“…Similar results can be obtained in other contexts knowledge intensive, as the field of health care with the implementation of lean culture (Toussaint et al, 2013), the lean approach requires new habits and new skills, lean concept is not a destination but a journey, which involves an insatiable quest for improvement, so lean philosophy and lean manufacturing are closely linked to continuous improvement and, both with improved operating performance (Toussaint et al, 2013;Monge et al, 2014aMonge et al, , 2014bMurugesan et al, 2012;Vinohd et al, 2012;Koenigsaecker, 2009;Cooper et al, 2008), while Murugesan et al, (2012) and Vinohd et al, (2012) indicate that achieving greater operational efficiency obtained through lean manufacturing has a significant, positive and direct impact on the competitive advantages of the business including: quality at first intention, reduced delivery times and productivity gains (Ghosh, 2013;Monge et al, 2014aMonge et al, , 2014b.…”