The sustainability of Lean in pediatric healthcare: a realist review

Abstract

BackgroundLean is a quality improvement management system from the Toyota manufacturing industry. Since the early 2000’s, Lean has been used as an intervention for healthcare improvement. Lean is intended to reduce costs and improve customer value through continuous improvement. Despite its extensive use, the contextual factors and mechanisms that influence the sustainability of Lean in healthcare have not been well studied. Realist synthesis is one approach to “unpack” the causal explanations of how and why Lean is sustained or not in healthcare. We conducted a realist synthesis using the context (C) + mechanim (M) = outcome (O) heuristic, to further develop and refine an initial program theory with seven CMO hypotheses, on the sustainability of Lean efforts across pediatric healthcare.MethodsOur search strategy was multi-pronged, iterative, and purposeful in nature, consisting of database, gray literature, and contact with three healthcare organizations known for Lean implementation. We included primary research studies, published and unpublished case studies or reports, if they included Lean implementation with a pediatric focus and sustainability outcome. We used the Normalization Process Theory and the National Health Services Sustainability Model, an operational definition for Lean and a comprehensive definition for sustainability as guidance for data extraction and analysis. Our initial program theory with was refined using a blend of abductive and retroductive analytical processes.ResultsWe identified six published primary research studies, two published quality improvement case studies, and three unpublished quality improvement case reports. Five CMO hypotheses from our initial program theory were substantially supported after synthesis, “sense-making and value congruency,” “staff engagement and empowerment,” and the “ripple effect” or causal pathway between Lean implementation outcomes that served as facilitating or hindering contexts for sustainability. Overall, there was variation with the conceptualization and measurement of sustainability.ConclusionsThis study is the first to examine Lean sustainability in pediatric healthcare using realist methods. Future research should examine whether the predictors of implementation are the same or different to sustainability and evaluate the underlying mechanisms that influence the sustainability of Lean. There is also a need for research to develop and test conceptual models and frameworks on sustainability.Systematic review registrationPROSPERO-CRD42015032252.Electronic supplementary materialThe online version of this article (10.1186/s13643-018-0800-z) contains supplementary material, which is available to authorized users.

A realist evaluation to identify contexts and mechanisms that enabled and hindered implementation and had an effect on sustainability of a lean intervention in pediatric healthcare

“…Similar to our realist review findings [22], the degree to which mechanisms occurred was influenced by external pressures to use Lean [57], the complexity of care processes [7], the fit between Lean and local context [7, 57]; and other competing needs or demands [58], such as the constant change in healthcare environments. Early stages of implementation led by the consultancy company failed to customize Lean to local contexts, this triggered some pitfalls to the normalization of Lean in practice (e.g., feelings of disconnect, negative perceptions, resistance to Lean and a lack of support for Lean).…”

“…Phase 1 consisted of initial program theory development. Phase 2 consisted of a realist review to further develop and refine our initial program theory [22]. Phase 3, reported in this paper, was a realist evaluation to test and refine our program theory and context (C) + mechanism (M) = outcome (O) configurations (CMOcs) developed during phase 1 and 2 of this research.…”

Utilisation of tools to facilitate cross-border communication during international food safety events, 1995–2019: a realist synthesis protocol

“…This tool allows for assessment of multiple study designs concurrently, it has theoretical and content validity and it has also been tested for efficiency and reliability 41 42. To assess relevance, each document will be scored as one of the following categories (adopted from Wozney et al 43 and Flynn et al 44): (1) low/no contribution; (2) medium contribution or (3) high contribution. Evidence will also be assessed as either objective (empirical) or subjective (anecdotal).…”

Breathing exercises in people with COPD: A realist review

“…high (both high), medium (poor relevance or rigour) and low quality (both poor). Besides, the two researchers independently evaluated the methodological quality of each study using a systematic mixed method appraisal tool (MMAT; Supplementary File S3), which was Flynn et al, 2018;Pluye et al, 2009;Wozney et al, 2017). However, we did not exclude any articles of relatively poor quality so that future researchers could review all of the included studies.…”

“…The eligibility criteria of included studies were based on the rigour and relevance of the realist review (Pawson et al., 2005) and the included articles were divided into three grades, accordingly: high (both high), medium (poor relevance or rigour) and low quality (both poor). Besides, the two researchers independently evaluated the methodological quality of each study using a systematic mixed method appraisal tool (MMAT; Supplementary File S3), which was a standard tool for quality evaluation of mixed methodology, qualitative and quantitative studies, with a scoring range of 0–100% (100% if all evaluation standards were met; Flynn et al., 2018; Pluye et al., 2009; Wozney et al., 2017). However, we did not exclude any articles of relatively poor quality so that future researchers could review all of the included studies.…”