking patient safety. The improvement of cash flow and cost saving are mainly coming from reduction inventory holding, minimize storage area, utilities, personnel and damage items.( Lai and Cheng, 2016 , Raj et al., 2022 ). Moreover, companies and manufacturers could not have the ability to bring the raw materials during the lockdown and even after restriction were lifted so for the critical items such as ventilators and intensive care unit items, its highly important to be on set without interruption( Raj et al., 2022 ). A third solution is to establish a contingency response plan with the supplier or with other healthcare institutions as well as considering a rapid communication between all sectors in timely manner to reduce the delaying of delivery and avoiding overstocking and shortages (mutual aid) (( Cheng and Podolsky, 1996 , Lai and Cheng, 2016 , Peng and Pang, 2019 , Okeagu et al., 2021 ). This type of effective and timely manner agreement should include essential supplies and priority medicines was very useful to overcome JIT limitation and maintaining resilience supply chain during health crisis like COVID-19. ( Doughty et al., 2020 ).

JIT systems are difficult to operate and require the close monitoring of supply consumption. The supply forecast needs to be calculated using statistical tools and techniques to ensure accurate forecasting( Li 2015 ), as JIT relies on accurate data describing the consumption of the resources. Thus, JIT may not be ideal for every institution and often requires extensive preliminary planning to ensure that the system can work appropriately. Each institution needs to assess their situation and ability to establish a JIT system by weighing the costs and benefits of such a system.

Another issue related to JIT is transportation and delivery costs, which tend to be high. The cost mainly depends on the transport type and vehicle used, and the distance traveled. The system is designed to decrease inventory and order stock when needed, relying on the certainty of on-time delivery. This may mean frequent deliveries, which decreases efficiency and increases delivery-associated costs, which is an additional cost factor that needs to be considered and discussed with suppliers( Kim and Rifai 1992 ).

5. JIT systems during COVID-19: increases in demand

The COVID-19 pandemic has substantially impacted global supply chains and extensively disrupted of the flow of supplies, increasing demand for key materials( Leite et al., 2020 ). These supply chain disruptions had serious consequences that placed health workers and patients at risk. During the pandemic, the high demands for PPE, medications, and equipment such as ventilators exposed the instabilities in healthcare supply chain frameworks, many of which relied on JIT systems( Chunning and Kumar 2000 ). Accordingly, many HCOs faced major issues with their supply chains and experienced shortages and understocking of many of important supplies. Additionally, the supplies of active pharmaceutical ingredients (APIs) from China and India, vaccines, and essential medical supplies were limited, delaying global supply amidst surges in demand. The world is still suffering from disruptions in its supply chains( Chowdhury et al., 2021 ).

To protect local supplies, some countries in Asia and Europe terminated the export of PPE, leading to a continued reduction in global stockpiles. Thus, countries that mainly depended on imported supplies experienced serious PPE shortages; the pandemic exposed their fragility and dependency on the current supply chain system. The shortages during the pandemic were directly related to the use of JIT systems which failed to meet the unexpectedly high demand, placing many HCOs at risk of having insufficient supplies. The challenges that arose during the pandemic showed why the JIT method should be used with caution in healthcare systems, proving that HCOs need extra supplies to mitigate the risks of present and future delays and disruptions.( Andaneswari and Rohmaiena, n.d. , Gereffi, 2020 ).

The experience obtained from the pandemic has highlighted the importance of proactive supply chain management in healthcare. During the pandemic, JIT systems created havoc for healthcare organizations, driving up the costs of supplies and placing extra pressure on already taxed healthcare budgets and systems that were trying to provide life-saving care. Thus, under JIT systems, due to lack of sustainable inventory for such these items, if inventory is unavailable during a pandemic, HCOs may experience widespread stock shortage. Many medications necessary for mechanical ventilation (sedatives, vasopressors, and paralytics) were in limited supply.

6. Recommendations to overcome current challenges

6.1. digitize and automate supply chain processes.

Globally, supply chain systems have faced many challenges, especially during the pandemic, indicating that a new strategy is warranted to address the shortcomings of the current system. To minimize inefficiencies and build robust systems, we recommend building an integrated supply chain framework using tools such as big data, the Internet of Things (IOT), blockchain, cloud computing, and artificial intelligence (AI) to directly link HCOs to suppliers and facilitate HCO purchasing processes. These tools can help HCOs to accurately predict their demand and visually track their consumption ( Dash et al., 2019 , Wang et al., 2019 ). This transition from traditional operators to a more automated system that enables AI and machine learning will require a secure, transparent, and trustworthy platform to exchange information among all stakeholders as an efficient inventory management tool. This integrated supply chain system will improve inventory levels, rationalize processes, streamline purchasing, and help to build better relationships with suppliers. The supplier–HCO relationship is key to improving hospital supply chain systems, as these systems are built on the trust between hospitals and suppliers( Gurtu and Johny 2021 ).

6.2. Positive behavior strategies

JIT can benefit healthcare organizations by helping them to operate more efficiently, minimize operation costs, and increase productivity. However, these systems need special considerations to run successfully: positive attitudes and behavior toward the new methods must be developed, and the capacity and readiness of the current system for a major change must be assessed. Moreover, estimations of consumption patterns must be accurate, so tools are needed to calculate and predict which items are associated with higher (e.g., lifesaving items) and lower risk if out of stock. The long-term impacts of the pandemic have shown many healthcare systems the benefit of direct relationships with suppliers. This emphasizes the importance of cooperation and trust between HCOs and suppliers. Hospitals being directly connected to suppliers, without an intermediary distributor, will facilitate the supply process and will determine whether a given supply chain is cost-effective or needs modification. Applying a supplier relationship management strategy can be used as a tool to create a better supplier relationship system by closely measure supplier processes and build a more efficient and positive relationship. Institution that adapt such strategy demonstrated a substantial benefit in term of reduction of inventory, sustainability, and efficiency process even for centralized procurement.( Ezzahra et al., 2018 , Amoako-Gyampah et al., 2019 ) Once a system is working, employees need to be aware of its value and be trained on how to use it properly. After implementation, the system will require continuous evaluation and monitoring to inform necessary adjustments which is essential for a success of JIT system.( Okeagu et al., 2021 ).

6.3. Strategic sourcing

Despite the financial and nonfinancial benefits of JIT systems, such a system may not be the right choice for all HCOs; for some, JIT may not optimize the healthcare supply chain. Ensuring the maintenance of an emergency inventory is the best and safest choice for the healthcare industry during pandemics( Leaven et al., 2017 ). Adopting a direct sourcing model can both ensure that an organization receives the products it needs at a sustainable cost and that supplies will be sufficient during disruptions. Additionally, diversification by having multiple suppliers will mitigate future shortages, as having a single supplier may put an organization at risk of running out of stock.

6.4. National stockpiles

A regional stockpiling infrastructure is one method of overcoming JIT inventory issues. Strategic national stockpiles (SNSs) help a whole region to secure healthcare services by maintaining strategic quantities of all medical and surgical items. These stockpiled supplies are vital for supporting national health security during pandemics and other crises. Supplies from these stockpiles can be delivered to HCOs within hours( Branson 2021 ). Countries that used their SNSs during the pandemic were able to meet the surge in demand and overcome the medical shortages to some extent, especially at the beginning of the pandemic. However, the stockpile system was ultimately unable to equip various regions with necessary healthcare items to ensure the safe and effective management of the pandemic( Rule 2021 ). These SNSs were deficient, so a more substantial and well-maintained stockpile approach is needed to provide a more robust response to any unexpected surges in demand and to anticipate future needs( Gerberding 2020 ). The pandemic has highlighted the importance of strengthening the domestic healthcare supply chain system and enhancing communication at all levels between government and private entities to enable sharing of information regarding supply and needs, especially during crises( Huang and Varmus 2021 ).

6.5. Just-in-case systems

Healthcare leaders have learned many lessons during the pandemic, so they will hopefully be prepared for future challenges. The COVID 19 pandemic has forced leaders to rethink and consider just-in-case (JIC) instead of JIT systems, which focus on lean management by reducing inefficiencies and waste through the supply chain and lowering investments. JIC is a type of demand-based supply chain system. The key to JIC is focusing more on the continuity of work and operations. Creating an inventory buffer through JIC systems is one way to mitigate supply chain disruptions and prevent HCOs running out of supplies( Swierczek and Szozda 2019 ). During purchasing planning, the planner creates a 10 % inventory buffer, particularly for life-saving and essential items, in case of high demand caused by an influx of patients. Thus, some HCOs might consider moving from JIT to JIC systems, maintaining sufficient inventories to minimize uncertainties in supply and demand, and focusing on balancing efficiency with a flexible and reliable supply chain, and using “Par” level for each item when it becomes in a very low level and even an one item is a backbone of JIC process( Coslett 2022 ). It could be organized by using such inventory software connecting to each item by barcode would track each one. if the attention is not paid from warehouse, HCOs would confront shortages. However, JIC systems require increased stock to address potential delivery delays, which increases costs for the organization, which is opposite of the intent of JIT approaches. In a JIC system, an emergency plan must be considered, and higher costs and longer delivery times must be expected. Thus, caution is required in the assessment of the risks and benefits of these systems to ensure that the inventory buffer costs less than the risks it would offset( Chopra and Sodhi 2004 ). Nonetheless, both benefits cannot be simultaneously obtained. JIC overcomes the limitations of JIT and satisfies customer demands, but at higher cost. Thus, a balance should be reached between JIT and JIC approaches to achieve a balanced and resilient system( Kerr and Houghton 2010 ).

6.6. Supply chain risk management systems (SCRMs)

During pandemics, demand may surge, exceeding the ability of the supply chain to quickly respond. Unanticipated surges can disturb the normal inventory plan and may compromise both public and national health security during pandemics and other emergencies. A vital task in healthcare decision making is to recognize and address critical risks in any supply chain system. Thus, supply chain risk management systems (SCRMs) are implemented to identify areas where surges in demand may occur so plans can be accordingly designed( Swierczek and Szozda 2019 ). The overall aim of an SCRM is to ensure that supply chains perform well, with smooth and continuous flows of supplies, and to promote supply chain resilience and robustness. SCRMs should consider all aspects of supply chains and their associated stakeholders, including individuals and organizations, and examine the impact of stakeholders on supply chain resilience. In healthcare supply chains, several strategies can be implemented to mitigate risk and maintain supply-and-demand stability. Inventory can be managed by shifting toward a supply chain that minimizes disruption and leverages technology to manage increasingly complex processes and supplier relationships that require real-time monitoring, such as forming a surplus supply of critical inventory; securing critical assets; using highly accurate forecasting that depends on high-quality information and fast decision making; creating an optimal and standardized fulfillment processes, which will require centralized visibility using an online portal; measuring and monitoring stock consumption using predictive analytics tools; and tracking the trends in orders and usage volumes to support prediction ( Monczka et al., 2015 , Wang et al., 2019 ).

We recommend using a risk management approach to sort multiple suppliers into tiers of revenue impact and suggest using tier-specific tactics, such as continual supply monitoring and buying insurance. Additionally, an express delivery system can be implemented by contracting a third-party source with experience in this field. To ensure functionality during a pandemic or disaster, items can be directly purchased from vendors using cash within one or two days. Collaboration with clinicians and prioritization of patient outcomes are needed, along with decisions about how space is used in provider facilities( Croom 2001 ).

6.7. Using analytical models

Analytical models are other tools that can be used to optimize decision making within supply chain processes. One of the main challenges in ensuring resilience in supply chains is mitigating the ripple effect, which is the propagation of supply chain disruptions that impact the chain’s resilience and performance. At the beginning of the pandemic, several ripple effects were reported due to supplier disruptions in some countries, which then spread downstream in the supply chain, leading to shortages. Several approaches to controlling supply chain resilience have been explored using analytical models such as Bayesian networks, which are powerful analytical tools for risk management and uncertainty assessments. Application of this technique in the supply chain field is relatively new and requires further studies. Bayesian networks can be used to identify causal risk factors associated with supply chain processes; therefore, they can be integrated with machine learning algorithms using big data to overcome many uncertainties and logistical issues( Hosseini and Ivanov 2020 ).

6.8. Future supply chain frameworks

With the future development of new technologies, a hybrid system using the JIT approach may become easier and less costly to implement, and may overcome the limitations of current JIT systems. The system should be able to monitor the average consumption rates of supplies and support projections for future inventory management. Using a barcode system for supplies can provide up-to-date and accurate assessments of stock use and identify any unused inventory( Scanlin 1997 ). Stock can be categorized into different classes according to turnover rate, emergency and urgent use, or price.

A more comprehensive digital supply chain system will be able to estimate use patterns to enable proactive supply management approaches and inform decisions on product distribution. The formation of digital systems will enable a more data-driven supply chain strategy, including data modeling to assess different scenarios. This will allow decision makers to more proactively approach planning for future events( Snowdon and Saunders 2022 ). Another technique that may be used is the integration of a networking system that connects HCOs with their suppliers. This could simplify and increase the accuracy of the ordering process by eliminating the need for intermediaries. This will necessitate the use of comprehensive dashboards that are able to track items from production through shipment to end-user consumption. Data gathered from this dashboard can be used to guide decision making. These technologies will reduce the number of employees required for managing inventory, which in turn will reduce errors and costs. Moreover, monitoring must be performed using a predefined indicator to continuously evaluate the function of the supply chain and benchmark performance against its peers. The system should also be able to identify alternative products and supplies, which would mitigate the effects of any crisis by avoiding dependency on certain pipelines and disruptions related to critical products and services( Kua-Walker 2010 ).

In recent years, HCOs have been moving toward leaner and increased integration strategies in their supply chains. The benefits of this approach are minimized inventory and reduced costs, but this approach poses potential risks( El Baz and Ruel 2021 ). Thus, a trade-off exists between a lean strategy (cost-saving approach) and resilience (robustness), which must be balanced. This is called a “leagile” supply chain, which balances efficiency and resilience through supply chain risk management, taking advantage of both strategies( Ahmed and Huma 2021 ).

In reference of lean process that helps organizations for dealing and managing their supply chain, particularly the critical items, it suggests. First, implementing the lean process in each administrative department. Those departments including warehouse, purchasing, finance, and human resources. Innovation by focusing on quality and productivity with elimination of non-value added activities for each department and section is the cornerstone for implementing the lean process. Then, starting for using map process by considering each steps that are presentation, consultation as in Kiezen Approch, prioritization, Pilot team and methodology application respectively . Second, using such kind of advance system like Med-Approve which can contain all hospitals information with addresses and vendor as well. Each hospital has special code number to use to identify each entity with an icon for meeting agenda to discuss each item for getting approvals as a stock item for all hospitals especially for medical and surgical items. Finally, the benefits of applying lean process is to improve workers performance and the quality with confidence which creates a good environment in each entity ( Monteiro et al., 2015 , Rossiti et al., 2016 ).

7. Conclusions

In conclusion, JIT is a lean methodology that can provide financial and operational benefits. However, caution is needed in specific situations to prevent the breakdown of the system, which would compromise the ability of healthcare systems to deliver care. JIT works properly when the organization has reliable and accurate demand forecasting and works with reliable suppliers, especially if the suppliers use local manufacturers, which considerably impacts the supply chain process. Above all, to be ready for any future emergencies, lessons must be learned from the response to the current COVID-19 pandemic and used to improve overall supply chain systems; HCOs must identify several suppliers and ensure a sustainable stockpile, particularly in areas with many tertiary hospitals. In the future, researchers should evaluate the practicability of the JIT approach by performing evaluations from different perspectives, including costs, efficiencies, benefits, and risks.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

• Ahmed W., Huma S. Impact of lean and agile strategies on supply chain risk management. Total Qual. Manage. Business Excell. 2021; 32 :33–56. [ Google Scholar ]
• Amoako-Gyampah K., Boakye K.G., Adaku E., et al. Supplier relationship management and firm performance in developing economies: a moderated mediation analysis of flexibility capability and ownership structure. Int. J. Prod. Econ. 2019; 208 :160–170. [ Google Scholar ]
• Andaneswari, A. K. and Q. Rohmadiena, The Disruption of Personal Protection Equipment Supply Chain: What Can We Learn from Global Value Chain in the Time of Covid-19 Outbreak? Global South Review. 2, 171-188.
• Aptel O., Pourjalali H. Improving activities and decreasing costs of logistics in hospitals: a comparison of US and French hospitals. Int. J. Account. 2001; 36 :65–90. [ Google Scholar ]
• Baum N. Just in time’means more dimes in your pocket: Stocking only what your practice needs takes careful planning, but offers big savings. The Bottom Line) Urol. Times. 2006; 34 :28. [ Google Scholar ]
• Brandon-Jones E., Squire B., Autry C.W., et al. A contingent resource-based perspective of supply chain resilience and robustness. J. Supply Chain Manage. 2014; 50 :55–73. [ Google Scholar ]
• Branson R., Dichter J.R., Feldman H., Devereaux A., Dries D., Benditt J., Hossain T., Ghazipura M., King M., Baldisseri M., Christian M.D. The US strategic national stockpile ventilators in coronavirus disease 2019: a comparison of functionality and analysis regarding the emergency purchase of 200,000 devices. Chest. 2021; 2 :634–652. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Canel C., Rosen D., Anderson E.A. Industrial Management & Data Systems; 2000. Just-in-time is not just for manufacturing: a service perspective. [ Google Scholar ]
• Cheng T., Podolsky S. Springer Science & Business Media; 1996. Just-in-time manufacturing: an introduction. [ Google Scholar ]
• Chopra S., Sodhi M. Supply-chain breakdown. MIT. Sloan Manage. Rev. 2004; 46 :53–61. [ Google Scholar ]
• Chowdhury P., Paul S.K., Kaisar S., et al. COVID-19 pandemic related supply chain studies: a systematic review. Transport. Res. Part E: Logist. Transport. Rev. 2021; 148 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Chunning, Z. and A. Kumar, 2000. JIT application: process-oriented supply chain management in a health care system. Proceedings of the 2000 IEEE International Conference on Management of Innovation and Technology. ICMIT 2000.'Management in the 21st Century'(Cat. No. 00EX457), IEEE.
• Coslett, B. G., 2022. Just-In-Time/Just-In-Case Inventory Management as an Influence on Supply Chain Disruption in Medical Systems Based in the Southeastern United States During the COVID-19 Pandemic.
• Croom S. Restructuring supply chains through information channel innovation. Int. J. Operat. Prod. Manage. 2001 [ Google Scholar ]
• Dash R., McMurtrey M., Rebman C., et al. Application of artificial intelligence in automation of supply chain management. J. Strategic Innov. Sustain. 2019; 14 :43–53. [ Google Scholar ]
• De Vries J. The shaping of inventory systems in health services: a stakeholder analysis. Int. J. Prod. Econ. 2011; 133 :60–69. [ Google Scholar ]
• Dennision R., Kathawala Y., Elmuti D. Just-in-time: Implications for the hospital industry. J. Hospital Market. 1994; 8 :131–142. [ PubMed ] [ Google Scholar ]
• Doughty, H., F. Chowdhury, N. B. T. C. E. P. W. Group, et al., 2020. Emergency preparedness, resilience and response guidance for UK hospital transfusion teams. Transfusion Medicine. 30, 177-185. [ PMC free article ] [ PubMed ]
• Dwivedi S., Kothiyal P. Inventory management: A tool of identifying items that need greater attention for control. Pharma Innov. 2012; 1 :125. [ Google Scholar ]
• El Baz J., Ruel S. Can supply chain risk management practices mitigate the disruption impacts on supply chains’ resilience and robustness? evidence from an empirical survey in a COVID-19 outbreak era. Int. J. Prod. Econ. 2021; 233 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Ezzahra, S. F., A. Ahmed and R. Said, 2018. Literature review on successful JIT implementation in developing countries: obstacles and critical success factors. 2018 International Colloquium on Logistics and Supply Chain Management (LOGISTIQUA), IEEE.
• Gerberding, J., 2020. The Role of the Strategic National Stockpile in Pandemic Response.
• Gereffi G. What does the COVID-19 pandemic teach us about global value chains? the case of medical supplies. J. Int. Business Policy. 2020; 3 :287–301. [ Google Scholar ]
• Gurtu A., Johny J. Supply chain risk management: literature review. Risks. 2021; 9 :16. [ Google Scholar ]
• Hosseini S., Ivanov D. Bayesian networks for supply chain risk, resilience and ripple effect analysis: a literature review. Expert Syst. Appl. 2020; 161 [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Huang, C. and H. Varmus, 2021. The Strategic National Stockpile during the COVID-19 Pandemic: Lessons and Recommendations.
• Jackson, T. L., 2017. Just-in-time for Healthcare, Productivity Press.
• Karkowski T.A., Karkowska D., Skoczylas P. Just-in-time method in the management of hospital medication stock. Przedsiębiorczość i Zarządzanie. 2017; 18 [ Google Scholar ]
• Kaswan M.S., Rathi R., Singh M. Just in time elements extraction and prioritization for health care unit using decision making approach. Int. J. Qual. Reliab. Manage. 2019 [ Google Scholar ]
• Kelle P., Woosley J., Schneider H. Pharmaceutical supply chain specifics and inventory solutions for a hospital case. Operat. Res. Health Care. 2012; 1 :54–63. [ Google Scholar ]
• Kerr D., Houghton L. Just in time or just in case: a case study on the impact of context in ERP implementations. Australasian J. Information Syst. 2010; 16 :5–16. [ Google Scholar ]
• Kester L., Kirschner P.A., van Merriënboer J.J., et al. Just-in-time information presentation and the acquisition of complex cognitive skills. Comput. Hum. Behav. 2001; 17 :373–391. [ Google Scholar ]
• Kim G.C., Rifai A.K. Efficient approach to health care industry material resource management: an empirical research. Hospital Mater. Manage. Quarter. 1992; 13 :10–24. [ PubMed ] [ Google Scholar ]
• Kua-Walker, Y. A., 2010. Can a just-in-time inventory system help reduce costs and increase productivity in hospitals?
• Lai K.-H., Cheng T.E. Routledge; 2016. Just-in-time logistics. [ Google Scholar ]
• Leaven L., Ahmmad K., Peebles D. Inventory management applications for healthcare supply chains. Int. J. Supply Chain Manage. 2017; 6 :1–7. [ Google Scholar ]
• Lee S.M., Lee D., Schniederjans M.J. Supply chain innovation and organizational performance in the healthcare industry. Int. J. Operat. Prod. Manage. 2011 [ Google Scholar ]
• Leite H., Lindsay C., Kumar M. COVID-19 outbreak: implications on healthcare operations. TQM J. 2020 [ Google Scholar ]
• Li, J., 2015. Just-in-Time Management in healthcare operations.
• Mathur B., Gupta S., Meena M.L., et al. Healthcare supply chain management: literature review and some issues. J. Adv. Manage. Res. 2018 [ Google Scholar ]
• Monczka R.M., Handfield R.B., Giunipero L.C., et al. Cengage Learning; 2015. Purchasing and supply chain management. [ Google Scholar ]
• Monteiro M.F., Pacheco C.C., Dinis-Carvalho J., et al. Implementing lean office: a successful case in public sector. FME Trans. 2015; 43 :303–310. [ Google Scholar ]
• Moons K., Waeyenbergh G., Pintelon L. Measuring the logistics performance of internal hospital supply chains–a literature study. Omega. 2019; 82 :205–217. [ Google Scholar ]
• NAVIGANT, 2018. Hospitals’ Supply Chain Savings Opportunity Increases to $25.4 Billion a Year. NAVIGANT SUPPLY CHAIN ANALYSIS.
• Neil R. The ups and downs of inventory management. Mater. Manage. Health Care. 2004; 13 :22–26. [ PubMed ] [ Google Scholar ]
• Okeagu C.N., Reed D.S., Sun L., et al. Principles of supply chain management in the time of crisis. Best Pract. Res. Clin. Anaesthesiol. 2021; 35 :369–376. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Peng H., Pang T. A mutual-aid mechanism for supply chains with capital constraints. Int. J. Manage. Sci. Eng. Manage. 2019; 14 :304–312. [ Google Scholar ]
• Raj A., Mukherjee A.A., de Sousa Jabbour A.B.L., et al. Supply chain management during and post-COVID-19 pandemic: mitigation strategies and practical lessons learned. J. Business Res. 2022; 142 :1125–1139. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Rossiti, I., S. M. Serra and I. A. Lorenzon, 2016. Impacts of lean office applications in the supply sector of a construction company. Proceedings of the 24th Annual Conference of the International Group for Lean Construction.
• Rule T.A. Toward a more strategic national stockpile. Tex. A&M L. Rev. 2021; 9 :49. [ Google Scholar ]
• Scanlin T. A case for'just in time:'could it be right for your hospital, too? J. Healthcare Resour. Manage. 1997; 15 :10–14. [ PubMed ] [ Google Scholar ]
• Siddiqui A. The importance of just in time JIT methodology and its advantages in health care quality management business –A scoping review. Biomed. J. Scient. Tech. Res. 2022; 42 :33317–33325. [ Google Scholar ]
• Snowdon A.W., Saunders M.J. Healthcare Management Forum, SAGE Publications Sage CA; Los Angeles, CA: 2022. Supply chain integration as a strategy to strengthen pandemic responsiveness in Nova Scotia. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Swierczek A., Szozda N. An International Journal; Supply Chain Management: 2019. Demand planning as a tamer and trigger of operational risk disruptions: evidence from the European supply chains. [ Google Scholar ]
• Wang R., Yu C., Wang J. Construction of supply chain financial risk management mode based on Internet of Things. IEEE Access. 2019; 7 :110323–110332. [ Google Scholar ]

• Research article
• Open access
• Published: 28 August 2021

Lean adoption in hospitals: the role of contextual factors and introduction strategy

• Angelo Rosa 1 ,
• Giuliano Marolla   ORCID: orcid.org/0000-0002-2095-8641 1 ,
• Federico Lega 2 &
• Francesco Manfredi 1  

BMC Health Services Research volume  21 , Article number:  889 ( 2021 ) Cite this article

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In the scientific literature, many studies describe the application of lean methodology in the hospital setting. Most of the articles focus on the results rather than on the approach adopted to introduce the lean methodology. In the absence of a clear view of the context and the introduction strategy, the first steps of the implementation process can take on an empirical, trial and error profile. Such implementation is time-consuming and resource-intensive and affects the adoption of the model at the organizational level. This research aims to outline the role contextual factors and introduction strategy play in supporting the operators introducing lean methodology in a hospital setting.

Methodology

The methodology is revealed in a case study of an important hospital in Southern Italy, where lean has been successfully introduced through a pilot project in the pathway of cancer patients. The originality of the research is seen in the detailed description of the contextual elements and the introduction strategy.

The results show significant process improvements and highlight the spontaneous dissemination of the culture of change in the organization and the streamlined adoption at the micro level.

The case study shows the importance of the lean introduction strategy and contextual factors for successful lean implementation. Furthermore, it shows how both factors influence each other, underlining the dynamism of the organizational system.

Peer Review reports

Over the last decade, healthcare has been called upon to respond to the increasing pressures arising from changes in demand – due to epidemiological changes and the demand for quality and safety – and increased costs due to the introduction of new technologies [ 1 , 2 ]. These major challenges are exacerbated by the shrinking resources available in health systems and, for most countries, by the principle of universal access to patient care. In order to meet the patients’ needs, a hospital must utilize a number of scarce resources at the right time: beds, technological equipment, staff with appropriate clinical skills, medical devices, diagnostic reports, etc. [ 1 , 2 ].

One of the most relevant issues for the management of a healthcare provider is the management of patient flows in order to purchase, make available, and use these scarce resources at the right time and in the right way, and to ensure the best possible care [ 3 , 4 , 5 ]. In this scenario, hospitals need to focus on the patient pathways in order to ensure fast, safe, and high-quality service [ 3 , 6 , 7 , 8 ]. The search for solutions to these challenges has extended beyond the boundaries of healthcare practices to study organizational methods and paradigms that have been successfully implemented in other sectors [ 3 , 5 ]. Among these, lean thinking has proven to be one of the most effective solutions for improving operational performance and process efficiency and for reducing waste [ 5 , 9 ]. Lean is a process-based methodology focused on improving processes to achieve a customer ideal state and the elimination of waste [ 10 ]. Waste is defined as the results of unnecessary or wrong tasks, actions or process steps that do not directly benefit the patient. The taxonomy of waste is: overproduction, defects, waiting, transportation, inventory, motion, extra-processing and unused talent [ 3 , 4 , 5 ]. In addition, lean addresses other key service issues such as continuous improvement and employee empowerment, whether healthcare professionals or managers [ 1 , 11 , 12 ]. Lean healthcare is defined as a strategic approach to increasing the reliability and stability of healthcare processes [ 7 , 13 , 14 ].

The first documented cases of lean applications in a hospital setting (HS) date back to the late 1990s. These aimed at improving patient care processes, interdepartmental interaction, and employee satisfaction [ 1 , 2 ]. The Virginia Mason Medical Center is one of the first and most emblematic examples of a successful migration of lean methodology from the manufacturing sector to healthcare. The hospital, based on the principles of the Toyota Production System, created the Virginia Mason Production System, a holistic management model in continuous evolution that not only had a strong impact on the quality of the services provided and on the reduction of lead time, but it also led to a decrease in operating costs [ 14 , 15 ]. Over time, many hospitals have followed in the footsteps of the Virginia Mason Medical Center [ 8 , 16 , 17 ]. The lean paradigm crossed the US border and spread to other countries such as Canada and England [ 5 , 12 ]. It was not until the early 2000 that the model was introduced in European hospitals [ 12 , 16 ].

The implementation of the lean paradigm in HS environments has increasingly attracted the attention of researchers and professionals. The interest in lean in HSs was fostered by the idea that the paradigm was particularly suitable for hospitals because its concepts are intuitive, compelling, and, therefore, easy for medical staff to use [ 18 , 19 ]. However, over time, alongside the evidence of successful implementation of lean in HSs, much of the research has shown failures in adopting the paradigm [ 5 , 20 , 21 ]. Moreover, a literature review showed that most of the cases were characterized by a partial implementation of lean methodologies and concerned single processes in the value chain or restricted technical applications [ 20 , 22 ]. Even today, few hospitals apply lean principles at a systemic level [ 23 , 24 ].

The failure of lean implementation is a hot topic. Many authors who have focused their studies on social and managerial issues have highlighted the existence of factors that either enable or hinder the implementation of lean. These factors are mostly related to the context and the implementation strategies [ 5 , 16 , 25 , 26 , 27 ]. Lean implementation is not self-evident, and the process of transforming an organization into a lean organization requires a long-term strategic vision, a commitment by management, and a culture of change in the entire organization [ 5 , 16 , 26 ]. Contextual factors influence successful implementation and introduction strategy; lean adoption, in turn, changes contextual factors. A lean transformation must be planned and managed; it is not a quick solution, but a strategic plan in constant evolution [ 5 , 28 , 29 ]. From this point of view, the introduction phase plays a fundamental role in implementation because it facilitates the dissemination of the lean principle in hospitals and enables the contextual elements that support change. Although most researchers have recognized the role of the introduction step, the impact of this phase on contextual factors has been poorly reported on in the literature [ 5 , 12 , 20 ]. Most of the articles have focused more on the benefits of this phase than on how to manage it.

In light of this, it is necessary to examine how hospitals introduce lean into their clinical pathways in order to explain the success of the lean implementation. Starting with an in-depth analysis of the contextual factors discussed in the literature, the document helps to clarify what drives success in lean implementation within the hospital. The research has therefore undertaken a critical study of the introduction of lean in the case study of the haematology ward at a university hospital in the south of Italy. The objective is to highlight: (a) the role of contextual factors for successful lean introduction and implementation in a hospital ward; (b) how the pilot project has improved the pathway of a cancer patient undergoing chemotherapy infusion; and, (c) how the success of the pilot project modified the contextual factors, facilitating the spread of lean within the organization.

The study has the merit of detailing all the lean introduction phases. The analysis period is about 2 years. The lean introduction started in May 2018 and lasted 7 months. The pilot project results refer to the follow-up period of December 2018 to May 2020, while the dissemination results refer to the period from December 2019 to May 2020.

The paper is structured as follows: In the following section, the theoretical background is provided. Section 3 describes the research methods, while Section 4 presents the results of the pilot project. Finally, Section 5 presents the conclusion, highlights some limitations of this study, and proposes some directions for further research.

Theoretical background

Most authors point out that the introduction phase is a crucial moment in lean implementation [ 10 , 12 , 16 ]. This phase reduces distrust of the method and organizational resistance to change. It shows the benefits of lean and assesses the organization’s ability to undertake continuous improvement. Many case studies report the success of lean in HSs by describing the use of lean instruments [ 8 , 30 , 31 ]. They offer the practitioners some methodological support, but not in a structured way since they do not provide a clear implementation roadmap [ 5 , 32 , 33 ]. Some authors have tried to fill this gap in the literature by offering guidelines for implementation. Augusto and Tortorella [ 33 ] suggests carrying out a feasibility study focused on the desired performance before implementing continuous improvement activities. The author suggests defining the techniques, roles, and results related to the improvement path. Curatolo et al. [ 5 ] argue that the improvement procedure has to take into account six core operational activities of business process improvement and five support activities. The six core operational activities are: selecting projects, understanding process flows, measuring process performance, process analysis, process improvement, and implementing of lean solutions. The five support activities are: monitoring, managing change, organizing a project team, establishing top management support, and understanding the environment. These studies, while offering further guidance on the process of introducing lean into a hospital, do not describe either the organizational context in which the method is being implemented or the strategies for its implementation [ 5 , 12 , 25 ]. The introduction of lean into a HS is not an easy task; there are many organizational issues to be addressed. Among these, the analysis of the context and the definition of the implementation strategy are the ones with the greatest impact on the success of the introduction [ 16 , 26 , 34 ].

The contextual elements are the special organizational characteristics that must be considered to understand how a set of interventions may play out [ 35 , 36 ]. They interact and influence the intervention and its effectiveness [ 34 , 36 ]. Two of the most cited contextual element are the drive to improve processes and the level of maturity [ 5 , 10 ]. The drive for improvement is represented by the exogenous and endogenous needs that act as triggers for the introduction of improvement methodologies [ 25 , 26 , 35 , 37 ]. The level of maturity refers to knowledge and experience in process improvement initiatives. It includes knowledge of methodologies and tools, experience gained, confidence, trust, and dissemination within the organization. Where the maturity is low, there is a risk of lean introduction failure in both the processes and the organization as a whole [ 5 , 16 , 38 ]. As long as the organization does not reach a fair level of maturity, the rate of change tends to be slow and sometimes frustrating. However, as the degree of maturity increases, lean implementation becomes a “day-to-day job” rather than a series of projects that take place at discreet moments [ 10 , 21 , 39 ]. Hasle et al. [ 39 ] highlighted that a high level of maturity allows for the implementation of principle-driven lean. Contextual elements include organizational and technological barriers such as resistance to change, lack of motivation, skepticism, and a lack of time and resources that inhibits the introduction and the implementation process [ 4 , 8 , 21 , 40 ]. The lean introduction process in HS is also complicated by the organizational context and the double line of clinical and management authority in hospitals [ 41 , 42 ].

With regard to internal contextual factors, many authors explored the readiness and sustainability factors influencing the adoption of lean. Readiness factors are those elements that improve the chances of lean implementation success; they provide the necessary skills and knowledge to enable organizational change [ 23 , 43 , 44 , 45 ]. The readiness and sustainability factors include any practices or characteristics that allow organizational transformation by reducing or nullifying potential inhibitors of success. High commitment and strong leadership of managers and physicians, continuous training, value flow orientation, and the hospital’s involvement in continuous improvement are just some of the most discussed topics [ 5 , 10 , 16 , 43 ]. Other examples include understanding employees needs, identifying the organization’s strategic objectives, project management, and teamwork [ 5 , 12 , 16 , 46 ].

From the study of the contextual elements described so far, some authors have developed models to assess the impact of context on the implementation of organizational improvement activities. Kaplan et al. [ 36 ] put forth the Model for Understanding Success in Quality (MUSIQ). The authors identified 25 key contextual factors at different organizational levels that influence the success of quality improvement efforts. They defined five domains: the microsystem, the quality improvement team, quality improvement support and capacity, organization, and the external environment. Kaplan et al. [ 36 ] suggest that an organization that disregards contextual factors is doomed to fail in implementing an improvement program; an organization that adopts a context-appropriate implementation strategy can change the outcome by triggering implementation enablers. Previous studies of lean adoption in HSs suggest that the fit between the approach taken and the circumstances will influence the chances of success [ 3 , 12 , 34 ].

There are two strategies for introducing lean in a HS, and they are characterized by the implementation level. The level of implementation refers to either micro or meso implementation. Brandao de Souza [ 16 ] defined meso-level implementation as the condition under which lean is spread throughout the organization and is implemented at the strategic level, while micro-level implementation is where lean is implemented at a single process level in discrete moments. Meso-level implementation is crucial for long-term success because a lack of integration in a lean system can lead to the achievement of local rather than global objectives and can also affect the sustainability of the paradigm [ 23 , 26 , 47 ]. However, organizations that want to implement lean at the strategic level often do not recognize the need for a long-term implementation program and introduce lean as a “big-bang initiative”. This leads in many cases to a failure to introduce the method [ 16 , 47 ]. Many researchers suggest introducing the lean approach through a pilot project run by a specially formed lean team [ 12 , 16 , 48 , 49 ]. The pilot project should be challenging, involve a process relevant to the organization, and require the use of a systemic approach. In particular, it should not be limited to the application of “pockets of good practice” or lean tools, but should include the systemic adoption of improvement programs such as the Plan-Do-Check-Act (PDCA) cycle [ 21 , 48 ]. Brandao de Souza [ 16 ] asserts that the first initiative should be tested on a relevant patient pathway. The lean team should be composed of clinical and non-clinical staff actively involved in the patient pathway. A pilot project that meets these conditions is a useful tool for increasing the maturity of the method within the organization [ 21 , 39 ]. It can increase the confidence of the team and staff in the lean approach and can promote the learning of lean methodologies and techniques [ 21 , 39 ]. Moreover, the pilot project activates the contextual elements, enabling the introduction of the model [ 10 , 12 ]. The successes of the pilot initiative must be celebrated and communicated within the organization [ 10 ]. When the first initiative leads to visible and easily quantifiable results, the method has a greater chance of spreading throughout the organization [ 10 , 12 , 16 ]. In light of these considerations, the lean implementation requires that the contextual elements and the introduction strategy be assessed at the same time. In addition, it would seem fair to assume that as contextual factors influence the introduction strategy, the results of the implementation strategy will influence the contextual factors.

In Fig.  1 , we propose an adaptation of the MUSIQ model [ 36 ] that shows the impact that the lean implementation strategy has on the contextual elements.

Our adaptation of the MUSIQ model

Study setting and design

This is an explanatory single-case study of the introduction of lean at a university hospital in Southern Italy. In particular, the introduction of lean in the pathway of a cancer patient undergoing infusion chemotherapy in a haematology ward will be discussed. This study was designed to evaluate how the contextual elements discussed so far have influenced the introduction of the method and how the successful pilot project has enhanced the internal context. We used the adaptation of the MUSIQ model [ 36 ] proposed in Fig. 1 to systematically trace the antecedents of the lean introduction and to explain how the success of the implementation strategy changes the contextual elements.

The work covers four periods over 2 years (Fig.  2 ). The first period concerns lean introduction and implementation strategy. The second is related to the pilot project implementation in the haematology ward. The third shows the pilot project results. The last assesses the impact of the pilot project on the dissemination of lean within the organization.

Stages of data analysis

Data collection

Different data sources and data collection methods are used with the aim of improving data validity through triangulation. The data sources are lean training documents, direct observations and nonparticipant observations, process performance reports, process data recorded by patients, and two questionnaires submitted to the hospital staff (the questionnaires assess the “pre” and “post” lean dissemination phases and the difference regards three open questions) (Fig. 2 ). The second author is the consultant who trained the lean team and coordinated the pilot project, and the first author conducted approximately 50 h of nonparticipant observations. The questionnaire was delivered to 25 medical department staff members in September 2018 and in May 2020. The first questionnaire focused on contextual factors that existed before the introduction of lean, and the second investigated changes in the contextual elements - in particular trust, maturity and lean dissemination. The semi-annual performance reports from 2017 to 2020 for the clinical pathway under examination include daily averages of the number of chemotherapies per chemo chair (MT), the patients’ length of stay (LOS), and the daily average of the percentage of patients undergoing chemotherapeutic infusion within 3 hours of hospital admission (P3). Each day, from September 2018, a document containing all the steps of the clinical pathway was given to each patient. For each activity, the patient recorded the start and end time, and a signature of the doctor or nurse was required. In the period of September 2018 – May 2020, the medical staff collected more than 1.250 reports from patients. The study also draws on 10 semi-structured interviews. The hospital CEO, the chief of the medical department, the nurse supervisor, the chief of the antiblastic chemotherapy handling units, and the chief of the clinical laboratory were interviewed in September 2018 and May 2020. The interviews focused on the contextual elements either enabling or inhibiting lean introduction or its dissemination, and ranged from 30 min to 1 hour in duration.

Data analysis

The factors described in Fig. 1 were used to systematically analyse the antecedents of the results and to understand their causal influence on the lean introduction. This data collection allows for the description of the case study. In addition, it simplifies the interpretation of the evidence that emerged through the study of the factors listed. The authors carried out a content analysis to classify the data by theme. The content analysis followed an inductive approach based on the identification of meaning units at the semantic level and the encoding of results [ 49 , 50 ]. Whenever researchers did not agree on semantic meaning, a new unit of analysis was proposed. The principle of consensus among all panel members was used to determine the interpretation, addition or deletion of elements of analysis. The discussion of the case study focuses on four themes: (a) contextual elements enabling or hindering lean introduction, (b) implementation strategy, (c) pilot project results, and (d) lean dissemination and adoption in hospital. These themes were submitted for review by the interviewees; their feedback was used to improve the accuracy of the case study description.

Case study presentation

The university hospital is a model of excellence in Italy for pre-clinical, translational, and clinical research and care activities. It is equipped with 110 beds to treat all types of oncological pathologies in adults. There are 115 researchers working there. The hospital is structured into six departments, of which three are clinical (Medical Area, Diagnosis and Imaging Therapy, Surgical Area), two are services, and one is an administrative/management department. The medical area includes four wards: medical oncology for thoracic pathology, medical oncology, haematology, medical oncology for oncology patient care. In 2015, the institute was accredited as a clinical cancer centre according to the Organization of European Cancer Institutes (OECI). Since 2015, evidence-based medicine and patient-centred care methodologies have been successfully implemented in the hospital, but no process improvement methodology has been used. In 2017, the hospital became a hub for oncological diseases, which led to an increased demand for care and services. The hospital has received national funds dedicated to hubs and has made investments in infrastructure improvements and the purchase of new innovative medical equipment.

Contextual factors enabling or hindering lean introduction

The description of the external and internal contextual factors, as revealed in the first questionnaire and the interviews, is given in Table  1 . Below is a brief description of each item.

External context and organizational elements driving lean introduction in the haematology ward

The analysis of the context revealed external and internal elements influencing the introduction of lean. Starting with the external elements, the most frequently discussed motivators that led to the search for methodologies for process improvement include the continuous increase in patient volume and the benchmark of process performance with other providers. Although the clinical results were above the national average, the increase in demand - especially in the medical area - highlighted the inability to manage the increasing flow of patients. The inability to manage the increasing number of patients also affected the performance of the process in the diagnostic area.

Internal elements driving the lean introduction were related to dissatisfaction with inefficient work practices within the medical area and the dissatisfaction of many patients who complained about long wait times and lengths of stay.

The choice of lean methodology derives from the desire to follow the example of certain Tuscan hospitals that have been using lean at a strategic level since 2015. These hospitals are considered the benchmark for continuous process improvement. One of these hospitals was already included in the 2013 OASI Report, edited by CERGAS - Bocconi, among the six Italian companies that were the first and best to successfully implement Lean Thinking in healthcare. In addition, the methodology was strongly sponsored by the clinical director and the general director of the hospital. They had participated in a 60-h regional training course on lean healthcare in the second half of 2017. During the training course, they studied case studies of excellence in lean implementation.

When, in May 2018, the hospital directorate proposed the introduction of lean methodology in the medical area, the head physicians showed strong resistance because of the resources that would need to be allocated to the implementation process. In addition, some doctors did not trust the method. This brought up some conflicts with the medical area managers. The haematology staff, represented by their head physician, were the only ones who explicitly agreed to implement the lean introduction. The department, as in most Italian hospitals, is structured as a clinical area where the physicians - in contrast to other professionals - were members of the ward organizationally. Haematology staff were strongly motivated to do research and achieve excellent process performance. They were interested in taking the opportunity to define excellent clinical pathways, as the ward was undergoing managerial and layout restructuring. In addition, the haematology staff believed that lean could further improve clinical performance and improve the patient-centred and evidence-based approach. Until mid-2017 the ward was part of oncology; afterward, it was made independent and new areas of the hospital were assigned to it. Since the ward became independent, one head physician, three doctors and four nurses have been hired. The department is equipped with the most modern medical equipment. The layout of the ward was not yet fully defined, and some rooms that could have potentially been assigned to medical, diagnostic and therapeutic activities had not been assigned to process activities. The ward shares the Antiblastic Chemotherapy Handling Unit (UMACA) and the analysis laboratory with the other four medical department wards in the hospital, so the staff needed to coordinate clinical processes so as not to create bottlenecks.

Since haematology is a strategic ward for the hospital, and in the last 2 years the demand for treatment has increased more than in other wards, the managers of the medical area have deemed it appropriate to introduce lean there. Haematology ward is considered strategic due to its high attractiveness and high immigration rates of patients from outside the region. These phenomena derive from the excellent reputation of the department in relation to the quality of care. Although the clinical pathways were characterized by excellent clinical outcomes, qualitative benchmarking activities (based on testimonials from physicians and patients) showed that the organization of the haematology patient pathway was very different compared to the benchmark (a Tuscan hospital) and that the patients’ perception of non-clinical service quality was lower. Although no investigation was carried out with respect to the ratio of equipment and personnel available per number of patients and amount of activities regarding the hospitals taken as benchmarks, the testimonials prompted management to come up with new specific, measurable, attainable, relevant and time - bound (SMART) goals (Table  2 ). The goals will be described in the next section.

Internal contextual elements enabling and hindering lean introduction in the haematology ward

At the organizational level, hospital management has strongly supported the introduction of the method. Since the haematology staff had no experience in process improvement activities, management provided the budget for an external consultant. In addition, three non-clinical personnel were allocated part-time to support the implementation of visual management systems and communication. The organizational structure of the ward has been modified to a matrix form. A team of three haematology ward physicians and two nurses was established and the ward’s head physician was elected project manager. The project manager had formal authority over the team and the personnel employed in the process to be improved; this reduced conflicts due to the double line of hierarchical authority. In this phase, the top-down decision-making approach was crucial to the successful restructuring of the organizational structure and the definition of the new organizational roles. The lean advisor supported the group for 8 months through training and project supervision. He coordinated two meetings per week and carried out Kata coaching activities. The theoretical training activity, lasting 5 week ends (in June 2018), was differentiated to accommodate technical and managerial competency needs. The team project manager and the medical area manager were trained on topics such as project management, team management, leadership, and the dissemination of lean. The members of the lean group were trained in lean techniques and tools. The key principles of lean thinking, the PDCA cycle methodology and lean assessment were taught to all participants. The most difficult barrier to overcome was the time available. The team agreed to spend 8 hours per week on training and pilot project implementation. The management of the team was facilitated by the experience gained with the implementation of the patient-centred care and evidence-based medicine. The motivation of the medical staff–microsystem element–and the focus on team management were key success factors for the involvement of team members. The culture of change introduced by patient-centred and evidence-based medicine was another enabling factor.

Implementation strategies

Pilot project definition.

Hospital managers and lean team members, who had experience in implementing patient-centred care methodologies, suggested starting a pilot project for the lean introduction. The consultant agreed. The team, with the support of the expert, analysed the clinical pathways in haematology. Six pathways emerged: a) diagnostic visits, b) biopsies, c) check-up visits, d) transfusions, e) infusion chemotherapies, and f) oral chemotherapies. Hospital managers argued that the pathway of the patient undergoing infusion chemotherapy was the most critical for patient and organization value. This process is the only one that involves several departments and requires a large amount of materials and time-consuming resources. In the first and second half of 2017 and 2018, there was a significant increase in the number of chemotherapeutic preparations. LOS, P3, and MT performance decreased during the same periods (Table  2 ). In addition, outpatient visits and the number of biopsies also increased. The medical staff stated that the increase in demand in the medical area had particularly affected the infusion therapy activities because they involved technical and instrumental resources that are shared with other departments (Table  2 ). The length of stay was analysed for patients undergoing short (LOS s ) and long-term infusion (LOS l ) chemotherapy. The first has a minimum duration of 90 min and a maximum of 180 min, and the second has a minimum duration of 181 min and a maximum of 360 min. Each patient was assigned to one of the infusion treatment classes. Process data were collected and analysed by the Department Management Control Office. The process performance data collection and reports were established in 2015 for the implementation of evidence-based medicine.

Pilot project implementation

The pilot project started in June 2018. The first month was dedicated to Gemba Walk, Methods-Time Measurement (MTM) and implementation of the 5S. In addition, the consultant trained the project manager, department managers and lean team members. There were many difficulties during the training period, especially with regard to process mapping and the concept of value, the latter being interpreted by doctors as clinical output. The non-medical staff dedicated to the project assisted the team in the drawing of the visual management material. A room in the medical department was dedicated for team meetings, and some notice boards were installed to post the materials developed during the project. The project activities were organized according to the Report A3 scheme. It followed the phases of the consolidated Deming cycle: Plan-Do-Check-Act (PDCA). Implementing the approach proposed by Deming allowed for the trial-and-error empirical method to be abandoned in favour of the “scientific” one. The PDCA allowed accurate planning of objectives and activities and their monitoring. The departmental managers and the consultant through the study of the national publications and explicit requests to colleagues in other hospitals - considered virtuous - identified the benchmark (Table  2 ). They took into account the hospital’s specific characteristics, such as the policy of not accepting haematochemical reports from outside for fragile patients. This choice is dictated by the risk management plan and affects P3 and MT performance. Time for blood sampling and haematochemical analysis is added to the cycle time; however, it eliminates many risks associated with clinical treatment.

The existing care process was mapped through Value Stream Mapping (VSM) based on the patient reports, Gemba walks, interviews, and direct observation. For instance, Fig.  3 shows the pathway of a patient undergoing short-term infusion chemotherapy. The cycle time in Fig. 3 was calculated over an observation period of 1 week and included 51 patients. In addition, the application of the Demand Map and the Spaghetti Chart were used to evaluate the ward nodes activated by the patients and the ward’s layout. These tools were useful in defining the possible sources of waste in the process. The application of these tools lasted more than 2 months and required several revisions. Once completed, the results were posted in the meeting room and were used for discussions with colleagues in the medical department. The lean team requested support from the consultant for the drafting of the VSM and for the layout analysis. In addition, the consultant was asked to simplify negotiations with staff from other departments who were reluctant to be subjected to time and method measurements. The negotiation activity required a degree of organizational effort. The facilitating elements were manifold: they enabled the involvement of staff opposed to the introduction of measuring instruments. In particular, the most effective were: the intervention of the directorate general, the delegation of hierarchical authority to the project manager and finally the endorsement of trade union committees. Moreover, during the planning phase, many difficulties emerged, including the selection of a unique and standardised measurement system, the coordination of work and meeting schedules, and the deadlines set by the project Gantt. Although the project manager was able to manage the team, he did not have enough experience in lean tools. The external consultant played a key role in managing these activities.

As-is process represented by VSM

At the end of the as-is analysis process, an Ishikawa diagram was used for the definition of root causes. Four root causes emerged from the meetings and interviews. They were patient flow management, coordination activities with other departments, layout, and Information Technology equipment (IT).

Patient flow management concerned the absence of priority in the management of patients based on the clinical path and the arrival of patients in the early hours of the morning. The lack of coordination with other departments led to delays in the preparation of infusion chemotherapy and blood test reports. The layout was such that the flow of doctors and nurses crossed the flow of patients, and this caused great inconvenience to the doctors and nurses. Also, the computer software was not compatible, which meant that the same data had to be recorded several times.

After some meetings and rigorous brainstorming, the lean team suggested changes to be made in the existing pathway. This was done by considering how patients could be divided into clusters so that the infusion activity could start as soon as possible without affecting other occurrences. Moreover, it is made possible to simplify the coordination between diagnostic units. The patient flow has been managed in such a way that long-term patients are given priority (first to be accepted and blood sampled), followed by patients needing biopsies, first visit, follow-up visit. Finally, short-term patients are treated in a way that limits waiting time and does not affect the activities of other departments. Theories of queues and operational research methodologies were implemented to address chemo chair saturation. A chemo chair activities plan was implemented through pull logic. In addition, the hospital engineer was involved in making sure the information systems were compatible. Whenever integrating the software was not possible, a data entry person was assigned to prevent medical staff from wasting their time on low-value activities. The ward layout has been modified to prevent patient flows from intersecting with the flows of doctors and nurses. In addition, the use of one room has been changed from a small warehouse to a blood collection room to increase the value of the activities carried out within it. The waiting rooms were moved outside the ward and, during the first 2 hours of the working day, the biopsy room was reassigned to blood collection activities to speed up the requests for therapies in UMACA. Patient intake, blood collection, and tube labelling activities have been paralleled to be performed simultaneously in the same room. The routes and modalities for the delivery of blood samples to the laboratories were revised in order to reduce the time and distance travelled by non-clinical staff. Tablet reporting systems were installed. Finally, a patient chemo chair allocation system was developed.

The resources needed for these changes were determined. The team tested and modified the changes during December 2018 and January 2019. The tests were evaluated based on the performance data, patient reports and the team’s expertise.

Pilot project results

In January 2019, it was decided to implement the new standard procedures that were tested in order to improve performance. The team met once a week for 6 months. On a monthly basis, performance was reviewed and new changes were tested. Clinical and nonclinical personnel from other wards and departments were invited to each weekly meeting to share with them the results of the pilot project, and to involve them in the lean methodology.

Every morning, the team leader investigated the impact of organizational changes in order to avoid conflicts. Organizational problems that emerged were discussed and resolved by consensus. In the follow-up phase, the consultant performed supervisory activities. Each week, the team leader performed the Kata coaching. During the first 6 months, the monitoring of activity was very frequent to prevent a return to old operating modes. Subsequently, when the staff had learned the new procedures, monitoring was reduced to once a month.

Table  2 and Fig.  4 shows the results achieved through the implementation of the pilot project. The objectives were not reached for all indicators; however, the results improved over time.

Figure  5 shows the to-be state of the same process analysed in Fig. 3 . From the cycle time analysis of each process step, the areas of waste eliminated are clear.

To-be process represented by VSM

The incremental improvements in process performance over time are explained by the need for staff to learn new procedures in the early period. In addition, the patients’ resistance to changing their habits also slowed down the improvement in performance. Patients have been educated over time, through an intense communication activity based on visual management systems and telephone reminders.

In addition to the results showed in Table  2 , the pilot project had a positive impact on the performance of other patient pathways in the medical department. The cycle time variability reduction and the levelling of the service demand allowed the UMACA and the analysis laboratory to better plan their activities. The new layout reduced waste due to unnecessary movement. Nurses walk 2 km less per day and doctors 1.5 km less per day. Software integration has reduced data logging time by 35 min per day for each doctor. Patients have evaluated the change positively. In particular, they have experienced a drastic reduction in wait times, and greater attention from the medical staff. Increased privacy and a precise time of service are other improvements reported by patients.

Finally, the clinical staff was satisfied with the new procedures because they reduce overloads and allowed for better planning of activities. They say that dividing patients into time slots based on clinical priority reduces stress and simplifies the coordination of activities with other departments. The success of the project was communicated internally and externally to the organization. In June 2019 the results were celebrated with a formal team award ceremony. The resulting Report A3 was posted on the bulletin boards in the hospital wards and in the reception area. By means of an internal circular sent to all medical directors, the directorate officially thanked the members of the lean team and highlighted the excellent results achieved in terms of waiting lists and process time reduction. In addition, the directorate funded the lean team’s participation to national conferences in order for the team to discuss the project. The improvement activities and results were described and summarized in an official report sent to the regional health authority and cancer patient associations (the latter were also given an evaluation form and an invitation to observe the optimised process in the field). Reporting was carried out by the hospital directorate and the project manager.

Lean dissemination and adoption in the hospital

Following several meetings between the directors and the primary doctors of the medical area, it became clear that there was a willingness to implement further improvement projects in other medical wards. The feedback from the pilot project team was a strong convincing factor. Moreover, the results of the external communication of the pilot project played a critical role in increasing the desire for emulation. The regional authorities requested for the project team to co-design the diagnostic and therapeutic care pathways (PDTA) of the haematology patient pathway inside the regional network. The patient association lobbied for similar projects to be implemented in other clinical oncology pathways. The change of internal context and enabling factors were of great importance at this stage. The drive to disseminate lean was characterized by both the need to improve process performance and to the desire to emulate the success of the project pilot. In addition, increased trust in the lean method has prompted the directors to provide a peer internal training program in the medical area. In June 2019, members of the pilot project lean team were promoted to the position of lean champions. Their role was to disseminate the lean methodology in the medical area and to train colleagues. The hospital directorate set up the Lean Support Office and assigned to it the three non-clinical resources that had already supported the pilot project. The first methodology to spread throughout the medical department was 5S. According to the lean sponsors, this methodology was a prerequisite for implementing lean methodologies in all wards and for facilitating inter-process lean implementation. Visual management systems have been implemented to facilitate changes and standardization of activities and to guide the patient through the hospital. The 5S methodology and visual management, which was initially underestimated by the medical staff, has solved many problems in the working environment. Increasing the availability of tools, simplifying the transmission of documentation, reducing errors in medical records and nursing diaries, reducing the duplication of requests and medical documentation, creating flexible workplaces, less movement and transportation in the hospital, and increasing patient autonomy are just some of the improvements achieved. However, the most important result to be achieved was an improvement in workplace wellbeing. Among the most used tools for 5S implementation and visual management are: checklists, one point lessons, kaizen forms, horizontal and vertical marking, red tags, Kanban, spaghetti charts. Finally, the demand map was implemented to trace the patient flow across the departments of the medical area and the vertical swim lanes and the resources/process matrix were utilized to identify staff involved in several processes and the potential bottlenecks (in addition to the UMACA and the blood chemistry laboratory). As of August 2019 many other lean projects have launched sometimes spontaneously and sometimes at the demand of department heads or project managers (Fig.  6 ). In August 2019, three projects were undertaken in the medical oncology for thoracic pathology and the medical oncology wards. Two of them concerned the same clinical pathway addressed in the pilot project, and the last one was the harmonization of protocols for caring for an oncological patient between departments. Each project has been implemented following the PDCA cycle (using the A3 report framework) with the support of one of the lean champions, who was assigned the role of project manager. Teams of three doctors and one nurse were dedicated to each project. In the planning phase, the tools adopted in each project were: spaghetti charts, VSM, Gemba Walk, standardized data collection sheets (both for patients and physicians), control charts, 5 Why or alternatively the Fishbone Diagram, definition of SMART objectives. In the “Do” phase, the solutions adopted for the resolution of problems are derived from Just in Time and agile approaches (especially for software’s’ integrations management). The pilot project A3 report was used as a knowledge management tool and resulted to be of great value to guide the implementation of the three projects. The members of the pilot project team supported their colleagues during the implementation of the three projects. This resulted in a positive impact on the quality and timing of the data collection activities, the drafting of the VSM, the definition of the KPIs and especially the root cause analysis. Even though the negotiation was simplified by peer training, support from more experienced colleagues and project management by a doctor, organizational and structural barriers emerged. The difficulty in getting the new procedures accepted, the impossibility of optimizing the layouts and the “not always respecting” the authority of the project manager limited the performance improvement. Although not all potential solutions have been implemented, the results obtained are evidence of the success of the projects.

Lean projects and dissemination activities

In September 2019 the diagnostic department started 5S and visual management implementation initiatives. In October 2019 the same initiatives were undertaken in the surgical department. These initiatives were spontaneously implemented. The managers of these departments have asked the hospital director to introduce lean in their departments. Given the maturity of the method and the number of doctors trained, hospital managers did not consider it possible to undertake systemic improvement pathways in all departments. However, they have changed the organizational structures of the departments into matrix structures. Two doctors with lean experience, per department, have been assigned the role of project manager. The project managers have sponsored peer training and Kaizen blitz activities throughout the hospital departments. In the period October to December 2019 more than 60 doctors and nurses were trained in 40-h courses by their colleagues (Fig. 6 ). Three Kaizen blitz projects in the diagnostic department and two Kaizen blitz projects in the surgical area were carried out (Fig. 6 ). In addition, a PDCA cycle project was implemented in the medical area for the stocking and tracking of drugs and instruments. Moreover, the two bin Kanban systems, drug tracking tools, optimisation of the position in the storage layout and systems for the analysis of consumption time series were implemented.

In December 2019, in all the departments discussed so far, doctors were involved in continuous improvement activities, with projects structured through the use of both PDCA cycle and Kaizen blitz. The activities were undertaken spontaneously without the supervision of a manager and without any impact on daily clinical activity. The maturity of the methodology, the support of colleagues, and trust were enabling elements. However, some barriers such as infrastructural constraints and coordination of doctors and nurses and information systems have frequently affected the implementation of the method and two projects failed.

Due to the success of implementations at the micro level, managers have attempted to implement the lean methodology at the meso level. Hospital managers discussed, formalized and communicate in organization the Lean Strategic Plan. In January 2020, the Lean Support Office was transformed into a lean projects control room and renamed as the Operations Management Office. The role of this office is to define lean development policies and to supervise continuous improvement activities. The office has been placed in line with the strategic direction. Two lean project managers, two hospital managers, and three administrative officers have been assigned to it. Lean assessment, to evaluate the degree of lean maturity in organization, and Honshi Kanri, to strategically govern change activities, were implemented to the organizational level. While the lean assessment revealed an increase in both advance in the use of lean tools and the principles behind them, the governance of strategic implementation through Honshi Kanri did not seem to provide the foreseen results. Operations management office project managers did not always agree with hospital directorate on project prioritization. In addition, there often were disagreements between the Operations Management Office staff and departmental project managers about when to launch a project and how to manage it and communicate project results. Although there were many process improvement projects underway, these have not always been decided harmoniously between the Operation Management Office and the hospital departments. Moreover, many projects undertaken spontaneously by lean teams were not communicated to the Operations Management Office, which was therefore unable to govern the dissemination of the method. Medical leadership in departments seemed to dominate over managerial leadership; thus, there is great difficulty in strategically governing continuous improvement.

The marked differences in the responses to the closed questions of the questionnaires submitted provide significant evidence of how lean has spread throughout the organization (Fig.  7 ).

Responses to the closed questions of the questionnaire

The marked differences in the responses to the closed questions of the questionnaires presented provide significant evidence of how lean has spread throughout the organization. In particular, the results show how standardisation, self-assessment, time for improvement and peer-to-peer training have become part of everyday working practice. Furthermore, problem solving and collaborative decision-making show significant improvements. These improvements were witnessed not only by management but also by doctors, nurses and technical staff in the medical area.

After the pilot project and the initial push for implementation by management, internal contextual factors changed radically within the organization. While initially sponsorship and management involvement were necessary for lean implementation, today the methodology is independently disseminated. In particular, small improvement groups have emerged that are able to address various challenges. Process vision and patient focus have become part of the hospital culture. Doctors claim that continuous improvements simplify daily work, save time, and increase the level of service and the number of services provided. However, although these changes occurred at the micro level, the organization failed to direct change at the strategic level. Thus, harmonization of lean projects according to the strategic direction of the facility has yet to be achieved.

In accordance with the findings of many researchers [ 10 , 16 ], this case study showed how a careful, context-driven lean introduction strategy facilitated the dissemination of lean - at micro level - within the hospital. The decision to implement lean was precipitated by external factors, including the need to improve the performance of processes in the medical area and to follow the example of other successful hospitals. The in-depth training by an external specialist and the pilot project, characterized by interdepartmental activities, the need for a systemic approach based on the Deming Cycle and the constant support of the external consultant, allowed the participants to acquire the necessary skills to support - sufficiently - the lean implementation in the clinical pathways of the medical department and to train their colleagues. The results of this project have been manifold. At the process level, there was a significant reduction in the patients’ length of stay, the wait times for haematological patients, the process time variability, and an increase in the number of daily chemotherapy therapies performed. At the medical area level, a spontaneous spread of the culture of improvement has emerged. Directorate commitment, motivation of the medical department staff and management, and the presence of a consultant were the main enabling factors for the success of the pilot project. In turn, the results of the pilot project were the trigger for the spread of lean in the hospital. The pilot project itself, and the changes made to standard procedures that were inspired by the intervention, altered the contextual elements, mirroring the MUSIQ model [ 18 , 26 , 36 ]. Moreover, as trust and maturity raised, the speed of lean dissemination increased. This confirms that knowledge of the lean method tends to reduce organizational barriers and resistance [ 5 , 21 , 51 , 52 ]. Kata training and coaching were other key elements for the dissemination of the methodology. Initially, the consultant carried out the training activity, and after the pilot project, the team members became trainers and project managers; in this way, lean spread in the organization spontaneously. Moreover, as stated by many researchers [ 12 , 21 , 46 ], the matrix structure and project managers helped the staff to support and better coordinate process improvement. The many projects activated in the period July 2019–March 2020 are the measure of the diffusion itself.

However, some issues have arisen. For the new working procedures, the willingness of and the acceptance by the staff is crucial to achieving and sustaining the results of lean initiatives; where this did not occur, conflicts arose and the speed of change slowed. In addition, although in the early stages of implementation the bottom-up approach must prevail over a top-down approach to facilitate consensus and trust among physicians, nurses, and all workers, during the dissemination phase a greater equilibrium between the two decision-making approaches must be achieved. In accordance with [ 2 , 5 , 10 ], this case study demonstrates the importance of the right balance between bottom-up and top-down approaches. Medical leadership tends to dominate managerial leadership such that continuous improvement, even though it takes place in clinical processes, does not follow the strategic organizational guidelines. This leads to conflicts between managers and medical staff. Organizational, technical and infrastructural obstacles have hindered the adoption of the methodology. It is clear from what has been found that the introduction strategy was correct, but that the implementation at the strategic level has not yet taken place. The context has changed considerably from an organizational point of view, but some barriers have not been overcome. The management, which strongly sponsored and supported the introduction and implementation of lean, was subsequently unable to guide the implementation at the strategic level.

Our adaptation to the MUSIQ model is useful for interpreting the relationship between lean introduction strategies and changing contextual elements. Looking backward through this model allows us to understand the links between contextual elements, lean implementation and outcomes.

Conclusions

This study revealed that the strategy of introducing lean has improved readiness, sustainability and confidence in the method within the organization. The growing maturity of the organization has encouraged lean dissemination. However, the choice of strategy depends heavily on contextual factors. The two factors, therefore, influence each other. Although the introduction strategy may facilitate the introduction of lean, it may be less important when certain organizational, technical and infrastructural barriers remain. This is particularly relevant for systemic implementation. Contextual elements, which changed over time, influenced the success of the implementation at micro-level. At the meso-level, however, the organization has not reached the maturity for a systemic implementation of the method.

As has already been shown in the literature, the determining factors for introducing the methodology refer to external and internal pressures. The level of commitment of both the leadership and management are decisive for the success of the implementation only if the staff is motivated. Furthermore, the analysis shows that managing lean implementation at the micro and meso-levels requires different types of efforts. While the level of maturity speeds up the adoption of lean at the clinical level, it is not true that the dissemination of lean at the operational level inevitably translates into its application at the strategic level. Medical leadership, reinforced by the success of lean project implementations, could instead undermine proper implementation at the meso-level. This experience strengthens the MUSIQ model and complements it by showing the importance of the lean introduction strategy and its impact on contextual factors.

Limitations and future research

The main limitations concern the complexity of detecting and analysing all the relevant social and organizational aspects that have characterized the introduction and dissemination phases and the observation period of the dissemination phase. Moreover, the expert content analysis could introduce opportunities for misinterpretation of the data. The relationship between the contextual elements and the pilot project results were mainly assessed through participant and patient reports, document studies, and observations. The authors used data triangulation and a review of hospital staff to overcome the limits of the content analysis. Given the specificity of the hospital’s contextual factors and strategic choices, it is also clear that the case study cannot be generalized.

The sustainability aspect of lean was not considered because the observational study was conducted over a period of only 2 years. To understand this issue, the authors will investigate the socio-technical aspects of lean and how the context supports continuous improvement over time.

Availability of data and materials

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Abbreviations

Hospital Setting

Information Technology

Length of stay

Number of chemotherapies per chemo chair

Methods-Time Measurement

Model for Understanding Success in Quality

Organization of European Cancer Institutes

Patients undergoing chemotherapeutic infusion within three hours of hospital admission

Plan-Do-Check-Act

Antiblastic Chemotherapy Handling Unit

Value Stream Mapping

Godman B, Novakovic T, Tesic D, Oortwijn W, Martin AP, Parker M, et al. Addressing challenges for sustainable healthcare in central and Eastern Europe. Exp Rev Pharmacoecon Outcomes Res. 2016;16(6):685–7. https://doi.org/10.1586/14737167.2016.1165610 Epub 2016 Mar 30. PMID: 26966924 .

Article   Google Scholar  

Teisberg E, Wallace S, O’Hara S. Defining and implementing value-based health care: A strategic framework. Acad Med. 2020;95(5):682–5. https://doi.org/10.1097/ACM.0000000000003122 PMID: 31833857; PMCID: PMC7185050.

Article   PubMed   Google Scholar  

Lum B, Png HM, Yap HL, Tan C, Sun B, Law YH. Streamlining workflows and redesigning job roles in the theatre sterile surgical unit. MJ Open Qual. 2019;8(3):e000583. https://doi.org/10.1136/bmjoq-2018-000583 .

Radnor Z, Holweg M, Waring J. Lean in healthcare: the unfilled promise? Soc Sci Med. 2012;74(3):364–71. https://doi.org/10.1016/j.socscimed.2011.02.011 .

Curatolo N, Lamouri S, Huet J, Rieutord A. A critical analysis of lean approach structuring in hospitals. Bus Process Manag J. 2014;20(3):433–54. https://doi.org/10.1108/BPMJ-04-2013-0051 .

Roemeling O, Land M, Ahaus K. Does lean cure variability in health care? Int J Oper Prod. 2017;37(9):1229–45. https://doi.org/10.1108/IJOPM-07-2015-0452 .

Chiarini A, Bracci E. Implementing lean six sigma in healthcare: issues from Italy. Public Money Manag. 2013;33(5):361–8. https://doi.org/10.1080/09540962.2013.817126 .

Parkhi SS. Lean management practices in healthcare sector: a literature review. Benchmarking. 2019;26(4):1275–89. https://doi.org/10.1108/BIJ-06-2018-0166 .

Joosten T, Bongers I, Janssen R. Application of lean thinking to health care: issues and observations. Int J Qual Health Care. 2009;21(5):341–7. https://doi.org/10.1093/intqhc/mzp036 .

Article   PubMed   PubMed Central   Google Scholar  

Womack JP, Jones DT. Lean consumption. Harv Bus Rev. 2005;83(3):58–68 148. PMID: 15768676 .

PubMed   Google Scholar  

Spear SJ. Fixing health care from the inside, today. Harv Bus Rev. 2005;83(9):78–91 158. PMID: 16171213 .

D’Andreamatteo A, Iannia L, Lega F, Sargiacomo M. Lean in healthcare: a comprehensive review. Health Policy. 2015;119(9):1197–209. https://doi.org/10.1016/j.healthpol.2015.02.002 .

Mazzocato P, Holden RJ, Brommels M, Aronsson H, Bäckman U, Elg M, et al. How does lean work in emergency care? A case study of a lean-inspired intervention at the Astrid Lindgren children’s hospital, Stockholm, Sweden. BMC Health Serv Res. 2012;12(28). https://doi.org/10.1186/1472-6963-12-28 .

Andersen H, Røvik KA. Lost in translation: a case-study of the travel of lean thinking in a hospital. BMC Health Serv Res. 2015;15(401). https://doi.org/10.1186/s12913-015-1081-z .

Goodridge D, Westhorp G, Rotter T, Dobson R, Bath B. Lean and leadership practices: development of an initial realist program theory. BMC Health Serv Res. 2015;15(1):362. https://doi.org/10.1186/s12913-015-1030-x .

Brandao de Souza L. Trends and approaches in lean healthcare. Leadersh Health Serv. 2009;22(2):121–39. https://doi.org/10.1108/17511870910953788 .

Ulhassan W, von Thiele SU, Thor J, Westerlund H. Interactions between lean management and the psychosocial work environment in a hospital setting - a multi-method study. BMC Health Serv Res. 2014;14(1):480. https://doi.org/10.1186/1472-6963-14-480 .

Kaplan HC, Brady PW, Dritz MC, Hooper DK, Linam WM, Froehle CM, et al. The influence of context on quality improvement success in health care: a systematic review of the literature. Milbank Q. 2010;88(4):500–59. https://doi.org/10.1111/j.1468-0009.2010.00611.x .

Nelson-Peterson DL, Leppa CJ. Creating an environment for caring using lean principles of the Virginia Mason production system. J Nurs Adm. 2007;37(6):287–94. https://doi.org/10.1097/01.NNA.0000277717.34134.a9 .

Mazzocato P, Savage C, Brommels M, Aronsson H, Thor J. Lean thinking in healthcare: a realist review of the literature. Qual Saf Health Care. 2010;19(5):376–82. https://doi.org/10.1136/qshc.2009.037986 Epub 2010 Aug 19. PMID: 20724397 .

Brandao De Souza L, Pidd M. Exploring the barriers to lean health care implementation. Public Money Manag. 2011;31(1):59–66. https://doi.org/10.1080/09540962.2011.545548 .

Kaplan GS, Patterson SH, Ching JM, Blackmore CC. Why lean doesn’t work for everyone. BMJ Qual Saf. 2014;23(12):970–3. https://doi.org/10.1136/bmjqs-2014-003248 Epub 2014 Jul 23.

Al-Balushi S, Sohal AS, Singh PJ, Al Hajri A, Al Farsi YM, Al AR. Readiness factors for lean implementation in healthcare settings--a literature review. J Health Organ Manag. 2014;28(2):135–53. https://doi.org/10.1108/JHOM-04-2013-0083 .

Article   CAS   PubMed   Google Scholar  

Henrique DB, Filho MG. A systematic literature review of empirical research in lean and six sigma in healthcare. Total Qual Manag Bus Excell. 2020;31(3–4):429–49. https://doi.org/10.1080/14783363.2018.1429259 .

Coles E, Wells M, Maxwell M, Harris FM, Anderson J, Gray NM, et al. The influence of contextual factors on healthcare quality improvement initiatives: what works, for whom and in what setting? Syst Rev. 2017;6(1):168. https://doi.org/10.1186/s13643-017-0566-8 .

Kaplan HC, Froehle CM, Cassedy A, Provost LP, Margolis PA. An exploratory analysis of the model for understanding success in quality. Health Care Manag Rev. 2013;38(4):325–38. https://doi.org/10.1097/HMR.0b013e3182689772 .

Tay HL, Singh PJ, Bhakoo V, Al-Balushi S. Contextual factors: assessing their influence on flow or resource efficiency orientations in healthcare lean projects. Oper Manag Res. 2017;10(3–4):118–36. https://doi.org/10.1007/s12063-017-0126-3 .

Hussain M, Malik M. Prioritizing lean management practices in public and private hospitals. J Health Organ Manag. 2016;30(3):457–74. https://doi.org/10.1108/JHOM-08-2014-0135 PMID: 27119397 .

Fournier PL, Jobin MH. Understanding before implementing: the context of lean in public healthcare organizations. Public Money Manag. 2017;38(1):37–44. https://doi.org/10.1080/09540962.2018.1389505 .

Chiarini A. Risk management and cost reduction of cancer drugs using lean six sigma tools. Leadersh Health Serv. 2012;25(4):318–30. https://doi.org/10.1108/17511871211268982 .

Gonzalez ME. Improving customer satisfaction of a healthcare facility: reading the customers’ needs. Benchmarking. 2019;26(3):854–70. https://doi.org/10.1108/BIJ-01-2017-0007 .

Terra JDR, Berssaneti FT. Application of lean healthcare in hospital services: a review of the literature (2007 to 2017). Prod. 2018;28(0):e20180009. https://doi.org/10.1590/0103-6513.20180009 .

Augusto BP, Tortorella GL. Literature review on lean healthcare implementation: assessment methods and practices. Int J Serv Oper Manag. 2019;32(3):285–306. https://doi.org/10.1504/IJSOM.2019.10019746 .

Fournier PL, Jobin MH. Medical commitment to lean: an inductive model development. Leadersh Health Serv. 2018;31(3):326–42. https://doi.org/10.1108/LHS-02-2018-0015 Epub 2018 Jul 3. PMID: 30016920 .

Improta G, Romano M, Di Cicco MV, Ferrero A, Borrelli A, Verdolina C, et al. Lean thinking to improve emergency department throughput at AORN Cardarelli hospital. BMC Health Serv Res. 2018;18(1):265–78. https://doi.org/10.1186/s12913-018-3654-0 .

Kaplan HC, Provost LP, Froehle CM, Margolis PA. The model for understanding success in quality (MUSIQ): building a theory of context in healthcare quality improvement. BMJ Qual Saf. 2012;21(1):13–20. https://doi.org/10.1136/bmjqs-2011-000010 .

Kringos DS, Sunol R, Wagner C, Mannion R, Michel P, Klazinga NS, et al. The influence of context on the effectiveness of hospital quality improvement strategies: a review of systematic reviews. BMC Health Serv Res. 2015;15:277. https://doi.org/10.1186/s12913-015-0906-0 PMID: 26199147; PMCID: PMC4508989.

Hasle P, Bojesen A, Jensen PL, Bramming P. Lean and the working environment: a review of the literature. Int J Oper Prod. 2012;32(7):829–49. https://doi.org/10.1108/01443571211250103 .

Hasle P, Nielsen PA, Edwards K. Application of lean manufacturing in hospitals- the need to consider maturity, complexity, and the value concept. Hum Factors Ergon Manuf. 2016;26(4):430–42. https://doi.org/10.1002/hfm.20668 .

Narayanamurthy G, Gurumurthy A, Subramanian N, Moser R. Assessing the readiness to implement lean in healthcare institutions – a case study. Int J Prod Econ. 2018;197:123–42. https://doi.org/10.1016/j.ijpe.2017.12.028 .

Bijl A, Ahaus K, Ruël G, Gemmel P, Meijboom B. Role of lean leadership in the lean maturity - second-order problem-solving relationship: a mixed methods study. BMJ Open. 2019;9(6):e026737. https://doi.org/10.1136/bmjopen-2018-026737 .

Waring JJ, Bishop S. Lean healthcare: rhetoric, ritual and resistance. Soc Sci Med. 2010;71(7):1332–40. https://doi.org/10.1016/j.socscimed.2010.06.028 .

Arumugam V, Antony J, Kumar M. Linking learning and knowledge creation to project success in six sigma projects: an empirical investigation. Int J Prod Econ. 2013;141(1):388–402. https://doi.org/10.1016/j.ijpe.2012.09.003 .

Wilson WJ, Jayamaha N, Frater G. The effect of contextual factors on quality improvement success in a lean-driven New Zealand healthcare environment. Int J Lean Six Sigma. 2018;9(2):199–220. https://doi.org/10.1108/IJLSS-03-2017-0022 .

Gonzalez-Aleu F, Van Aken EM, Cross J, Glover WJ. Continuous improvement project within kaizen: critical success factors in hospitals. TQM J. 2018;30(8):335–55. https://doi.org/10.1108/TQM-12-2017-0175 .

Stanton P, Gough R, Ballardie R, Bertram T, Bamber GJ, Sohal A. Implementing lean management/six sigma in hospitals: beyond empowerment or work intensification? Int J Hum Res Manag. 2014;25(21):2926–40. https://doi.org/10.1080/09585192.2014.963138 .

McIntosh B, Sheppy B, Cohen I. Illusion or delusion--lean management in the health sector. Int J Health Care Qual Assur. 2014;27(6):482–92. https://doi.org/10.1108/IJHCQA-03-2013-0028 .

Jimmerson C, Weber D, Sobek DK 2nd. Reducing waste and errors: piloting lean principles at Intermountain Healthcare. Jt Comm J Qual Patient Saf. 2005;31(5):249–57. https://doi.org/10.1016/s1553-7250(05)31032-4 .

Drotz E, Poksinska B. Lean in healthcare from employees' perspectives. J Health Organ Manag. 2014;28(2):177–95. https://doi.org/10.1108/JHOM-03-2013-0066 .

Morgan SJ, Pullon SRH, Macdonald LM, McKinlay EM, Gray BV. Case study observational research: a framework for conducting case study research where observation data are the focus. Qual Health Res. 2017;27(7):1060–8. https://doi.org/10.1177/1049732316649160 Epub 2016 May 22. PMID: 27217290 .

van Rossum L, Aij KH, Simons FE, van der Eng N, Ten Have WD. Lean healthcare from a change management perspective. J Health Organ Manag. 2016;30(3):475–93. https://doi.org/10.1108/JHOM-06-2014-0090 .

Savage C, Parke L, von Knorring M, Mazzocato P. Does lean muddy the quality improvement waters? A qualitative study of how a hospital management team understands lean in the context of quality improvement. BMC Health Serv Res. 2016;16(588). https://doi.org/10.1186/s12913-016-1838-z .

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All authors discussed the results and contributed to the final manuscript. GM conceived and designed the analysis, AR contributed data and analysis tools, FL and FM suggested the background reference model. The authors read and approved the final manuscript.

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Rosa, A., Marolla, G., Lega, F. et al. Lean adoption in hospitals: the role of contextual factors and introduction strategy. BMC Health Serv Res 21 , 889 (2021). https://doi.org/10.1186/s12913-021-06885-4

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Hardy Hospital’s Materials Management Case Study

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To draw appropriate recommendations, I find it important to highlight the goals that Caroline Highgrove aims to meet in the assignment that she is given by the Director of University Operations in Hardy Hospital. Caroline, the Director of Materials Management, evaluates the flow of materials in the hospital from the store to various hospital departments and the other way around. In this discussion, I shall use the findings by Caroline to assess the efficiency of material management in the hospital. Subsequently, I shall recommend on the way forward with key consideration to strategies that help the hospital to reduce its inventory expenses.

Accordingly, the current system of operation used by the hospital in stock-keeping is ineffective. As I go thorough Caroline’s observation, I also learn that stock-keeping units order materials in different sizes and frequencies. As such, some inventories are either in excess or they run out before others come in. To regulate these stock imbalances, it is my recommendation that the hospital devises firm policies regulating all its stock-keeping units.

While implementing this strategy, it is important that employees take seriously record-keeping since these records are useful in estimating the amount of stock expenditure at different times. According to Caroline, the information system of the hospital is unreliable because some employees do not bother to enter important information into computer systems. To address this weakness, I recommend that the hospital administration gets strict on employees who show laziness in their place of work.

Also, the hospital should come up with computerized ways to make sure that employees pass orders only after completion of specific computer programs. Besides, these programs should ensure that employees receive an okay feedback from the central information system to allow them go ahead with their order.

Moreover, I note the difficulty associated with making special orders in the hospital. In this context, head nurses, doctors and departmental coordinators engage in time-consuming activities not related to their job specifications. To overcome this inadequacy, the hospital needs to use more staff to handle stocks. The new staff should work closely with departmental heads, nurses and doctors to handle particulars related to stock orders. Implementation of this recommendation allows nurses and doctors to find more time to focus on matters related to their duties, and overall, the hospital benefits from better management of its materials.

Finally, the hospital incurs a lot of expenses in ordering and storing its supplies. Also, Caroline notes that the hospital pays a single worker $20 per hour for processing a line item. In addition, the hospital pays $4.60 per square foot for its 36,750 square feet storeroom. Other annual costs for running the storeroom include $160,000 for its five employees and $200,000 for miscellaneous expenses. These expenses are expensive for the hospital, and it is my recommendation that the size of the storeroom be halved. This means that all other expenses shall be cut down by the same margin, but a problem of where to keep the other half of the stock arises.

Fortunately, increasing the storage capacity for all departments addresses this problem. This storage capacity shall be increased at the physical site of each department to avoid movements to the storeroom. Again, this move shall lessen the frequency of ordering by half, and as such, the ordering expenses are also cut down. By so doing, the hospital shall reduce its ordering and storage expenses.

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Quality and Risk

Methods for Improving Materials Management

Andrew M. Harris, MD | Chris M. Harris, DBA

July 8, 2019

Inefficiencies in the health care setting are coming into sharp focus today as attention turns to decreasing waste and increasing patient safety. The operating room is a prime location for implementing Lean processes to that end. A timed delivery Kanban card system can lead to a more-efficient use of time, staff and materials in a hospital operating room as nurses spend more time with patient care and less time ordering materials.

As health care costs continue to rise and reimbursements decline, the focus on health care efficiency is increasing,(1) including the use of Lean management principles.(2-4) These principles initially were crafted and used in the manufacturing industry to improve productivity and efficiency by eliminating waste or non-value-adding activities.(5,6) Naturally, inefficiencies exist in health care as well, and addressing waste can lead to improved productivity, increased patient safety, and positive financial outcomes.(7-9)

The operating room is likely among the most expensive areas in the health care system, but it also is responsible for significant financial contributions.(10) Indeed, these two attributes make the OR prime for Lean development, as small improvements can lead to meaningful monetary gains. Studies have shown applying Lean thinking to the OR can improve flow, efficiency, and fiscal return by identifying and eliminating waste.(1,3,10)

Lean thinking identifies seven types of waste: overproduction, unnecessary inventory, waiting, waste of transporting, over processing, defects, and unnecessary motion (see Table 1).(11) In the OR, Lean interventions tend to focus on waiting, waste of transporting, overprocessing, and defects, but not on unnecessary inventory.(3,10,11) Considering 47 to 56 percent of OR budgets can be dedicated to inventory,(1) OR inventory likely would benefit from the application of Lean methodology.

Poorly managed OR inventory may lead to increased expedited shipping charges, oversupply, expired supplies and insufficient supplies.(1,12) Precise management can lead to a 15 to 30 percent reduction in supply costs.(13)

Deficiencies in OR inventory management can lead to patient safety issues as well. Studies have found up to 20 percent of nurses’ time may be dedicated to “logistics” such as traveling, delivering, retrieving and waiting, and much of this surrounds inventory in the OR.(9,12) Consequently, nurses are pulled away from caring for the patient, likely decreasing patient safety as a result.(9) Using expired supplies and running out of supplies are also important considerations, as both could lead to patient safety issues.

Using a timed delivery Kanban card system, or TDKCS, can support Lean implementation in OR inventory management to mitigate patient risk and improve financial success.

A multidisciplinary team of OR staff members, materials staff members, a urologist (also the vice chief of staff), and administrators was formed to create a process flow map of the existing OR materials management process (see Figure 1). Under the management process, each OR nurse was assigned inventory management for a specific materials section of the OR, such as laparoscopic materials, endoscopic materials, urologic materials, and general materials. The nurses counted and monitored inventory levels and placed orders with the head of the hospital’s materials management. The department head reviewed the orders and sent them to the chief financial officer, who reviewed and modified the orders as deemed necessary.

Figure 1. Process flow map of initial or materials ordering process

The nurses shared that there was no schedule for inventory management; they counted and ordered inventory when they had time to do so. On busy days, supplies waited until the next day. If there were several busy days in a row, supplies were ordered as needed. When a nurse was absent, the other nurses tried to help with the absent nurse’s supply duties.

Par levels were used as inventory goals; those used for initial modification in this study were set arbitrarily by the using physician several years previous. The OR nurses also revealed that they often ordered more materials than needed, knowing the order would likely be modified while moving up the administrative chain. There was minimal standardization of this process.

After the ordering process was mapped and examined, multidisciplinary meetings were held to address the implementation of the TDKCS, including the concept of runners, repeaters and strangers.(14) Runners are frequently used high-volume materials; repeaters are used frequently but less often than runners;(4) strangers are infrequently used low-volume materials.(14) The decision was made to begin TDKCS implementation with the materials involved in urologic cases, as the vice chief of staff was a practicing urologist and contributed information on materials issues he had experienced. Running out of specific materials for ureteroscopy was a common problem and initial efforts were targeted in this area.

The nurses identified a few frequently used urologic materials as difficult to manage. As illustrated in Figure 2, cards were made and placed in front of the products; the products could not be removed without removing the card first. The card receptacle was located near the identified runners (see Figure 3). The new inventory was then loaded on a first-in/first-out basis, such that the newest materials were placed in the back. This area was the OR materials “supermarket.”

Figure 2. Kanban card placed in front of product

Figure 3. Kanban card receptacle

The ideal route was identified and determined to be run once or twice a day. The route consisted of the materials team picking up the cards from the receptacle, getting the supplies, and restocking the items, thus eliminating the nurses’ involvement in inventory management of these items (see Figure 4). Once the cards were in place and both the OR team and materials team were educated on the process, they began using the card system. Inventory levels, expedited freight and nursing intervention were monitored.

Figure 4. TDKCS route

The TDKCS process resulted in more accurate inventory numbers of the tracked items. Once the route was running, nurses no longer counted and ordered these items; the materials team was now solely responsible for them. As the route evolved, more items were added and challenges emerged. Initially, carts were kept out of operating rooms so the materials staff wouldn’t have to change into scrubs to run the route. However, as the number of items increased, some were available only in the ORs. Therefore, the route had to be designed to enable the materials team access to the ORs. This was done by running the route at low-volume or OR down times. As items were added to the TDKCS, specialty carts were designed to effectively and efficiently run the route. A urology cart, orthopedics cart and endoscopy cart were created to keep items separate but available. The system was continually audited for flow issues and modified as needed to improve the route so the materials team could do its job without interfering with the OR staff.

As the route matured, the materials manager was able to predict appropriate inventory levels based on real-time usage data. This allowed for increased inventory turnover and decreased excessive in-stock inventory levels. The inventory footprint decreased through better inventory tracking, as did the time nurses spent counting and ordering inventory. TDKCS nearly eliminated expedited shipping. During the first two months, expedited shipping costs decreased by 20 percent. Since implementation, none of these items has had to be ordered and shipped via expedited freight, as the materials team is aware of real-time use and can order well in advance to maintain appropriate stock levels.

Using the TDKCS has several advantages, including removing from nurses the onus of ordering, potentially increasing patient safety, improving inventory management, improving financials, decreasing expedited freight, and expending minimal cost to implement and maintain.

Interestingly, although nurses do not receive formal education on materials management in nursing school, many ORs use nurses to manage approximately 80 percent of OR inventory.(12) Consequently, ORs frequently run out of important supplies, which leads to a stressful working environment and may lead to possible patient safety issues as nurses are pulled away from patient care.(12) The card system affords nurses the opportunity to focus less on materials and more on patient care, likely contributing to better patient outcomes.(9) The OR nurses simply pull the card and place it in a bin, allowing the materials department to track the inventory and the nurses to focus on patient care, commensurate with their training.

The card system also facilitates more efficient inventory management when nurses are absent, as the system precludes the need for nurses to cover each other’s ordering responsibilities and eliminates obvious problems therein. Kanban cards are also ideal for the on-call staff, who may not be familiar with supplies used in after-hours emergent cases, as the system requires minimal knowledge of materials to function well in the operating room.

With the TDKCS, the OR materials are managed more effectively because the materials department can track the specific items in real-time. This allows for more accurate assessment of item usage rather than arbitrary par levels, permitting inventory management using a perpetual rather than a periodic system.(1) A periodic system counts inventory on a scheduled basis and maintains par levels, assuming continued average use. This system leads to inaccurate inventory, excess supplies and supplies in multiple locations.(1) The perpetual system allows for real-time updating of inventory and increased knowledge of use patterns, allowing the materials department to make better-informed decisions about ordering materials.(1) The perpetual system also precludes the need for time-consuming inventory counts.(1,12)

Improved inventory management also has positive financial implications. Twelve inventory turnovers a year is the current recommendation to carry less product and decrease waste.(15) But, the typical operating room turns over inventory 2½ times a year, at most, highlighting a clear area for improvement.(15) Using a real-time inventory management system and stocking on a first-in/first-out basis reduces waste by limiting excess and expired supplies.(1) Ordering based on a real-time use likely leads to increased inventory turnover and less inventory in the hospital. Because in-house and expired materials do not produce income, higher inventory turnover leads to improved monetary gains.(1,12)

The TDKCS has advantages over other inventory management systems as well. The system was perfected by Toyota, arguably one of the leading Lean manufacturing systems,(16) is taught around the manufacturing world, and is considered the gold standard of waste elimination and efficient materials flow.(6,17) Initiation requires minimal startup cost and no additional personnel.(17) Rather than hiring new staff and implementing costly technological systems, the organization can rearrange current staff and materials flow.(1,12,17) The cards might need to be replaced as they become worn, and the route should be audited periodically and altered as more waste is identified and usage patterns change. However, the system is easily scalable and requires minimal upkeep.

There are disadvantages to implementation of the TDKCS as well, including barriers to adoption. In this case, the rapport between materials management and the OR staff was amenable during multidisciplinary meetings; however, trust was questionable. The OR staff’s primary concern was running out of supplies, in part because of the potential to increase patient safety issues as aforementioned — a concern the OR staff strongly reiterated. Fear of blame when supplies ran out also caused significant apprehension.

Discussions about how the OR staff prevented these issues before Lean implementation revealed that OR staff hid frequently used materials in multiple locations, including in lockers, different ORs, behind other materials, or on the wrong materials rack, all in an effort to have extras “just in case.” Other studies have confirmed similar issues in Lean implementation.(12) To build trust between the materials team and the OR staff and to instill confidence and trust in the system, the route began with six runners. Implementing the route slowly allowed monitoring for possible flow problems, which are much easier to fix with a small volume of items as opposed to the entire OR materials catalog. This method of implementation also allows staff members to quickly see how the route will work.

These “quick wins” or quick successes are paramount to establishing trust between the materials staff and the OR staff.(13) As the route continues to work as designed, trust in the system builds. More materials are then added to the TDKCS in a stepwise, methodical fashion. Lean team meetings continued after initial implementation to ensure the route was running well and to identify other runners to add based on the OR staff experiences. The staff elected to add the items most difficult to manage and monitor — likely, the items that frequently required expedited shipping or were out of stock.

Discussions after implementation revealed widespread acceptance of the system. The OR staff was pleased to have more time to focus on patient care. They were surprised that as they continued to pick materials for cases, the materials reappeared in the proper location without any effort on their part. The OR staff quickly stopped monitoring these items and handed over the job to the materials team. Job satisfaction increased and the stress level in the workplace decreased.

The materials team also mentioned benefits to the system (see Table 2). Specifically, tracking and counting the high-volume materials became more manageable. Team members quickly stopped worrying about excess, hidden inventory; incidents of urgently running materials up to the OR slowed dramatically; and the need to drive to other hospitals to borrow materials stopped.

Physician involvement in materials management is likely among the most efficient methods to reduce costs and contribute to success in the supply chain.(18,19) Other studies have stressed the importance of physician involvement in Lean implementation in the OR as well, involving both materials flow and patient flow through the OR process.(1,3,10,12,13) Additional quality studies in academic journals are needed to promote physician involvement in Lean implementation, as most current literature is published in journals infrequently read by physicians.(1) As hospitals continue to evolve and become “Leaner,” physician involvement likely will become increasingly important. This will not only benefit the hospital, but also might allow physicians to be part of this change rather than subject to it.

It is important to remember that Lean implementation encompasses several components, such as level scheduling, materials flow, workplace organization, information flow, operator and machine balance charts, supplier development, and identifying the seven types of waste.(1,3,10,11,14,20,21) Knowing where to begin can be difficult. Some Lean experts advise starting the Lean process by developing an efficient materials flow system for two primary reasons:

Inefficient flow of materials makes the proficient flow of other processes difficult.

Materials often take substantial capital and improvements lead to tangible monetary gains.(17)

Initially, waste in the materials process should be identified by using a process flow map, as illustrated in this study, which has been shown to effectively identify waste in manufacturing as well as in medicine.(17,22) Once waste is identified, a plan to remove the waste can begin to form.

This study was conducted in a small hospital, which may call into question the ability to generalize. A smaller hospital likely lends itself to easier implementation, team involvement, and route identification and flow. However, this method of materials management also has been effectively implemented in very large manufacturing environments with high volume materials turnover.(17) Nonetheless, further studies on materials management in the OR using this system are needed to confirm widespread applicability.

The Lean implementation team also sought guidance from a Lean professional (or sensei ) in materials flow with more than 10 years of experience, which might not be immediately available at all institutions. This Lean team also had an engaged and willing physician, who was also the vice chief of staff, to help with implementation and to help other surgeons get involved in Lean thinking. The initial materials targeted were those pertaining the vice chief of staff’s service and this likely contributed to the success. Willing physicians might not be available at all institutions, which may be a barrier to success.

Conclusions

Applying Lean principles to OR materials management using the TDKCS can be effectively implemented at minimal cost with desirable benefits. The TDKCS decreases waste and possibly leads to improved patient safety, fewer expired products, improved inventory management, increased nursing availability for patient care and improved financials. A multidisciplinary team involving all aspects of materials flow is crucial to success. Consideration of implementing this system is encouraged in other ORs as well as in other hospital areas.

Park KW, Dickerson C. Can efficient supply management in the operating room save millions? Curr Opin Anaesthesiol 2009;22(2):242-8.

“Going Lean in Healthcare.” IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement, 2005.

Collar RM, Shuman AG, Feiner S, et al . Lean management in academic surgery. J Am Coll Surg 2012;214(6):928-36.

Womack JP and Jones DT. Lean Thinking: Banish Waste and Create Wealth in Your Corporation . 1st Free Press ed. New York, NY: Free Press, 2003.

Waring JJ, Bishop S. Lean healthcare: rhetoric, ritual and resistance. Soc Sci Med 2010;71(7):1332-40.

Womack JP, Jones D, Roos D. The Machine That Changed the World: The Story of Lean Production. New York, NY: Free Press, 2007.

Leslie M, Hagood C, Royer A, et al . Using Lean methods to improve OR turnover times. AORN J 2006;84(5):849-55.

Sieber TJ, Leibundgut DL. Operating room management and strategies in Switzerland: results of a survey. Eur J Anaesthesiol 2002;19(6): 415-23.

Vesely R. Linking patient safety and the supply chain. Health care systems are integrating new patient-centered processes into delivery. Health Facil Manage 2015;28(12):37-9.

Cima RR, Brown MJ, Hebl JR, et al. Use of Lean and Six Sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center. J Am Coll Surg 2011;213(1):83-92; discussion 93-4.

Kasivisvanathan R, Chekairi A. The productive operating theatre and Lean thinking systems. J Perioper Pract 2014;24(11):245-8.

Graham J, Brewer MS, Byrd VT. Automating the supply chain in the OR. AORN J 1999;70(2):268-76.

Bilyk C. Don’t break the chain: importance of supply chain management in the operating room setting. Can Oper Room Nurs J 2008;26(3):21-22, 30-24.

Harris C, Harris R. Lean Connections: Making Information Flow Efficiently and Effectively . Boca Raton, FL: CRC Press, 2008.

Melson LM, Schultz MK. Overcoming barriers to operating room inventory control. Healthc Financ Manage 1989;43(4):28, 30-2, 34.

Krafcik J. The triumph of the lean production system. Sloan Manage Review 1988;30(1):41-52. https://www.lean.org/downloads/MITSloan.pdf

Harris R, Harris C, Wilson E. Making Materials Flow: A Lean Material-handling Guide for Operations, Production Control, and Engineering Professionals . Brookline, MA: The Lean Enterprise Institute, 2003.

Williams J. Dollars and sense engaging physicians in supply-cost control. Healthc Financ Manage 2007;61(4):62-8.

Feistritzer NR, Keck BR. Perioperative supply chain management. Semin Nurse Manag 2000;8(3):151-7.

Rother M, Harris R. Creating Continuous Flow. Brookline, MA: The Lean Enterprise Institute, Inc., 2001.

Harris C, Harris AM, Harris R. The blessings of a level schedule. Industrial Management 2015;57(6):6-19.

Harris C, Harris AM. Using lean manufacturing to improve patient care in a rural urological practice. Physician Leadersh J 2015;2(6):18-20.

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Possibilities and Benefits of Using Material Flow Information to Improve the Internal Hospital Supply Chain

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• Giuseppe Ismael Fragapane   ORCID: orcid.org/0000-0001-8915-509X 19 ,
• Aili Biriita Bertnum   ORCID: orcid.org/0000-0003-3092-5760 19 &
• Jan Ola Strandhagen   ORCID: orcid.org/0000-0003-3741-9000 19  

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The concept of Supply Chain Management has become increasingly important in healthcare and notably in hospitals. Information along the supply chain is the key element for analysis and improvement purposes. The aim of the study is to analyze and visualize the material flow at a Norwegian hospital to identify the possibilities and benefits in current and future planning and operation. The integration of IT enables combining material and information flow. Statically analyses of the material flow can support in planning and control of the logistics activities. The visualization of the material flow can support to take long-term decisions e.g. for distributing departments at the hospital.

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1 Introduction

The concept of Supply Chain Management (SCM) has become increasingly important in healthcare and notably in hospitals. The primary objective of SCM is “to integrate and manage the sourcing, flow, and control of materials using a total systems perspective across multiple functions and multiple tiers of suppliers” [ 1 ]. While literature concerning SCM on a strategic level is extensive, less academic literature focuses on tactical and operational challenges particular to the healthcare industry [ 2 ].

One of the key challenges and barriers for effective SCM in the healthcare industry is the lack of capital to build a sophisticated Information Technology (IT) infrastructure supporting supply chain operations [ 3 ]. Information along the supply chain is the key element for analysis and improvement purposes. In order to benchmark and measure performance improvements, it is important to define measures that track both material activities and related costs, and supply chain performance related to the core activity, patient care [ 2 ].

A recent literature review by Volland et al. [ 4 ] suggests that the availability of information across the supply chain can lead to more integrated supply chain concepts for hospitals. There is a need to understand how consistent IT systems and data standards across hospitals can improve the hospital supply chain. Several studies have shown that IT systems can improve purchasing decisions and reduce costs lowering inventory levels [ 5 ]. However, using SCM approaches in hospitals have proven to be more complex. The hospital supply chain has to manage a variety of product and service enterprises including medical consumables, pharmaceuticals, catering, laundry cleaning, waste management, home-care products, information technology, vehicle fleet management and general supplies [ 6 ]. Norwegian hospitals have started centralizing and automate both the external and especially the internal material flow [ 7 , 8 ]. Consequently, the IT and automated transportation systems collect and align a large amount of information across the supply chain.

A previous study on internal logistics in a Norwegian hospital visualized the material and information flow in order to analyze the current situation of the supply chain [ 8 ]. Several IT and sharing systems are used and materials can be tracked and controlled throughout the internal supply chain. However, the IT and automated transportation systems create a huge amount of data, mainly for monitoring and controlling purposes. This data is often not further used or analyzed for improvement purposes and is typically known as ‘idle data’ [ 9 ]. Increased computing power has facilitated the possibilities of using data analytics to discover patterns and improvement possibilities from datasets where a human would not necessarily have found a pattern.

This study aims at answering the following questions: How can visualization of material flow information improve the internal supply chain of a hospital? Further, how can the hospital supply chain benefit from an integrated IT system? The study will be based on the data collection from the previous study at a Norwegian hospital further explained in Sect.  3 .

The paper is structured as follows: Sect.  2 provides a background on related literature within hospital logistics and SCM. Section  3 presents an overview of the case hospital supply chain, followed by a description of the methodology. In Sect.  4 , the results of the statistical analysis are presented, which are further discussed in Sect.  5 . This research will end with recommendations for further improvements for the case hospital and future research within this topic.

2 Theoretical Background

Over the past 20 years, there has been an increase in healthcare expenditures in all OECD countries [ 10 ], which has motivated to improve the healthcare sector. A study by Poulin et al. [ 11 ] state that half of the logistics costs can be eliminated with efficient logistics management. Furthermore, Volland et al. [ 4 ] state that increasing logistics efficiency might not directly influence patient care but may give medical staff more time for patient related activities. It is important to recognize that logistics activities have an impact on the overall performance of the hospital [ 12 ].

Polater et al. [ 13 ] describe a hospital supply chain as “a complex system that requires the flow of products and services, in order to satisfy the needs of those who serve patients”, with the aim to “deliver products at the right time, for the purpose of fulfilling the requirements of those providing healthcare”. The hospital can be divided into an external and internal supply chain. The internal supply chain has to establish its own logistics network that correlates with external suppliers in order to supply the customer, in this case, the patient [ 14 ]. According to Volland et al. [ 4 ], the external supply chain has been received the most attention, while the internal supply chain is the weak spot in the hospital supply chain. Granlund and Wiktorsson [ 12 ] argue that the performance of the internal supply chain highly affects the overall performance, and remark the importance of continuous improvement in order to achieve increased competitiveness.

The focus of internal logistics is to provide supplies to the company’s core activities, which for hospitals is patient care. Logistics and material handling are described as an extensive and important part of the healthcare sector, but it is far from the sector’s core competencies [ 12 ]. A high variety of materials is often required in a hospital, which usually leads to complex logistics activities. In addition, different departments are responsible for various procurement activities, e.g. food services are responsible for the food supply, while pharmacy services are responsible for managing the procurement of pharmaceuticals, etc. [ 11 , 15 ], further increasing the complexity of SCM.

Introducing automation to logistics activities in the healthcare sector is viewed as a measure for improving efficiency and productivity [ 16 ]. The main challenges are knowledge transfer and adoption to technology, rather than the absence of available technology. Due to the complexity of the system, it is often difficult to establish central management and a consensus regarding the purpose of the system fitting all actors. It is crucial to distribute tasks and responsibilities appropriately, demonstrate the ability to have a comprehensive view on the planning process and to implement strategies and technologies on the basis of long-term benefits [ 12 ].

Several decisions and changes in hospitals have made the Automated Guided Vehicle (AGV) system a success and standard for material transportation in Norwegian hospitals. An AGV system can be defined as a driverless transportation system that is used for horizontal movement of materials, allowing for flexible material handling [ 17 , 18 ]. Some of the advantages of implementing an AGV system are increased productivity and flexibility, cost efficiency, savings in labor costs, reduced emissions and energy consumption, and improved safety [ 19 ]. In general, success factors for the implementation of automation in hospitals include benchmarking, learning from other industries, involving hospital personnel, and identifying the internal logistics functions. Therefore, available data about hospital logistics is crucial. While there has been a strong interest in establishing patient data, data of material flow are still less used and analyzed.

The Nordic countries are leading in eHealth applications. The number of general practitioners using electronic health records is among the highest in Europe [ 20 ]. While it is well known that IT in healthcare and social services have the potential to improve the welfare and efficiency of systems, the potentials of IT technologies to improve hospital logistics are still scarcely explored in hospitals. According to Johns [ 21 ], Information and communication technology (ICT) is an important tool for increasing competitiveness in the healthcare industry. Furthermore, ICT can help for total integration of healthcare systems.

3 Methodology

This study has used the mixed methods approach, combining qualitative and quantitative methods in order to strengthen the credibility of the results. More precisely, the methodology used is triangulation being one of the most common mixed methods designs. It is described as “the use and combination of different methods to study the same phenomenon” [ 22 ] and aims to “validate quantitative statistical findings with qualitative data results” [ 23 ]. The research design consists of a case study and literature study. A literature study was conducted to establish the state-of-the-art on hospital supply chain, internal transportation in hospitals, and IT supporting hospitals. Observations and semi-structured interviews were performed to give an understanding of the case hospital and internal supply chain.

The case study was carried out in a large Norwegian hospital that has a capacity of 800 beds. The hospital implemented and launched an automated material handling system in 2009. Today, the automated material handling system consists of 21 AGVs, transporting approximately 50–70 tons of goods every week between 114 pick-up and delivery stations in different buildings, at different levels and departments. Daily, 500–650 containers are transported by the AGV system. The AGV system is operated with a centralized structure.

A transportation schedule for the AGV system has been defined based on simulations, hospital layout, and battery management and maintenance. This schedule has been adapted to changing demand of goods over the years. Orders are dispatched to the nearest AGV. This dispatching rule was chosen to reduce AGV idle transportation time. The hospital has integrated a radio frequency communication system, connecting the different buildings, doors and elevators with the AGV system. The AGV can lift and move the wagons within the 4500-m guide-path that connects all departments. AGVs can operate continuously for approximately three hours and is then sent to be charged for one hour.

Several individual and group interviews have been conducted with employees from both the operating and planning departments of the hospital. The positions of the interviewed hospital employees are Technical System Administrator, Supply Planner, Operating Manager, and Operating Technician. Based on the data received from the case hospital, a statistical analysis of the material transportation was conducted. The data represents the internal material transportation from October 2017 until March 2018.

Based on the data retrieved from the AGV system of the case hospital, information about the material transportation were analysed to investigate the variety of transportation times and locations within the hospital. Figure  1 shows the average waiting and delivery times during the main hospital operation hours. During these hours, the following material groups are transported and supplied within the hospital: consumer and medical goods from both external suppliers and the central warehouse, waste, laundry, sterile goods, and food.

AGV transportation time during an average day of operation.

The pattern of transported goods is documented and clearly recognizable (see Fig.  2 ). Further, the material data provide insights about material supply during the different weekdays. The daily average amount of containers picked and delivered by the AGV at the different buildings within the hospital can be seen in Fig.  4 . Goods arrival and disposal is located in building 10, and clearly represents the highest volume of hospital material movement. Building 2 follows where the kitchen, central sterilization service, and the emergency department are located. Laboratories and specialized departments of the hospital are located in the rest of the buildings, with a considerably lower volume of material movement (Fig.  3 ).

Material groups transported and supplied within the case hospital during an average day

Average amount of containers picked and delivered at the different buildings within the case hospital per day.

Amount of containers picked and delivered, visualized in the case hospital layout.

5 Discussion and Conclusion

The hospital supply chain has high requirements for quality of services where timely delivery of materials is one of them. Lack of timely delivery of materials can have negative effects for a patient seeking treatment and care in a hospital. Sterile goods used in the operation departments must be delivered on time to ensure availability for any planned or acute medical operation. Patients need to receive their food within a certain time period in order to be ready for further operations or treatments.

The statistical analysis shows the transportation time of materials by AGVs in the case hospital. In general, the total transportation time varies throughout the day. While the average delivery time is rather stable, the waiting times are quite long at certain periods of the day. This can decrease the delivery precision of materials, which can lead to negative consequences for the patients. It can be argued that the waiting time is influenced by both transportation volume and AGV capacity in the specific periods. Balancing the transportation volume or combining deliveries to reduce the transportation volume are possible approaches for achieving timely delivery. This is possible since materials and respectively material groups transported and supplied during the operation hours of the case hospital varies strongly.

Changing the timely supply of materials can have critical consequences in hospitals. According to Abdulsalam et al. [ 24 ], the healthcare supply chain is more fragile on critical supplies compared to other industries. Some materials and products must always be available in case of an emergency. It can be critical or fatal if the patient cannot receive instantly treatment due to missing supplies. Even though customization is an increasing trend in most industries, some supplies in the hospital supply chain are highly customized and are one-of-kind products for one certain patient [ 25 , 26 ]. Often are a large number of actors involved in the hospital supply chain with different interests when supplying materials or products [ 24 ]. Thus, the hospital supply chain can be described as highly fragmented, which can prevent from operating as a system [ 26 ].

In general, not all materials moved within hospitals can be captured by the ICT system. Centralizing the material flow with the AGV system in a hospital can support to link the information along the supply chain and visualize the main material movements. The statistical analysis and the visualization of the material flow within the case hospital provide new opportunities to improve the timely delivery of materials and the performance of the internal hospital supply chain. Information derived from the statistical analysis supports the identification of material groups that can rather be moved outside of the overloaded operation hours.

The traceability and tracking of materials within the case hospital have been demonstrated in a previous study [ 8 ]. The integration of IT technologies in hospitals enables to combine the material and information flow along the supply chain and therefore to identify critical products. These measures help to identify and decide whether products can be transported in a different period or not. Visualizing the material flow in hospitals can support decision-makers in scheduling the material flow on a tactical level to balance the internal material flow to increase the timely delivery of materials. In the case hospital, the material traffic is strongly one-sided distributed.

The current policy in several countries is to expand larger hospitals and restructure them, and simultaneously close smaller hospitals [ 27 ]. The insights of the material flow information can support in deciding where to place new departments or where to move current departments. Decisions on centralizing or decentralizing, insourcing or outsourcing departments or inventories, and changing the time period of internal material supply can also be based on a statistical analysis of material flow. Future research should focus on how to link information both material flow and electronic health records to further improve decision-making and performance of hospitals. Thus, electronic health records can be integrated and be input for forecasting and planning the material flow.

Monczka, R.M., et al.: Purchasing and Supply Chain Management. Cengage Learning, Boston (2015)

Google Scholar  

McKone-Sweet, K.E., Hamilton, P., Willis, S.B.: The ailing healthcare supply chain: a prescription for change. J. Supply Chain Manag. 41 (1), 4–17 (2005)

Article   Google Scholar  

Burns, L.R.: The Health Care Value Chain: Producers, Purchasers, and Providers. Jossey-Bass, San Francisco (2002)

Volland, J., et al.: Material logistics in hospitals: a literature review. Omega 69 , 82–101 (2017)

Kumar, S., DeGroot, R.A., Choe, D.: Rx for smart hospital purchasing decisions: the impact of package design within US hospital supply chain. Int. J. Phys. Distrib. Logist. Manag. 38 (8), 601–615 (2008)

Gattorna, J.: Strategic Supply Chain Alignment: Best Practice in Supply Chain Management. Gower Publishing Company, Boston (1998)

Ullrich, G.: Automated Guided Vehicle Systems. Springer, Heidelberg (2015). https://doi.org/10.1007/978-3-662-44814-4

Book   Google Scholar  

Fragapane, G.I., et al.: Material distribution and transportation in a norwegian hospital: a case study. In: IFAC INCOM 2018, 16th IFAC Symposium on Information Control Problems in Manufacturing, Bergamo, Italy (in press)

Schmidt, R., Möhring, M., Härting, R.-C., Reichstein, C., Neumaier, P., Jozinović, P.: Industry 4.0 - potentials for creating smart products: empirical research results. In: Abramowicz, W. (ed.) BIS 2015. LNBIP, vol. 208, pp. 16–27. Springer, Cham (2015). https://doi.org/10.1007/978-3-319-19027-3_2

Chapter   Google Scholar  

OECD: Fiscal Sustainability of Health Systems (2015)

Poulin, É.: Benchmarking the hospital logistics process. CMA Manag. 77 (1), 20 (2003)

Granlund, A., Wiktorsson, M.: Automation in internal logistics: strategic and operational challenges. J. Logist. Syst. Manag. 18 , 538–558 (2014)

Polater, A., Bektas, C., Demirdogen, S.: An investigation of government and private hospitals’ supply chain management. In: 2014 International Conference on Advanced Logistics and Transport (ICALT) (2014)

Rivard-Royer, H., Landry, S., Beaulieu, M.: Hybrid stockless: a case study: lessons for health-care supply chain integration. Int. J. Oper. Prod. Manag. 22 (4), 412–424 (2002)

Ozkil, A.G., et al.: Service robots for hospitals: A case study of transportation tasks in a hospital. In: 2009 IEEE International Conference on Automation and Logistics (2009)

Bačík, J., et al.: Pathfinder-development of automated guided vehicle for hospital logistics. IEEE Access 5 , 26892–26900 (2017)

Vis, I.F.A.: Survey of research in the design and control of automated guided vehicle systems. Eur. J. Oper. Res. 170 (3), 677–709 (2006)

Article   MathSciNet   Google Scholar  

Mehrabian, A., Tavakkoli-Moghaddam, R., Khalili-Damaghani, K.: Multi-objective routing and scheduling in flexible manufacturing systems under uncertainty. Iran. J. Fuzzy Syst. 14 (2), 45–77 (2017)

MathSciNet   MATH   Google Scholar  

Bechtsis, D., et al.: Sustainable supply chain management in the digitalisation era: the impact of Automated Guided Vehicles. J. Clean. Prod. 142 , 3970–3984 (2017)

Bergstrøm, R., Heimly, V.: Information technology strategies for health and social care in Norway. Int. J. Circumpolar Health 63 (4), 336–348 (2004)

Johns, P.M.: Integrating information systems and health care. Logist. Inf. Manag. 10 (4), 140–145 (1997)

Chris, V., Nikos, T., Mark, F.: Case research in operations management. Int. J. Oper. Prod. Manag. 22 (2), 195–219 (2002)

Hesse-Biber, S.N.: Mixed Method Research - Merging Theory with Practice. The Guilford Press, New York (2010)

Abdulsalam, Y., et al.: Health care matters: supply chains in and of the health sector. J. Bus. Logist. 36 (4), 335–339 (2015)

Dobrzykowski, D., et al.: A structured analysis of operations and supply chain management research in healthcare (1982–2011). Int. J. Prod. Econ. 147 , 514–530 (2014)

Rimpiläinen, T.I., Koivo, H.: Modeling and simulation of hospital material flows. In: Tenth International Conference on Computer Modeling and Simulation, UKSIM 2008. IEEE (2008)

Giancotti, M., Guglielmo, A., Mauro, M.: Efficiency and optimal size of hospitals: Results of a systematic search. PLoS ONE 12 (3), e0174533 (2017)

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Acknowledgement

This research received funding from the strategic research area NTNU Health in 2018 at NTNU, Norwegian University of Science and Technology. The authors also gratefully acknowledge the case hospital that made it possible to carry out this study.

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Giuseppe Ismael Fragapane, Aili Biriita Bertnum & Jan Ola Strandhagen

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Fragapane, G.I., Bertnum, A.B., Strandhagen, J.O. (2019). Possibilities and Benefits of Using Material Flow Information to Improve the Internal Hospital Supply Chain. In: Ameri, F., Stecke, K., von Cieminski, G., Kiritsis, D. (eds) Advances in Production Management Systems. Towards Smart Production Management Systems. APMS 2019. IFIP Advances in Information and Communication Technology, vol 567. Springer, Cham. https://doi.org/10.1007/978-3-030-29996-5_28

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Describes one approach to meeting the health‐care cost reduction challenge through the hospital materials management function. Highlights the value of taking a proactive stance to meet the challenge; transferring technology across industry sectors, such as employing a just‐in‐time inventory management system in clinical areas of hospital materials management, and adopting a win‐win managerial philosophy. Features a case study to demonstrate the ideas in practice.

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Heinbuch, S.E. (1995), "A case of successful technology transfer to health care: Total quality materials management and just‐in‐time", Journal of Management in Medicine , Vol. 9 No. 2, pp. 48-56. https://doi.org/10.1108/02689239510086524

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Logistics in hospitals: a case study of some Singapore hospitals

Affiliation.

• 1 School of Mechanical and Aerospace Engineering, Nanyang Technological University, Singapore.
• PMID: 20690464
• DOI: 10.1108/17511870710764041

Purpose: The purpose of this paper is to investigate logistics activities in Singapore hospitals. It defines various types of activities handled by a logistics division. Inventory management policy and the use of information and communication technologies (ICT) for logistics purposes are also discussed. The study identifies the nature of strategic alliances in Singapore's health care industry.

Design/methodology/approach: This study was conducted by utilizing a framework for data collection, pre-testing the questionnaire and conducting interviews. Various relevant literature was reviewed to design the questionnaire.

Findings: This study finds that logistics division carry out many related activities and some of them also provide engineering services. The hospitals make use of ICT. The hospitals are clustered under various groups to minimize the cost of operation, including the logistics related costs. However, hospitals do not see alliances with suppliers as a strategic option; rather they focus on outsourcing of logistics services. The findings also show that Singapore hospitals have a good stocking policy for both medical and non-medical items so that changes in patient mix can be easily handled.

Originality/value: Singapore is continuously improving its health care industry and therefore, the findings will help hospitals in other regions to adopt some of the practices, like concentrating on local vendors, outsourcing, clustering, and maximum use of information technology as competitive factors that can improve the service and reduce the cost of operation. The paper suggests motivators and barriers to the use of ICT in logistics in the health care industry.

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This success story serves as an inspiring example for other healthcare facilities looking to overcome similar challenges and enhance their service delivery. With the right tools and strategies, hospitals can significantly improve their operational efficiency and patient satisfaction, ultimately contributing to better overall healthcare outcomes. 

Use the Case Studies filter to read more success stories in our Journal . 

1. "Legacy Systems And The Impact on Patient Logistics and Care" February 2024 https://www.vectorcare.com/journal/legacy-systems-and-the-impact-on-patient-logistics-and-care

2. "The Vital Role of NEMT in Enhancing Health Outcomes" May 2024 https://www.vectorcare.com/journal/the-vital-role-of-nemt-in-enhancing-health-outcomes

3. "Reducing The Administrative Burden: How Technology Can Empower Healthcare Professionals" September 2023 https://www.vectorcare.com/journal/how-technology-can-empower-healthcare-professionals ‍

4. "https://www.vectorcare.com/journal/why-choose-a-tech-driven-transportation-marketplace" July 2024 https://www.vectorcare.com/journal/why-choose-a-tech-driven-transportation-marketplace

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