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described organizational characteristics critical to implementing Lean and to which they attributed its success so far, including: strong leadership and the importance that leaders embody qualities they are espousing, willingness to engage all levels of staff in the change process, and willingness to adjust performance measures according to new job roles. However, many noted that values and norms surrounding clinical practice are often at odds with the Lean principle of standardizing work to eliminate waste, representing the biggest challenge for physicians who are socialized into a culture where independent thinking and autonomy is valued. The availability of resources was also cited as an important factor in executing changes, including time to do one's regular work while implementing change, time to absorb new ideas and changes, and proper space configurations to support the change. Conclusions: Lean represents a non-traditional approach to managing the delivery of medical care. In a Lean operating system, value is seen first from the patient perspective and while this is a point of easy agreement, how that principle is operationalized can be fraught with challenges that must be negotiated. These challenges may be addressed in part by strong leadership and adequate resources. Further study is currently underway as the effort is extended to additional sites in the organization, with additional findings to be presented on how Lean can be successfully implemented in health care.

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