Purpose Numerous and diverse organizations have implemented lean principles and practices, which concentrate on improving the efficiency of business processes by reducing cost, waste, consumptions and effort. However, previous assessments have not focused on the leanness of the supply chain in a health-care setting. This paper aims to introduce a method for assessing the successful implementation of lean principles and tools in a supply chain. Furthermore, this paper validates the method in a health-care organization. Design/methodology/approach This paper starts with an extensive literature review on assessing leanness and using multi-grade fuzzy logic. Then, a conceptual model was developed to measure leanness. The conceptual model was validated by discussing the initial version with select academic experts, especially those who deal with leanness in health-care organizations. After responding to the experts’ valuable comments, the health-care organization that is the focus of this case study was chosen based on two criteria. The first criterion was the organization’s ability to participate in the study, and the second was the organization’s commitment to implementing lean principles. These criteria were important to ensure the organization had the necessary foundation for implementing change initiatives such as lean process improvements. Next, a multi-grade (multi-attributes) fuzzy logic was used for leanness measurement. A leanness index was calculated, and the results were validated using experts from the case study organization. Finally, the weaker areas of the organization’s processes were identified to point the way for further improvements. Findings The assessment indicated that the case study organization is not lean. The organization’s weaker attributes were identified, and improvements have been suggested. Research limitations/implications This study focused on a single health-care organization, which was selected from a limited pool of potential organizations, namely, organizations which are accredited by both the Saudi Central Board for Accreditation of Healthcare Institutions and the Joint Commission International. The scope of future research should be extended to multi-case studies to enhance the findings presented in this paper. This paper’s findings can be used to help decision-makers at health-care providers to implement lean thinking in supply chain processes. Practical implications This research may be interest to practicing supply chain managers, as it proposes what enablers, factors and attributes should be emphasized in lean implementation. The proposed model can work as an assessment tool to identify the gap between the present level of leanness and the desired leanness state so the health-care organization can identify what can be improved. This model enables decision-makers in hospital supply chain to take suitable actions for improving lean implementation level. Originality/value This study makes an original contribution to the body of research concerning lean principles; the study developed a conceptual model for leanness assessment that can be applied to the supply chain of health-care organizations. Indeed, the conceptual model is likely to be useful for assessing leanness outside of the health-care field, which suggests avenues for future research.

Purpose -The main purpose of this paper is to present lean implementation in hospital supply chain management (HSCM) and propose a new conceptual framework tailored specifically to the needs of Saudi healthcare organizations. Design/methodology/approach -This paper starts with an in-depth review of existing frameworks or models for lean implementation in healthcare in general and in the HSCM specifically. Based on the literature studies and taking experts' opinions into account, a new framework for lean implementation in the Saudi HSCM is presented. Findings -A new lean implementation framework is therefore offered to decision makers in the healthcare organization for implementing a lean approach in HSCM practices. Research limitations/implications -This study focused on healthcare organizations, which were selected from hospitals operated by ministry of health and only those hospitals that are accredited by both the Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI) and the Joint Commission International (JCI). The framework is limited to Saudi healthcare. Practical implicationsThe LSCM framework is easy to understand and use without much complexity. This simplicity makes the LSCM applicable in healthcare settings. Further, LSCM was validated in three different hospitals, and it helped them to identify and improve their non-added activities, thereby readying them for lean deployment in HSCM.. Originality/value -little attention has been paid to implementing a lean approach by healthcare providers in developing countries. This study presents a new framework that is considered the first of its kind for implementing lean in HSCM in Saudi. This framework could help HSCMs' decision makers to implement lean successfully in HSCM practices.

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Objective To assess the usefulness of serum ferritin and soluble interleukin-2 receptor (sIL-2r) levels as markers of disease activity in childhood systemic lupus erythematosus (cSLE) and their role in screen for subclinical macrophage activation syndrome (MAS). Patients and methods This is a cross-sectional analysis of prospectively collected data. Consecutive children who met the Systemic Lupus International Collaborating Clinics (SLICC) criteria were enrolled between June 2015 and June 2017. All patients interviewed and assessed for disease activity using SLE disease activity index (SLEDAI). Biochemical and serological tests including markers of disease activity and MAS were measured by standard laboratory procedure. Results A total of 31 (25 female; 6 male) consecutive cSLE patients with a mean age of 10.6 (±3.2) years were included. The most frequent manifestations were mucocutaneous and musculoskeletal (84%) followed by hematological (64.5%) then renal involvement (58%). Twenty-two patients had active disease (SLEDAI ≥ 4), with a mean of 9.8. Mean serum ferritin and sIL-2r were 555 (±1860) and 2789 (±1299) respectively. Both correlated significantly with leucocyte, platelet count, transferrin, C3 and SLEDAI ( p < 0.05). Additionally, sIL-2r had positive correlation with ANA, ds-DNA and C4. Both ferritin and sIL-2r had weak correlation with ESR, but no correlation with CRP. Twelve patients had a recent infection. However, they were comparable to patients without infection with regard to all clinical and laboratory features. Three patients had MAS proved by bone marrow aspiration. Conclusion Measurement of serum ferritin and sIL-2r might help in assessing disease activity of cSLE. Both might be good screening markers for MAS in cSLE. A larger prospective study is required to allow more definitive conclusions.

BackgroundChildren with lupus nephritis particularly, diffuse proliferative and membranous glomerulonephritis, may necessitate potent immunosuppressive medications and occasionally combined therapy.ObjectiveTo report the beneficial effects of tacrolimus (TAC) in children with refractory lupus nephritis from a single tertiary pediatric rheumatology clinic.MethodsThis is a retrospective case series of children with refractory lupus nephritis treated with TAC after failure of aggressive immunosuppressive treatment. All patients were evaluated at the time of initiation of TAC and at last follow-up visit by assessing the following response parameters: cSLE Disease Activity Index (SLEDAI), urine protein/creatinine ratio, urine sediments, serum albumin, complement (C3 and C4), anti-double-stranded DNA (dsDNA) antibody levels, and renal function assessed by glomerular filtration rate (eGFR).ResultsThree children (two girls and one boy) with lupus nephritis and persistent nephrotic-range proteinuria failed prednisone treatment as well as sequential treatment of cyclophosphamide, mycophenolate mofetil (MMF), and rituximab. When TAC was administered along with MMF and prednisone, all patients showed improvement in response parameters, namely, SLEDAI, serum albumin, and proteinuria, and prednisone doses were significantly weaned off and discontinued in two patients. However, eGFR remained stable during the treatment period. TAC was well tolerated, and no adverse effects were observed.ConclusionTAC combined with MMF can be considered as an alternative therapeutic option for children with refractory lupus nephritis particularly those with persistent nephrotic-range proteinuria.