Accepted Manuscript

Assessing the readiness to implement lean in healthcare institutions – A case study

Gopalakrishnan Narayanamurthy, Anand Gurumurthy, Nachiappan Subramanian,

Roger Moser

PII: S0925-5273(17)30434-6
DOI: 10.1016/j.ijpe.2017.12.028
Reference: PROECO 6914

To appear in: International Journal of Production Economics

Received Date: 8 July 2017

Revised Date: 20 December 2017
Accepted Date: 26 December 2017

Please cite this article as: Narayanamurthy, G., Gurumurthy, A., Subramanian, N., Moser, R., Assessing
the readiness to implement lean in healthcare institutions – A case study, International Journal of
Production Economics (2018), doi: 10.1016/j.ijpe.2017.12.028.

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Assessing the readiness to implement lean in healthcare institutions – A case study

Gopalakrishnan Narayanamurthy *
Postdoctoral Research Fellow
University of St. Gallen
Mailing Address: University of St. Gallen, Dufourstrasse 40a, CH-9000 St. Gallen, Switzerland.

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E-mail: [email protected] / [email protected]
Phone: +918943687765

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Anand Gurumurthy
Associate Professor, Area of Quantitative Methods & Operations Management

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Indian Institute of Management Kozhikode (IIMK)
Mailing Address: Indian Institute of Management Kozhikode (IIMK), IIMK Campus P.O.,
Kunnamangalam, Kozhikode, Kerala – 673570, India.

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E-mail: [email protected]
Phone: +91-495-2809435
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Nachiappan Subramanian
Business and Management
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University of Sussex
Mailing Address: University of Sussex, Falmer, Brighton BN1 9SL, United Kingdom
Email: [email protected]
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Phone: +44 1273 872982

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Roger Moser
Assistant Professor of International Management
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University of St. Gallen (HSG)

Mailing Address: University of St.Gallen, Dufourstrasse 40a, CH-9000 St.Gallen, Switzerland.
Email: [email protected]
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Phone: +41 71 224 73 54

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*Corresponding Author
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Author’s Biography

Gopalakrishnan Narayanamurthy is a postdoctoral research fellow at the University of St. Gallen. His
research is in the area of healthcare operations management, process improvement, and sharing
economy. He is a recipient of 2015 Fulbright-Nehru Doctoral Research Fellowship, 2016 Emerging
Economy Doctoral Student Award (EEDSA) from Production and Operations Management Society
(POMS) and 2017 Paul R. Lawrence Fellowship from Case Research Foundation and North American
Case Research Association (NACRA). His research papers and teaching case studies have been

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published and presented in several international and national forums.

Anand Gurumurthy is an Associate Professor in the area of “Quantitative Methods and Operations

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Management (QM&OM)” at the Indian Institute of Management, Kozhikode (IIMK), Kerala, India.
Earlier, he was an Assistant Professor with the Mechanical Engineering Department of Birla Institute

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of Technology & Science (BITS) Pilani, Pilani Campus, Rajasthan, India, where he also completed
his PhD in the area of Lean Manufacturing and ME in Manufacturing Systems Engineering. He
received his BE in Mechanical Engineering from the University of Madras, India. He has around 12

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years of teaching/research experience. He started his career as a Production Engineer with one of
India’s leading industrial houses – the TVS Group. He has published around 40 papers in peer-
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reviewed national and international journals such as International Journal of Production Research, and
Production Planning & Control. He has also presented many papers in various national/international
conferences. His current research interests include application of lean thinking in other sectors,
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benchmarking, multi-criteria decision making models and operations management.

Nachiappan (Nachi) Subramanian is a Reader in Operations and Logistics Management at University

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of Sussex. Nachi is a Senior Fellow of Higher Education Academy, UK. Previously, Nachi worked at
University of Nottingham Ningbo, China for five years and at Thiagarajar College of Engineering,
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Madurai, India for twelve years. He has 17 years of academic experience and 2 years of industrial
experience. He conducted his post-doctoral research at University of Nottingham, United Kingdom
under BOYSCAST fellowship program and received Australian Endeavour Research Fellowship
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Award. He obtained career award and young scientist fellowship award from Indian government
agencies to augment his research on supply chain modelling. Nachi has published over 70 articles in
refereed journals. He guest edited several special issues in leading operations management journals.
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Nachi has supervised several undergraduate students’ dissertations, forty postgraduate dissertations
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and eight PhD student theses.

Roger Moser is Assistant Professor of International Management at the University of St.Gallen and
Adjunct Professor at IIM Udaipur. His research focuses on access-based services, global sourcing,
market entry, emerging and frontier markets in Asia, and business development. He has published in
various international journals, such as Journal of Operations Management, Journal of Supply Chain
Management, and Journal of Business Research.
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Assessing the readiness to implement lean in healthcare institutions –

A case study

Abstract

We develop a lean readiness framework and an assessment methodology to quantify the

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readiness of healthcare institutions for implementing lean. We use stakeholder theory

and work with a lean implementation team responsible for process improvement in a

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healthcare group to develop the framework. The framework uses fuzzy based input

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derived from the stakeholders of the healthcare institution to generate an overall ranking

through ideal solution technique. The assessment method derives input from the

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readiness scores shared by various stakeholders. The ranking suggests future
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improvement areas to prepare the healthcare institution for a lean implementation

project. We provide an alternative perspective of assessing the lean readiness of

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healthcare institutions before beginning a lean implementation project for both

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researchers and practitioners. Our research is the first to develop a lean readiness
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framework for healthcare institutions and demonstrate it using an assessment technique.

Keywords: Lean Operations, Readiness, Assessment, Fuzzy Logic, Healthcare

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Institution, Service.
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1. Introduction
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Recently, lean has seen numerous applications in healthcare institutions, which include

hospitals and clinics, physician practices, nursing homes, and health maintenance

organizations (e.g. Poksinska, 2010; Mazzocato et al., 2010; Hicks et al., 2015;

Narayanamurthy and Gurumurthy, 2017). Lean has been used to remove duplicate

processes and unnecessary procedures such as recording patient details in multiple

places, patients being moved to multiple wards, excessive waiting by patients for
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doctors and consultants, and uncoordinated discharge processes resulting in a longer

length of stay than necessary (Radnor, 2011). According to Radnor et al. (2012), 35% of

process improvement publications are in the context of healthcare. Therefore, lean as a

tool has a huge potential to drive healthcare reforms.

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Despite the wide application of lean in healthcare, the success rate has remained

very low. Past experiences of lean implementation projects in healthcare institutions

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show that failure rates range between 50 percent and 95 percent (Thelen, 2016). We

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identified the following three major reasons from literature for the large proportion of

failures:

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Absence of adaptation - Metrics on process boundaries, roles and
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responsibilities, operational processes, customer expectations, demand and

variation, as well as strategy are subjective and perceptual in service

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organizations (Radnor, 2011). Especially for knowledge-intensive service

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sectors such as healthcare, the reasons for the introduction of lean practices

focusing on improving the value, process and flow are not clear (Radnor and
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Bucci, 2007). This lack of adaptation of the lean concept to service contexts
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such as healthcare increases the probability of failure.

Lack of readiness - Articles published in literature have discussed the

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importance of readiness aspects and have agreed that being ready for lean
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implementation is a prerequisite to be successful in the roll out of lean projects

(e.g. Gurumurthy et al., 2013; Garza-Reyes et al., 2015), especially in the health

care sector (e.g. Radnor, 2011; Al-Balushi et al., 2014). Lean sensei and

consultants attribute the failure to already existing inefficiencies in the

management systems rather than concerns brought about by introducing the lean

elements to the firm (Wilson, 2013). For instance, the lack of knowledge about

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the lean concept, the lack of a system to resolve employee issues, or the absence

of appropriate training systems, etc. have been found to be among the major

sources of lean implementation failures.

Even though lean implementation can start at the fringe of an organization and

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grow organically if successful (bottom-up approach), a decision to adopt lean is

an organization wide (i.e. healthcare institution wide) initiative strategically

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taken by the top management (top-down approach). Hines et al. (2008) and

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Bhasin (2012) affirm that any strategy including lean, regardless of its strengths,

will not be accepted if it is outside an organization’s culture. As adopting lean is

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highly resource intensive (e.g. time, labor, money, etc.), the top management of
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a healthcare institution wants to do it right the first time (a practice in lean) by

investing sufficiently in becoming ready for a lean implementation project

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through putting an appropriate culture and infrastructure in place. Supporting

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this claim, literature has also confirmed that the lack of corporate culture and

change management represent a fundamental issue causing failure in lean

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implementation projects (Saurin et al., 2011) and has highlighted the importance
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of readiness for a successful lean implementation.

Lack of systemic approach - Although lean implementation is increasingly

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prevalent in healthcare institutions, the literature suggests that healthcare

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organizations implementing lean are short-term focused and take the piece-meal

approach of deploying only simple tools and techniques for solving selected

problems (De Souza 2009). No healthcare institution has fully institutionalized

lean to the level of Toyota on the ability to design and improve the work, share

the resulting knowledge from the work, and develop people for work (Spear,

2005, pp. 91; Losonci et al., 2011).

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Our research addresses the above-listed reasons for the failure of lean

implementation projects in healthcare institutions. This research is imperative as it is

necessary to not only adapt the lean philosophy to the healthcare context by capturing

the intricacies and by acknowledging the key differences, but also to assess the

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readiness of the healthcare institutions to guide them along the lean journey. A lean

journey comprises of three different stages, namely readiness (pre-implementation

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stage), lean practices (implementation stage), and lean performance (post-

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implementation stage) (Narayanamurthy and Gurumurthy, 2016). Our research is a step

towards the objective of addressing the identified common reasons for the failure of

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lean projects by contributing to the readiness stage (pre-implementation stage) of a lean
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journey. Narayanamurthy and Gurumurthy (2016) have carried out a review of lean

assessment techniques and called for future studies to focus on readiness (pre-
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implementation) assessments in lean projects implemented across sectors such as

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healthcare, software development, etc. Our study is also a response to this call for

research. In sum, we develop a stakeholder-based healthcare institution readiness

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instrument and append it with a mathematical model for assisting process improvement
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practitioners of healthcare institutions.

Organizational readiness, in general, is defined as the ability of the organization

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to undergo a smooth transformation to respond to the changing needs and expectations

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of its internal and external environment. Readiness of the organization to undergo

change is primarily decided by the change commitment and change efficacy of an

organization’s members to implement the announced organizational change (Weiner et

al., 2008). Borrowing from change management literature, readiness for change is seen

as ‘the cognitive perspective to the behaviours of either resistance to, or support for, a

change effort (Armenakis et al. 1993: 681-682). Such perceptions can facilitate or

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undermine the effectiveness of a change intervention/initiative (Armenakis et al. 1993;

Eby et al., 2000). Organization theory literature has seen lean implementation as a

change agent as it can completely change the way value delivery is perceived and

achieved (e.g. Piercy & Rich, 2009; Tsasis & Bruce-Barrett, 2008). For instance, to

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achieve the objective of a smooth lean implementation, a healthcare institution needs to

consider aspects such as awareness to realize the requirement for process improvements,

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development of an improvement strategy with a roll out plan, a culture to focus on

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customer requirements, a systemic processes view, the practice of using data to drive

improvements, engaged staff with appropriate training, a committed leadership team,

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and knowledge of demand, capacity, and variation (Radnor, 2010; Radnor, 2011).
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Therefore, in the context of lean implementation, we define healthcare institution

readiness as the healthcare institution’s ability to smoothly imbibe the reengineering

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changes with least resistance from the stakeholders for the effective and sustainable use
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of the lean tools in order to achieve the targeted outcomes. Healthcare institution

readiness can also be defined as the satisfactory attainment of prerequisites before

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proceeding with any re-engineering/improvement in a healthcare institution. For

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example, without understanding customer values and needs it would not be possible to

develop a value stream map. Similarly, without understanding the variation in data used
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for visual management charts, it would be meaningless and even hard to interpret the
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available information (Abdulmalek and Rajgopal, 2007; Radnor and Bucci, 2007). Any

preparation that is done before the actual lean rollout can be seen as becoming ready for

the change. Actual lean implementation begins when the healthcare institution starts

directly attacking the inefficiencies and wastes in a value stream by following the five

tenets of lean (Womack and Jones, 2009). This understanding helps in demarcating the

boundary between readiness (pre-implementation) and rollout (implementation) stage.

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The overarching research questions (RQ) that we try to answer in this study is as

follows: What are the prerequisites that a healthcare institution has to satisfy to become

ready for implementing lean and how to measure the readiness of a healthcare

institution using these prerequisites? By answering these research questions, we are

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confident to achieve the following objectives:

(1) Identifying the readiness factors for healthcare institutions by comprehensively

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reviewing the lean implementation literature in healthcare institutions.

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(2) Proposing a lean readiness framework for healthcare institutions based on the

factors identified from the literature review.

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(3) Developing a readiness instrument that provides a categorization of healthcare
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institutions based on their readiness level.

(4) Developing a mathematical model applying the lean readiness framework to assess
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the readiness level of a healthcare institution.

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Thus, our research contributes to the healthcare literature in at least three ways.

First, we introduce the importance of considering healthcare institution’s readiness for

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successful lean implementation projects. In particular, we identify a set of readiness

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factors for implementing lean practices in healthcare institutions. Second, we develop a

stakeholder-based lean readiness framework by grouping the identified readiness factors

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under six different stakeholders. Lean implementation in healthcare institutions

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literature clearly indicates that the implementation of each lean practice depends on a

specific stakeholder of the healthcare institution. Hence evaluating the readiness of

those stakeholders is a paramount prerequisite for lean implementation. Finally, we

develop a single numeric readiness index for healthcare institutions to estimate their

readiness level.

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2. Literature review

Our literature review primarily focusses on the implementation of lean in healthcare

institutions and draws insights on the readiness aspects of lean implementation.

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2.1. Lean implementation in healthcare institutions

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We carried out a detailed review of over 130 papers adopting a case study research

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methodology to document the experience of implementing lean in various healthcare

institutions. Table 1 and Table 2 show a snapshot of the literature review on

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implementation of lean in healthcare institutions. Table 1 captures the name of the
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healthcare institution studied, research question addressed, and results obtained. Table 2

captures the lean practices and performance measures documented in the literature. The
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review showed that close to 60% of the literature have documented the lean
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implementation experiences of healthcare institutions in the USA and UK. Emergency,

nursing, cardiac, and pharmacy departments have seen widespread implementations of

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lean. The review also revealed that over 85% of the literature discussed lean
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implementation in multispecialty hospitals. A common observation across all the studies

was that lean implementation procedures, lean practices, and performance measures
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adopted in healthcare institutions were contextual and varied from case to case. For
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instance, King et al. (2006) used a process mapping tool to group patients together for

minimizing complex queuing in the emergency department, whereas Jimmerson et al.

(2005) adapted Value Stream Maps (VSM) and problem-solving A3 report tools to

improve patient or information flow issues across multiple departments. However, lean

implementation in the manufacturing sector has largely adopted a standard procedure

fitting with the five tenets of lean proposed by Womack and Jones (2009). A possible

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explanation for these variations in the healthcare institution context could be the

problem-driven lean adoption approach. Most of the healthcare institutions analyzed in

the literature review used lean as a toolbox to solve some immediate problems faced.

Studies have indicated the importance of proper orientation for getting ready before

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rolling out lean projects (Narayanamurthy et al., 2017). Based on the evaluation of the

research questions addressed and the results obtained in the reviewed papers (listed in

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Table 1), we can conclude that no framework or assessment tool for the lean readiness

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of healthcare institutions exist.

“Insert Table 1 & Table 2 here”

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As part of our review, we also captured the lean practices and performance
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measures documented in the literature (listed in Table 2). A key observation was that

these practices and performance measures were primarily targeting specific stakeholders
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of healthcare institutions. Building on to this observation, we clustered the practices and

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performance measures under different stakeholders namely the leadership and executive

team, the lean sensei and team, the frontline management team (employees of the
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healthcare institution), the patients and other customer groups, supplier groups, etc.
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Overall, the implementation of these lean practices and performance measures were

found to be driven by the stakeholders of the healthcare institution. This triggered the
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motivation to develop a lean readiness framework based on stakeholder theory

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(Harrison and Wicks, 2013) as discussed in detail in section 3 of this paper.

In addition, we attempted to identify implicitly mentioned readiness factors from

the review of lean implementation projects in the healthcare literature. Very few studies

have discussed the readiness aspects explicitly confirming the importance of pursuing

future studies in the readiness domain (e.g. Radnor, 2011; Al-Balushi et al., 2014). Few

studies in the general lean literature have also documented the aspects of readiness (e.g.

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Gurumurthy et al., 2013; Garza-Reyes et al., 2015). In Table 3, we present a snapshot

list of readiness factors identified from the reviewed studies. In section 3, we use inputs

from this table to develop a stakeholder-based lean readiness framework. In the detailed

review carried out by Narayanamurthy and Gurumurthy (2016) on lean assessment, they

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found hardly any indication of lean assessment techniques to evaluate the readiness of

an organization.

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“Insert Table 3 here”

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2.2 Research gaps

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As the success or failure of a lean project heavily depends on the healthcare institution’s
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proactive readiness, it becomes imperative to understand this aspect in the context of

lean implementation by developing a methodology for the assessment of the readiness

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of healthcare institutions. Our review of literature presented above clearly revealed the
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following gaps:

1) The absence of a lean readiness framework that can be used by practitioners for
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checking if healthcare institutions are sufficiently ready to begin their lean journey.
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2) A lack of discussion on the importance of stakeholders in making the healthcare

institution ready for their lean journey.

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3) The unavailability of methodology for systematically assessing the readiness of a

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healthcare institution and quantifying the level of readiness of different

stakeholders.

Our research addresses the above-listed gaps to assist healthcare practitioners in

diagnosing their healthcare institution’s lean readiness.

3. Stakeholder-based lean readiness framework for healthcare institutions

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Our literature review on the implementation of lean in healthcare institutions (Table 1 to

Table 3) showed that the deployment of lean practices and performance measures

depends heavily on the involved stakeholders of the healthcare institution. For instance,

implementing “5S”, a practice for housekeeping, has to be carried out by employees and

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in particular, the front-line employees such as physicians, nurses, lab technicians, etc.

Hence, the “employee” stakeholder has to be trained and made ready on this lean

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practice for its successful implementation. Similarly, all other lean practices can be

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mapped to a prime stakeholder who plays a predominant role in the successful

implementation. Therefore, we develop a stakeholder-based lean readiness framework

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(Harrison and Wicks, 2013), to check the readiness of the different stakeholders.
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Phillips (2003) defines a firm’s legitimate (or normative) stakeholders to be

those to whom the firm owes an obligation based on their participation in the
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cooperative scheme that constitutes the organization and makes it a going concern. It
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includes stakeholders external to the firm namely customers, communities in which the

firm operates, and suppliers in the list of legitimate stakeholders. In addition to these,
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internal stakeholders include the executive team and different employee groups
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(Harrison and Wicks, 2013). Stakeholder theory has been widely used to understand

how efficiently and effectively different stakeholders (both internal and external) can be
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cooperatively involved to achieve high performances along the triple bottom line
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dimensions of an organization and ensure to keep all the stakeholders happy (Freeman

et al. 2007). Stakeholder theory’s key objective is to create a higher level of well-being

for the stakeholders involved in a system of value creation led by the firm. The

implementation and management of any change such as lean at the firm impacts its

stakeholders and value creation processes. Ensuring the stakeholder’s readiness for lean

implementation enhances the well supported positive relationship between stakeholder-

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oriented management and firm performance (Choi & Wang, 2009; Freeman et al., 2010)

and also between lean implementation and operational performance (Yang et al., 2011;

Khanchanapong et al., 2014; Qi et al., 2017). As a result, stakeholder theory provides a

suitable perspective to study the readiness of a firm to implement lean as conceptualized

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in Table 4.

Our proposed framework is unique to the context of healthcare. For instance, the

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elements (also stakeholders) such as frontline management team and patients and other

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customer groups are uniquely operationalized to healthcare institutions and would be

absent in the context of manufacturing. Frontline management teams of healthcare

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institutions comprise of physicians, nurses, and other medical staffs while the frontline
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management teams in a manufacturing firm would comprise of shop floor employees,

supervisors, foreman, line managers, and team leaders. Similarly, patients and other
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customer groups such as patient’s close family, visitors of patient, laboratories, etc. of
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healthcare institutions are very different from the customers of manufacturing firms.

Even though stakeholder theory is applicable to several other industries, the

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operationalization of the theory and associated elements and sub-elements has to be

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restated by anchoring to the industry’s context. We believe this to be also the strength of

the framework proposed in our research as it can explain the readiness of firms
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operating in different industry sectors by only adapting the operationalization of the

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elements and sub-elements.

We describe each of the elements and list the associated sub-elements of our

lean readiness framework below. Refer to Appendix I for the detailed description of the

sub-elements within an element and the rationale for considering it.

“Insert Table 4 here”

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3.1. Leadership and executive team

The leadership and executive team generally ideate the need for lean in their healthcare

institution and visualize the journey they will take to reach the aspired future state.

Hence, they need to be prepared for what it will take to succeed in this journey. Their

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lack of readiness will introduce unexpected challenges and resource constraints that will

push them to drop the lean initiative taken up at their healthcare institution. The

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leadership and executive team can prepare to become ready by addressing the following

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sub-elements: strategic agenda alignment, organic structure and open culture, systems

approach, instituting lean positions, lean know-how, job security, and top management

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commitment.
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The leadership and executive team has to align their healthcare institution’s

strategic agenda (vision and mission) in line with the objective of implementing lean.
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To align their strategy, the top executive team has to be trained first on the basics of
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lean and have to concretize their lean know-how to understand what can be realistically

expected from implementing lean and how important their role is in achieving the
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expectations. This will also signal to the physicians, nurses, and other medical staffs of
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their healthcare institution that the top management is committed and serious about this

transformation. To achieve the lean know-how, leadership and executive team have to
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approach consultants of lean in healthcare who are also known as lean sensei. The
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leadership and executive team has to institutionalize dedicated lean positions (such as

lean sensei, lean champions, etc.) with the responsibility of introducing lean concepts to

the employees of the healthcare institution and support them along the lean journey. The

readiness of the leadership and executive team can be determined by few other aspects

such as the organization structure (mechanistic or organic) and employee job security

(no fire policy). The leadership and executive team of the healthcare institution can be

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considered better ready for lean implementation if they have truly adopted organic

structure with open culture of making all the employees feel important and there is no

fear of termination for cutting costs or for revealing the inefficiencies in the process.

Finally, the maturity in readiness of the leadership and executive team is determined by

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its ability to adopt systems approach in solving problems and taking decisions.

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3.2. Frontline management team

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Frontline management teams including the physicians, nurses, and other medical staffs

in a healthcare institution play a very significant role in implementing a variety of lean

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practices. Even though it is the leadership and executive team which decides on rolling
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out lean, it is the frontline management team that implements lean in the actual

operations of a healthcare institution. The readiness of a frontline management team can

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be achieved by addressing the following sub-elements: customized hands-on training,

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knowledge of the existing systems, multi-skilled, team-working culture, respect for

peers and subordinates, least resistance to change, and employee involvement and
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engagement.
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Customized hands-on training has to be provided to all physicians, nurse, and

other medical staffs on the prerequisites and basic concepts of lean through pilot
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projects and demonstrations to help them understand what lean transformation looks
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like. The entire frontline management team has to be knowledgeable on the existing

systems. They should have a full understanding of all the activities and functional areas

within and across the process and be capable of proposing suggestions for redesigns in

future. Physicians, nurses, and other medical staffs have to be trained and experienced

with multiple skills to work in different positions within and across processes in the

healthcare institution. They have to be experienced in working in teams with an

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objective to improve the patient experience and overall team performance. Respect for

peers and subordinates between different departments and across employee levels has

to be inculcated. Frontline management team is considered to be ready when they do not

exhibit resistance to change and develop the ability to quickly learn/unlearn from the

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experience to improve the efficiency of the processes. The meaningful involvement and

engagement of physician, nurse, and other medical staff including healthcare

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institution’s senior doctors have to be inculcated. Nurses and other medical staffs have

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to embrace ownership of the processes to identify and recommend improvements in

their day-to-day job and associated processes.

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3.3. Lean sensei and team

The lean sensei and team represent the expert committee that will plan, guide, and
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coordinate the lean journey of the healthcare institution by acting as a bridge between
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leadership and executive team’s expectations and frontline management team’s efforts.

This team has to be visualized by the leadership and executive team well before
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beginning the lean journey and have to be brought onboard at the earliest. Usually, the
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lean sensei and team is a composition of lean consultants (expertise in lean philosophy)

and proactive frontline management team members (expertise in healthcare institution’s

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“as-is” status). The readiness of the lean sensei and team can be evaluated using the
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following sub-elements: expertise of sensei and team, lean journey roadmap, comfort

with the team responsible for implementing lean, traveling together attitude, and

process-learning metrics.

A lean sensei and team should have expertise in lean implementation for

successfully guiding the healthcare institution in its lean journey. The lean sensei has to

form the team such that the members complement each other’s expertise and holistically

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have the adequate expertise to start the lean journey. Complete details on how the lean

implementation will be rolled out in the healthcare institution called as lean journey

roadmap need to be planned in detail by the lean sensei and team. Comfort with the lean

team captures how comfortable are the frontline management team in interfacing with

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the lean sensei and team. Lean sensei has to create a climate of encouragement and urge

the frontline management team to work in hands with lean sensei and team for

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improving the experience of patients. Lean sensei and team have to impart traveling

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together attitude among all the stakeholders of the healthcare institution to synchronize

all their viewpoints and ensure that everyone is on the same page for the lean journey to

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be started. Lean sensei and team have to identify process-learning metrics that have to
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be relevant, recognizable, and easy to implement before proceeding with the lean

journey.
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3.4. Patients and other customer groups

Patients and other customer groups such as patient’s close family, visitors of patient,
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laboratories, neighboring societies, etc. will be impacted by a lean transformation.

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Customer groups can be either internal (inpatient) or external (outpatient) to the

healthcare institution. Moreover, a lean transformation of a healthcare institution is

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pursued to add value defined by the customers. Hence, healthcare institutions have to
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understand the aspects related to customers before proceeding with the lean

implementation and inform patients about the planned lean transformation in the future

and to involve them in the process. The readiness for this stakeholder group can be

evaluated through the following sub-elements: knowledge of customer groups, patient

respect, involvement and engagement, and patient’s knowledge of “end to end” process

pathway.

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Knowledge of both internal and external customer groups is essential to rightly

define the value for these customer groups such that they can be linked to different

improvement initiatives that will be taken up in the future. Respecting, involving and

engaging patients and other customer groups in the treatment process is an essential

PT
readiness aspect for succeeding along a lean journey. Patient’s knowledge of “end to

end” process pathway indicates how much the healthcare institution has involved and

RI
engaged the patient and has informed them about their processes.

SC
3.5. Supplier groups

U
Supplier groups play a very important role in successfully implementing lean projects in
AN
healthcare institutions as they can potentially increase or decrease the existing wastes.

Supplier groups have to be ready for a lean implementation project, which can be
M

measured by understanding the following sub-elements: supplier collaboration and

D

partnership, supplier involvement and alignment, and supplier service quality.

Supplier collaboration and partnership increase the readiness for lean

TE

implementation at healthcare institutions as it increases the ability to monitor and share

EP

real time information. Supplier involvement and alignment can be achieved by aligning

the supplier’s vision and mission to the healthcare institution. High supplier service
C

quality achievement by delivering consistently good quality product and services is also
AC

an important characteristic of a supplier who is ready for lean implementation.

3.6. Healthcare institution attributes

Healthcare institution attributes are those characteristics of healthcare institution

(similar to focal organization in a supply chain context) which needs to be made

favorable for lean implementation. This involves primarily fixed resource investments

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that are independent of lean implementation. The readiness of the attributes related to

the healthcare institution can be evaluated using the following sub-elements: data

measurement system, capacity and demand matching efforts, past change experiences,

and patient and employee safety.

PT
Accurate data measurement system has to be in place to monitor the processes in

the healthcare institution. Data compatibility across processes and departments has to be

RI
ensured before beginning the lean journey. Capacity and demand matching efforts have

SC
to be taken by the healthcare institution to optimally utilize its fixed and variable

resources to achieve maximum efficiency. Past change experiences of the healthcare

U
institution with different initiatives other than lean needs to be relooked. Learnings from
AN
the past experience need to be incorporated in the current initiative to avoid repetition of

mistakes. Ensuring patient and employee safety is a key prerequisite before any change
M

initiative. A safe environment and conducive conditions that can prevent injuries and
D

strain on both patients and frontline management team are mandatory for a healthcare

institution.
TE

The lean readiness framework described above is used to assess the lean
EP

readiness of a healthcare institution using fuzzy input based similarity to ideal solution

assessment method.
C
AC

4. A methodology for lean readiness assessment of healthcare institutions

Our stakeholder-based lean readiness framework developed in the previous section had

been verified by brainstorming with the lean implementation team of a healthcare

institution group. Subsequent to the verification, we used our lean readiness framework

to collect data from a healthcare unit (within the healthcare institution group) which was

planning to implement lean in near future.

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4.1. Case organization

The case organization we studied in this research is part of a larger healthcare group,

which comprises of multiple hospitals, primary care clinics, a home care, and a medical

PT
transportation center. The healthcare group is known for its excellence in family health

and specialization, including primary, maternity, orthopedics and post-acute care. The

RI
entire healthcare group has over 7,500 employees and 850 physicians who are highly

SC
committed to deliver compassionate health care that puts the patient and their needs

first. We submitted the proposal for assessing the readiness to implement lean at this

U
healthcare institution to the lean sensei of the healthcare group. On reviewing the
AN
proposal and after discussing with us on the objectives of this study, the lean sensei

proposed a primary care clinic within their healthcare group as an ideal candidate for
M

our research. The lean sensei and his team were also interested to check how the
D

proposed clinic performed in our readiness evaluation and what can they focus on to

improve before beginning the actual implementation of lean. We visited the healthcare
TE

unit once every week for over three months. We first started by getting introduced to
EP

different stakeholders, followed by collecting data necessary for assessing the readiness,

and finally interpreted the results obtained from the assessment. The lean sensei and his
C

team of the healthcare group assisted in achieving the objectives during all the visits by
AC

connecting with physicians, nurses, and other medical staff of the healthcare unit.

4.2. Fuzzy input based readiness assessment method

Fuzzy technique helps in overcoming the “imprecise”, “vague”, “partial truth” and

“multi-possibility” in responses. For instance, it takes into consideration the concept of

partial truth, where in our study the truth-value can vary from “fully ready” to “not

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ready". Fuzzy sets were introduced by Zadeh (1965) to represent data and information

processing non-statistical uncertainties. The fuzzy technique uses degrees of truth as a

mathematical model of vagueness and probability associated with it as a mathematical

model of ignorance. In addition, this technique is capable of tolerating the blurred

PT
boundary in definitions and enables assessors to use linguistic terms to assess indicators

in natural language expressions (Lin and Chen, 2004).

RI
As the readiness for lean implementation in a healthcare institution is to be

SC
assessed, we expect the assessors to be not much aware of lean philosophy and

readiness of all stakeholders of the institution for lean implementation. It is very likely

U
that assessors provide variable answers when asked for how ready a particular
AN
stakeholder of the healthcare institution is. For instance, one assessor might find a

particular stakeholder to be “somewhat ready”, but second assessor can interpret the
M

same stakeholder to be “almost ready”. The fuzzy technique helps in such instances to
D

arrive at a more appropriate truth by using the result of reasoning from such inexact,

imprecise, and partial knowledge in which the sampled answers are mapped over a
TE

spectrum.
EP

Based on the review carried out by Narayanamurthy and Gurumurthy (2016),

lean assessment studies in services are scarce and almost non-existent in the context of
C

healthcare institutions. Their review also showed that lean assessment studies in
AC

manufacturing context have used fuzzy techniques significantly apart from other

methodologies such as Mahalanobis distance, data envelopment analysis, analytic

network process, and value stream mapping to conduct the assessment. Among these

methods, we selected the fuzzy technique for carrying out the assessment as it is close

to realistic judgments and have been frequently prescribed in the manufacturing context

but have not been put to use in the healthcare sector (Abbod et al., 2001). In this

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research, we develop Fuzzy Input Based Similarity to Ideal Solution Readiness

Assessment Method by adopting the procedure proposed by Chen and Hwang (1992),

Triantaphyllou and Lin (1996), Wang and Elhag, (2006), and Wang and Lee (2008)

(Figure 1).

PT
“Insert Figure 1 here”

We collected input fuzzy data for the assessment method from a physician,

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nurse, executive team member, member of the lean sensei team, and staff of the primary

SC
care clinic using the instrument shown in Table 5 and Table 6. We developed linguistic

scale for the readiness evaluation by discussing with the members of lean sensei team.

U
The linguistic scale we used for measuring the Extent of Readiness of sub-elements and
AN
Importance Weight of readiness elements and sub-elements is shown in Table 7. A

snapshot of the final linguistic data collected by us on the Extent of Readiness and
M

Importance Weights for LRF1 is shown in Table 8. Similarly, we collected data for all
D

the remaining elements and sub-elements.

“Insert Table 5 to Table 8 here”

TE

Based on the corresponding relation between the linguistic terms and fuzzy
EP

numbers as listed in Table 7, we approximated and averaged the linguistic terms of

Extent of Readiness and Importance Weight using fuzzy numbers. Assume that a
C

committee of m evaluators, i.e., Et, t = 1, 2, ..., m, conduct the healthcare institution’s

AC

readiness evaluation. Let Fj, j = 1, 2, . . ., n; be set of readiness factors within a

particular stakeholder category which need to be evaluated for assessing the healthcare

institution’s readiness for implementing lean. Let Rtj = (ajt, bjt, cjt) be the fuzzy numbers

approximating the linguistic Extent of Readiness given to Fj by the assessor Et, and let

Wtj = (xjt, yjt, zjt) be the fuzzy numbers approximating the linguistic Importance Weight

assigned to Fj by the assessor Et. Using the average fuzzy Extent of Readiness Rj and

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average fuzzy Importance Weight Wj, we calculated the aggregation of the opinions of

experts as

Rj = (aj, bj, cj) = (Rj1 (+) Rj2 (+) . . . (+) Rjm)/m (1)

Wj = (xj, yj, zj) = (Wj1 (+) Wj2 (+) . . . (+) Wjm)/m (2)

PT
For example, consider the conversion of Extent of Readiness and Importance

Weight for the lean element ‘LRF1.1’ into fuzzy number as shown in Table 9. We

RI
obtained the Fuzzy average Extent of Readiness and Importance Weight in the last row

SC
of Table 9 by following the procedure shown in eq. (1) and (2). Similarly, we averaged

the Extent of Readiness and Importance Weight fuzzy numbers for the elements and

U
sub-elements in the lean readiness framework.
AN
“Insert Table 9 here”

We computed the product of average fuzzy numbers of Extent of Readiness and

M

Importance Weight of sub-elements to calculate the readiness level as shown in Table

D

10. We evaluated centroid score of readiness level to generate the readiness value of

each of the sub-elements as shown in Table 10.

TE

“Insert Table 10 here”

EP

We computed the fuzzy Extent of Readiness for elements by applying equation 3

on sub-elements within an element of lean readiness framework (Kao and Liu, 2001).
C

Let Rj and Wj (where j = 1, 2, . . ., n; and n is the number of sub-elements within an

AC

element) denote the average fuzzy Extent of Readiness and Importance Weight given to

a sub-element ‘j’ within an element of lean readiness framework by the assessors. We

computed the Extent of readiness of an element as

(3)

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We computed the product of fuzzy numbers of Extent of Readiness (using

equation 3) and average Importance Weight of elements to calculate the readiness level

of elements as shown in Table 11. We evaluated the centroid score of readiness level to

generate the readiness value of each of the elements as shown in Table 11.

PT
“Insert Table 11 here”

Finally, we computed the overall Healthcare Institution Lean Readiness Index

RI
(HLRI) by applying equation 3 but at the element level. For computing HLRI, Rj and

SC
Wj (where j = 1, 2, . . ., n; and n is the number of elements in the lean readiness

framework) denote the computed fuzzy Extent of Readiness and Average Importance

U
Weight for element ‘j’ respectively. HLRI determines the aggregated extent of readiness
AN
attained by putting together all the stakeholders of the case organization. Our

computation showed HLRI of the case organization as (4.797, 5.744, 6.703) with
M

centroid score of 5.75, which can be used as a metric for conveying the readiness of the
D

healthcare institution.

To translate HLRI into an appropriate linguistic level for easy interpretation, we

TE

identified a linguistic label from the natural language expression set of the Healthcare
EP

Institution Lean Readiness (HLR). HLR set consists of five levels as shown in Figure 2.

Several methods such as the Euclidean distance, successive approximation, and

C

piecewise decomposition have been proposed in the literature for matching the
AC

membership function with linguistic terms. For this research, we used the Euclidean

distance method as it is the most intuitive method for perceiving proximity (Lin et al.

2006). Assuming the natural-language Healthcare Institution Lean Readiness level

expression set to be HLR, UHLRI and UHLRi represent the membership functions of the

HLRI and of the natural-language Healthcare Institution Lean Readiness ‘i’,

respectively. We calculated the distance between UHLRI and UHLRi as

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(4)

where p={x0, x1, ……, xm} Ϲ [0, 1] so that 0 = x0<x1< …. <xm = 1.0

PT
“Insert Figure 2 here”

The distance between the HLRI and natural-language HLR i is then calculated

RI
and the closest natural expression with the smallest distance between UHLRI to UHLRi is

SC
identified. Using eq. 4, we calculated the Euclidean distance‘d’ between HLRI and each

member in the set HLR:

U
D (HLRI, Not Ready) = 7.116
AN
D (HLRI, Low Ready) = 4.985

D (HLRI, Average Ready) = 1.968

M

D (HLRI, Close to Ready) = 2.626

D

D (HLRI, Ready) = 4.553

TE

From Figure 3, it can be clearly inferred that the equivalent linguistic label that

is close to the primary care clinic’s lean readiness level is “Average Ready”.
EP

“Insert Figure 3 here”

C

4.3. Ranking using similarity to ideal solution technique

AC

The technique for order of preference by similarity to ideal solution (TOPSIS) works

such that the chosen alternative has the minimum distance from the positive ideal

solution which maximizes the benefit criteria and minimizes the cost criteria, and has

the maximum distance from the negative ideal solution which maximizes the cost

criteria and minimizes the benefit criteria (Wang and Elhag, 2006; Wang and Lee, 2008;

Mittal and Sangwan, 2015). Triantaphyllou and Lin (1996) developed a fuzzy version of

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the TOPSIS method that leads to a fuzzy relative closeness for each element. TOPSIS is

a practitioner-friendly technique for ranking elements through measuring Euclidean

distances.

We used the fuzzy readiness level obtained for all the elements and sub-elements

PT
of lean readiness framework for computing fuzzy positive ideal solution (FPIS) and

fuzzy negative ideal solution (FNIS). Using equations (5) and (6), we computed FPIS

RI
and FNIS of the sub-elements given in Table 12 respectively:

A* = (v1*, v2*, …, vn*)

SC
(5)

Where vj* = maxi {vij3}, i=1, 2,…, m; j=1, 2,…, n.

U
A- = (v1-, v2-, …, vn-) (6)
AN
Where vj- = mini {vij3}, i=1, 2,…, m; j=1, 2,…, n.

The distance (di*, di-) of fuzzy readiness value of each sub-element i=1, 2,…, m
M

from the FPIS and the FNIS is computed using equation 4 as shown in Table 12. The

closeness coefficient (CCi) represents the distances to the FPIS (A*) and the FNIS (A-)
D

simultaneously. The CCi of each sub-element is calculated using Equation (7):

TE
EP

(7)

The closeness coefficients for sub-elements are given in Table 12. We adopted
C

similar procedure to rank separately the sub-elements within each element (Table 13)
AC

and rank the six elements (Table 14).

“Insert Table 12 to Table 14 here”

5. Results

As a result of the assessment, we ranked the stakeholders along with its sub-elements in

the proposed lean readiness framework depending on their level of readiness. Results of

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this readiness assessment provided several insights for the lean sensei and team about

the healthcare unit and highlighted the weak areas that needed to be focused on before

beginning the implementation of lean. The primary care clinic we assessed in this study

is “Average Ready” for beginning the lean journey with an HLRI value of 5.75. On

PT
improving the weak elements and sub-elements of the lean readiness framework, the

primary care clinic is expected to move to the “Close to Ready” category and potentially

RI
reach the “Ready” category with maximum feasible HLRI value.

SC
5.1. Ranking of readiness sub-elements across all stakeholders

U
In Figure 4, we plot the CCi of all the sub-elements put together in an increasing order
AN
to reveal the areas of focus for improving the readiness of the case organization across

all stakeholders. We applied a Pareto principle to identify the critically weak areas (20%
M

of least ranked elements) that need to be focused on for improving the readiness of the
D

case organization. To identify the strong areas where the assessed healthcare unit was

doing much better, we used the same Pareto principle (20% of top ranked elements). Six
TE

strong and weak sub-elements were identified as listed in Table 15.

EP

“Insert Figure 4 here”

“Insert Table 15 here”

C
AC

5.2. Ranking of readiness sub-elements within a stakeholder group

In Figure 5, we plot the CCi of the sub-elements under each element in an increasing

order to reveal the areas of focus within an element for improving the readiness of

individual stakeholders of the assessed healthcare unit and in turn increase the readiness

of the entire unit. We used the Pareto principle to identify the weak areas that need to be

focused on by each stakeholder to improve the readiness of the primary care clinic and

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also to identify the strong areas of each stakeholder. The sub-elements within a

stakeholder group whose closeness coefficients are below and above the set threshold

are listed in Table 16.

“Insert Figure 5 here”

PT
“Insert Table 16 here”

RI
5.3. Ranking of stakeholders

SC
In Figure 6, we plot the CCi of the stakeholders in an increasing order. This plot

provides us with insights on the stakeholders who need to be focused for improving the

U
lean readiness of the primary care unit. We applied the Pareto principle to identify the
AN
weakly ready and strongly ready stakeholders and listed them in Table 17.

“Insert Figure 6 here”

M

“Insert Table 17 here”

D

6. Discussion
TE

6.1. Triangulating the readiness level of the case organization

EP

Our current study adopts a case study methodology. Consequently, we qualitatively

triangulate the quantitative results obtained from the assessment to establish the rigor of
C

the procedure adopted and robustness of the results obtained (Jick, 1979; Eisenhardt,
AC

1989). Our results of the readiness assessment showed that Leadership and Executive

Team (LRF 1) in the case organization is “Average Ready” with strong job security

policies (LRF 1.6) and lean positions instituted (LRF 1.4). The top management has to

work on embracing a systems approach mindset (LRF 1.3) in all the other stakeholders

of the healthcare unit. A systems approach can be embraced by listening to the opinions

of stakeholders from all levels. This requires, for example, a revision of the healthcare

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unit’s organization structure with respect to an organic and open culture (LRF 1.2).

Changes implemented in such a restructuring have to be communicated to all the

stakeholders of the healthcare unit. Subsequent to the communication of restructuring

initiatives, the top management has to initiate trainings on lean knowhow (LRF 1.5) for

PT
all the stakeholders to guide them in understanding how this newly obtained autonomy

can be put into effective use.

RI
Similarly, the Frontline Management Team (LRF 2) is “Average Ready” with a

SC
strong respect for peers and subordinates (LRF 2.5) and complete involvement and

engagement of physician, nurse, and staff (LRF 2.7). The frontline management team

U
has to work on improving its knowledge of existing systems (LRF 2.2) such as process
AN
pathway, processes that need to be completed by patients and frontline management

team before entry and exit of patients to the healthcare unit, etc. The frontline
M

management team has to receive customized hands-on training (LRF 2.1) from the team
D

of the lean sensei to overcome their resistance to change (LRF 2.6). To address the

customized hands-on training requirement, the lean sensei and team had started a “lean
TE

readiness laboratory”. As a result of the training and better understanding of the

EP

existing systems, the frontline management team’s multi-skill abilities (LRF 2.3) are

expected to improve.
C

The Lean sensei and team (LRF 3) is also “Average Ready” at the assessed
AC

healthcare unit. This can be attributed to the regular guidance of two lean experts who

directly reported to the lean sensei of the healthcare group. The expertise of the sensei

and team (LRF 3.1) at the assessed healthcare unit was maintained strong. The team

was planning to use this clinic as a laboratory for the employees within the healthcare

group where they can experience and learn about becoming ready before beginning the

lean journey. Lean sensei and team have to work on improving the comfort of frontline

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management team towards the lean team (LRF 3.3). To achieve this, the lean sensei and

team were planning to get onboard a proactive frontline management team member

from the assessed healthcare unit who can motivate and set up a climate of

encouragement for the lean journey implementation. In addition, it can establish a

PT
structured workforce planning to facilitate in changing employee’s role and rotation of

employees across teams or functions. The lean sensei and team have to focus on

RI
developing a detailed lean journey roadmap (LRF 3.2) for the assessed healthcare unit

SC
which has to be communicated to all the stakeholders of the unit.

In the case of Patients and other customer groups (LRF 4), the readiness level is

U
“Low Ready”. The strong sub-element is the respect, involvement and engagement of
AN
patients (LRF 4.2). Assessed healthcare unit has to improve the knowledge of its

patients on “end to end” process pathway (LRF 4.3) from entry to exit. By consulting
M

with lean sensei and team, frontline management team of the assessed healthcare unit
D

can develop and display charts explaining the “end to end” process pathway of patients

depending on the care required.

TE

The primary care clinic has to focus on improving its “Not Ready” supplier
EP

groups (LRF 5) and “Low Ready” healthcare institution attributes (LRF 6). Key

suppliers of the assessed healthcare unit have to be identified, informed, and involved in
C

improving the readiness before beginning the lean journey. Collaboration with few key
AC

suppliers (LRF 5.1) such as the consumable suppliers, pharmacy companies, and

equipment suppliers can be established to create long-term relationship and trust. The

executive responsible for purchasing function has to discuss with the identified key

suppliers to further improve its existing service quality system with measurable metrics

(LRF 5.3). Attributes of the healthcare unit (LRF 6) has to be revisited for ensuring that

all the prerequisites required for any change management are in place. The assessed

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healthcare unit is doing well on its patient and employee safety policies (LRF 6.4)

which can be anchored upon for reducing the resistance to change among the frontline

management team. The healthcare unit has to work on improving its capacity and

demand matching efforts (LRF 6.2) by using the past data collected from the existing

PT
systems.

The triangulation performed is also expected to assist practitioners in

RI
understanding how to interpret the results obtained from readiness assessment.

SC
6.2. Lean readiness laboratory

U
To address the areas of improvements identified in the case organization, the lean sensei
AN
and team had decided to initiate a “Lean Readiness Laboratory”. The objective of this

“Lean Readiness Laboratory” was to convey the weak areas of readiness to the
M

stakeholders of the healthcare unit by practically pilot testing small process

D

improvement initiatives that are limited in scope but run deep in mindsets. Extreme

attention was paid to the micro-details of the small process improvement initiatives
TE

implemented during pilot testing. The details were reflected upon at the end of the day
EP

to list the challenges faced and understand it from the lens of weak readiness areas as

identified through the assessment. This laboratory was used as an environment for
C

helping the people to learn and to facilitate the creation of engaged teams with
AC

knowledge on lean (Radnor, 2010; Radnor, 2011). The Lean Readiness Laboratory

created the excitement within teams to fundamentally change the way they work. This

Laboratory also laid the groundwork for other healthcare institutions within the

healthcare group to solve their business problems by adopting or adapting the lean

philosophy. The lean sensei and team decided that the Lean Readiness Laboratory had

to be created with the following three characteristics:

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• Leadership: leaders of the laboratory have to demonstrate passion for change

and ability to build a sense of community and engagement around the

improvement work

• Place: laboratory must be able to host locally the project team and the planning

PT
tools (wall space and working sessions)

• Visibility: laboratory must have high visibility in the healthcare unit

RI
(improvements made should be easy to notice)

SC
The lean sensei and team expected that the learnings obtained by the

stakeholders of the clinic using the Lean Readiness Laboratory would help them in a

U
smooth transition towards implementing lean for optimizing the eight flows of
AN
healthcare: flow of patients, staff, families and visitors, information, medications,

supplies, equipment and process engineering. Preparing for lean readiness can help the
M

healthcare unit in stabilizing before defining, testing and implementing the most
D

appropriate care delivery model (Jones et al., 2005). It also ensures that the healthcare
TE

unit has the conducive culture profile for succeeding in lean implementation by

matching the patient and organizational expectations (e.g. acting with humane
EP

orientation by always putting the patient first, nurturing trust and confidence to achieve

high collectivism, lower level of assertiveness and finding joy in what they do, etc.)
C

(Bortolotti et al., 2015).

AC

6.3. Research implications, limitations and future directions

By proposing a framework with six stakeholder groups and associated sub-elements of

lean readiness, we do not suggest that these factors are exhaustive. The parsimonious

model proposed using stakeholder theory only includes the relevant readiness factors

that are specific enough to capture core features and broad enough to capture the range

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of the lean phenomenon. Even though the readiness factors in this study were identified

from an indepth literature review and were validated in a case organization, other

factors unique to healthcare institution’s context might still be present. This trade off is

an inbuilt limitation for any parsimonious and generalizable (abstracted) framework

PT
(Eisenhardt, 1989).

Proposed framework overlooks the impact of external forces such as level of

RI
competition in the market, lean status of competitors, regulatory requirements, demand

SC
for healthcare services in the market, etc. For instance, healthcare institutions in a

market with low competition would be much behind in its readiness level in comparison

U
to those operating in high competing market. Readiness factors that are seen as a basic
AN
order qualifier in a high competing market could be seen as an order winner in a low

competing market. Internal factors such as healthcare institution’s size, ownership,

M

affiliation, accreditation, etc. would also impact the readiness for lean implementation.
D

Future empirical studies can conduct a cross-sectional survey to understand the

relationship between these internal and external characteristics of healthcare institution

TE

and its readiness level (Jones et al. 2005), which can be operationalized as the readiness
EP

score computed using the assessment method proposed in this study. On confirming a

significant impact through our analysis, these factors have to be controlled in future
C

empirical models dealing with readiness for lean implementation.

AC

Stakeholders of a firm depend on both the firm and its other stakeholders to

achieve their own objectives. Stakeholder interests are inseparably connected in a

system of value creation in which each stakeholder provides resources or influence in

exchange for some combination of tangible and/or intangible goods (Sachs & Rühli,

2011). Experience of several firms have showed that stakeholders have enough

overlapping interests to make them function integratively in generating value to become

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better off over time (Freeman et al. 2007; Harrison and Wicks, 2013). According to

Harrison and Wicks (2013), neglect of any one stakeholder could set off a downward

spiral in the system as the firm’s other stakeholders respond to what they observe. This

dependence across stakeholders can be expected to have significant influence on the

PT
readiness of stakeholders. Future research should seek to examine how readiness of one

particular stakeholder influences the readiness of another stakeholder. Future

RI
researchers can also investigate the impact of conflicting or cooperating relationship

SC
between stakeholders on their individual readiness as well as the overall readiness of the

organization. This investigation will call for devising strategies to impart readiness

U
among stakeholders depending on their relationship - cooperate or conflict.
AN
As we use a single case study methodology, the findings of this study may not

be entirely generalized in the healthcare sector. But the readiness framework developed
M

is theoretically generalizable and can be directly applied to a different unit of

D

assessment such as emergency units, cardiac, pharmacy, etc. within a healthcare

institution. However, the assessors have to ensure that the operationalization of the
TE

readiness framework is done for the particular unit through the involvement of the
EP

directly affected stakeholder groups. For instance, if the unit of readiness assessment is

an emergency department (ED), then the physician, nurse, and staff working for that
C

particular ED (frontline management team) have to be focused on for collecting the

AC

data.

As this study only reports the readiness assessment of a single healthcare

institution at a particular point in time, future studies can also extend the proposed

framework by conducting a longitudinal readiness assessment study within a single

healthcare institution or by conducting a comparative study across different healthcare

institutions. This would provide insights on how the proposed assessment technique

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compares and contrasts different healthcare institutions or a single healthcare institution

at different points in time on their readiness level.

The motivation for this study is drawn from theoretical arguments and anecdotal

evidences that emphasize the need for readiness to succeed in the implementation of

PT
lean in a healthcare institution. Future research could test empirical models linking

readiness to lean implementation through quantitative surveys. This would help in

RI
generalizing the impact of readiness (if any) on the outcome of lean implementation by

SC
answering the question “how differently healthcare institutions at varying readiness

level perform in their future lean implementation journey”.

U
Even though the proposed assessment methodology overcomes the stated
AN
limitations of other assessment techniques, it adds complexity to the procedure of

readiness assessment. Assessors interested in only using the stakeholder-based lean

M

readiness framework in their assessment can treat Table 4 as a simple checklist for
D

conducting their assessment. Every healthcare institution is unique and has its own

strengths and weaknesses. Acknowledging these and accordingly adapting the lean
TE

philosophy to suit the healthcare institution’s context can also be considered as part of
EP

the readiness initiative. Future research can take this up as an extension of this study to

broadly group the hospitals into different categories and propose directions for the
C

adaptation of lean philosophy.

AC

The line where pre-implementation stops and lean implementation starts could

be blurred in practice. The understanding and operationalization of lean readiness

construct can vary between healthcare institutions. We acknowledge this limitation in

deploying lean readiness assessment. However, healthcare institutions can overcome it

by being consistent in its readiness operationalization throughout the lean journey. For

instance, in this study, we operationalized readiness as any preparation that can be done

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before the actual lean implementation for re-engineering/improvement. The actual lean

implementation starts when the healthcare institution begins to directly attack the

inefficiencies and wastes in a value stream by following the five tenets of lean

(Womack and Jones, 2009). This understanding is expected to help in demarcating

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readiness (pre-implementation) and implementation stage.

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6.4. Practice implications

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The stakeholder-based perspective for evaluating the readiness of a firm for

implementing lean can help managers to determine where their attention is needed in

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order to facilitate the roll out of lean projects (Harrison and Wicks, 2013). Stakeholder-
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based lean readiness framework can assist practitioners in ensuring that all the

prerequisites are in place before kick starting the lean implementation journey (Radnor,
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2011; Gurumurthy et al., 2013; Al-Balushi et al., 2014; Garza-Reyes et al., 2015). The
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proposed lean readiness framework and its demonstrated assessment method are capable

of identifying the strengths and weaknesses of a healthcare institution that needs to be

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acknowledged and addressed before beginning a lean transformation. Using the

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proposed assessment methodology, a stakeholder’s readiness for lean implementation

can be improved which in turn has been proven to increase the firm performance (Choi
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& Wang, 2009; Freeman et al., 2010) and operational performance (Yang et al., 2011;
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Khanchanapong et al., 2014; Qi et al., 2017).

Our proposed lean readiness framework can also be directly used as a checklist

to conduct a simple, qualitative assessment if the assessors are comfortable with

overlooking the subjectivity and impreciseness of the responses expected to be received.

However, as the adoption and implementation of lean is a strategic decision, it is

recommended to control for the impreciseness of the responses received. The chances of

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top management getting mislead by the binary (0 or 1) as well as absolute responses (1-

5) gathered through checklist/instrument is very high as it fails to take into

consideration the concept of partial truth, where the truth value can vary from “fully

ready” to “not ready". Therefore, we believe that the proposed fuzzy logic based

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assessment methodology will deliver more robust result in comparison to a checklist

based assessment.

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The lean readiness laboratory described is also expected to provide guidelines

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for other healthcare institutions interested in imitating it. Stakeholder-based lean

readiness framework helps in accounting the stakeholders for the level of readiness

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attained by the healthcare institution. Practitioners have to conceptualize healthcare
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institution readiness as a continuum rather than a binary measure (ready or not ready).

As the proposed readiness assessment procedure delivers a single numeric continuous

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metric representing the overall readiness of the healthcare institution, practitioners can
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use this metric to perform readiness benchmarking with self or with others.

A detailed explanation of the procedures of the assessment along with the

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complete readiness instrument developed can assist healthcare practitioners in easily

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conducting the readiness assessment. The proposed assessment methodology has been

kept simple to make it easier for deployment at the case organization and to make it
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acceptable by practitioners. The step-by-step description of the methodology is also

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expected to ensure the pursuit of readiness assessment. The computations involved can

also be automated into a user-friendly platform in future such that it just takes numerical

inputs from the assessors to deliver the status of readiness of different stakeholders and

associated sub-elements. We expect the lean readiness assessment methodology

proposed and demonstrated in this study to significantly reduce the huge failure rates of

lean implementation in healthcare institutions (Thelen, 2016).

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7. Conclusion

By conducting a detailed literature review of case studies describing the implementation

of lean projects in healthcare institutions, we identified the readiness factors for

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beginning the lean journey in a healthcare institution. This addressed the first research

objective of this study. We used stakeholder theory to understand the readiness factors

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identified as each factor’s achievement were directly attributable to a stakeholder.

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Through this understanding of readiness factors, we grouped them into stakeholders

(elements) and sub-elements within a stakeholder to form the stakeholder-based lean

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readiness framework. This addresses the second research objective of this study. Using
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the proposed fuzzy input based assessment method and similarity to ideal solution

technique, we ranked the elements and sub-elements listed in the readiness framework
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at overall and stakeholder level for a primary care clinic in USA. We also ranked
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stakeholders based on the readiness scores obtained from the assessment method.

Finally, based on these rankings, we computed a numeric index for the assessed
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healthcare unit and identified future focus areas to improve the readiness of the
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healthcare unit before beginning the lean journey. This addresses the third and fourth

research objective of this study. On reviewing the results of the readiness assessment
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carried out in this study, lean sensei and team of the primary care clinic decided to begin
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an initiative in the name of Lean Readiness Laboratory for ensuring smooth transition

during the process of implementing lean.

Our research provides with a new perspective of assessing the readiness of a

healthcare institution before pursuing implementation of lean. Our study is unique in

terms of developing a lean readiness framework and demonstrating a lean readiness

assessment technique in the context of healthcare institutions. Usage of fuzzy input

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based assessment method to assess the readiness of a service organization (i.e.

healthcare institution) and similarity to ideal solution to rank the elements is also an

unique attempt.

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Acknowledgments

The first author is grateful to the United States-India Educational Foundation and to the

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J. William Fulbright Scholarship Board for supporting his research. We authors also

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thank all the employees of the case organization for supporting us in conducting this

project. Finally, we are thankful to the anonymous reviewers, editor and numerous

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colleagues who provided valuable feedback on this research.
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References

1. Abbod, M. F., von Keyserlingk, D. G., Linkens, D. A., & Mahfouf, M. (2001).

Survey of utilisation of fuzzy technology in medicine and healthcare. Fuzzy Sets and

Systems, 120(2), 331-349.

PT
2. Abdulmalek, F. A., & Rajgopal, J. (2007). Analyzing the benefits of lean

manufacturing and value stream mapping via simulation: A process sector case

RI
study. International Journal of production economics, 107(1), 223-236.

SC
3. Al-Balushi, S., Sohal, A. S., Singh, P. J., Al Hajri, A., Al Farsi, Y. M., & Al Abri, R.

(2014). Readiness factors for lean implementation in healthcare settings–a literature

U
review. Journal of health organization and management, 28(2), 135-153.
AN
4. Arbós, L. C. (2002). Design of a rapid response and high efficiency service by lean

production principles: Methodology and evaluation of variability of performance.

M

International journal of production economics, 80(2), 169-183.

D

5. Armenakis, A. A., Harris, S. G., & Mossholder, K. W. (1993). Creating readiness

for organizational change. Human relations, 46(6), 681-703.

TE

6. Bhasin, S. (2012). An appropriate change strategy for lean success. Management

EP

Decision, 50(3), 439-458.

7. Bortolotti, T., Boscari, S., & Danese, P. (2015). Successful lean implementation:
C

Organizational culture and soft lean practices. International Journal of Production

AC

Economics, 160, 182-201.

8. Bushell, S., & Shelest, B. (2002). Discovering lean thinking at progressive

healthcare. The Journal for Quality and Participation, 25(2), 20.

9. Chand, D. V. (2011). Observational study using the tools of lean six sigma to

improve the efficiency of the resident rounding process. Journal of graduate

medical education, 3(2), 144-150.

38
 ACCEPTED MANUSCRIPT

10. Chen, S. J., & Hwang, C. L. (1992). Fuzzy multiple attribute decision making

methods. In Fuzzy Multiple Attribute Decision Making (pp. 289-486). Springer

Berlin Heidelberg.

11. Choi, J., & Wang, H. (2009). Stakeholder relations and the persistence of corporate

PT
financial performance. Strategic Management Journal, 30(8), 895-907.

12. De Souza, L. B. (2009). Trends and approaches in lean healthcare. Leadership in

RI
Health Services, 22(2), 121-139.

SC
13. Díaz, A., Pons, J., & Solís, L. (2012). Improving healthcare services: Lean lessons

from Aravind. International Journal of Business Excellence, 5(4), 413-428.

U
14. Eby, L. T., Adams, D. M., Russell, J. E., & Gaby, S. H. (2000). Perceptions of
AN
organizational readiness for change: Factors related to employees' reactions to the

implementation of team-based selling. Human relations, 53(3), 419-442.

M

15. Eisenhardt, K. M. (1989). Building theories from case study research. Academy of
D

management review, 14(4), 532-550.

16. Freeman, R. E., Harrison, J. S., & Wicks, A. C. (2007). Managing for stakeholders:
TE

Survival, reputation, and success. Yale University Press.

EP

17. Freeman, R. E., Harrison, J. S., Wicks, A. C., Parmar, B. L., & De Colle, S. (2010).

Stakeholder theory: The state of the art. Cambridge University Press.

C

18. Garcia, M. (2014). Using Lean Management Principles to improve Patient

AC

satisfaction and reduce wait times at UnM Gi/endoscopy. UNM CIR Journal of

Quality Improvement in Healthcare, 2.

19. Garza-Reyes, J. A., Ates, E. M., & Kumar, V. (2015). Measuring lean readiness

through the understanding of quality practices in the Turkish automotive suppliers

industry. International Journal of Productivity and Performance Management,

64(8), 1092-1112.

39
 ACCEPTED MANUSCRIPT

20. Gurumurthy, A., Mazumdar, P., & Muthusubramanian, S. (2013). Graph theoretic

approach for analysing the readiness of an organisation for adapting lean thinking: A

case study. International Journal of Organizational Analysis, 21(3), 396-427.

21. Harrison, J. S., & Wicks, A. C. (2013). Stakeholder theory, value, and firm

PT
performance. Business ethics quarterly, 23(01), 97-124.

22. Hicks, C., McGovern, T., Prior, G., & Smith, I. (2015). Applying lean principles to

RI
the design of healthcare facilities. International Journal of Production Economics,

SC
170, 677-686.

23. Hines, P., Found, P., Griffiths, G., & Harrison, R. (2011). Staying Lean: thriving, not

U
just surviving. LERC, London.
AN
24. Jick, T. D. (1979). Mixing qualitative and quantitative methods: Triangulation in

action. Administrative science quarterly, 24(4), 602-611.

M

25. Jimmerson, C., Weber, D., & Sobek, D. K. (2005). Reducing waste and errors:
D

piloting lean principles at Intermountain Healthcare. The Joint Commission Journal

on Quality and Patient Safety, 31(5), 249-257.

TE

26. Jones, R. A., Jimmieson, N. L., & Griffiths, A. (2005). The impact of organizational
EP

culture and reshaping capabilities on change implementation success: The mediating

role of readiness for change. Journal of Management Studies, 42(2), 361-386.

C

27. Kao, C., & Liu, S. T. (2001). Fractional programming approach to fuzzy weighted
AC

average. Fuzzy sets and Systems, 120(3), 435-444.

28. Khanchanapong, T., Prajogo, D., Sohal, A. S., Cooper, B. K., Yeung, A. C., &

Cheng, T. C. E. (2014). The unique and complementary effects of manufacturing

technologies and lean practices on manufacturing operational performance.

International Journal of Production Economics, 153, 191-203.

40
 ACCEPTED MANUSCRIPT

29. King, D. L., Ben-Tovim, D. I., & Bassham, J. (2006). Redesigning emergency

department patient flows: application of lean thinking to health care. Emergency

Medicine Australasia, 18(4), 391-397.

30. Lin, C. T., & Chen, C. T. (2004). A fuzzy-logic-based approach for new product

PT
Go/NoGo decision at the front end. IEEE Transactions on Systems, Man, and

Cybernetics-Part A: Systems and Humans, 34(1), 132-142.

RI
31. Lin, C. T., Chiu, H., & Chu, P. Y. (2006). Agility index in the supply chain.

SC
International Journal of Production Economics, 100(2), 285-299.

32. Losonci, D., Demeter, K., & Jenei, I. (2011). Factors influencing employee

U
perceptions in lean transformations. International Journal of Production Economics,
AN
131(1), 30-43.

33. Mazzocato, P., Savage, C., Brommels, M., Aronsson, H., & Thor, J. (2010). Lean
M

thinking in healthcare: A realist review of the literature. Quality and Safety in Health
D

Care, 19(5), 376-382.

34. Mittal, V. K., & Sangwan, K. S. (2015). Ranking of drivers for green manufacturing
TE

implementation using fuzzy technique for order of preference by similarity to ideal

EP

solution method. Journal of Multi-Criteria Decision Analysis, 22(1-2), 119-130.

35. Narayanamurthy, G., & Gurumurthy, A. (2016). Leanness assessment: a literature

C

review. International Journal of Operations & Production Management, 36(10),

AC

1115-1160.

36. Narayanamurthy, G., & Gurumurthy, A. (2017). Is the hospital lean? A mathematical

model for assessing the implementation of lean thinking in healthcare

institutions. Operations Research for Health Care. In Press, Corrected Proof.

Available online at https://doi.org/10.1016/j.orhc.2017.05.002 (last accessed on 27

November 2017).

41
 ACCEPTED MANUSCRIPT

37. Narayanamurthy, G., Gurumurthy, A., & Moser, R. (2017). “8A” Framework for

Value Stream Selection – An Empirical Case Study. Journal of Organizational

Change Management. Ahead of Print.

38. Pham, H. H., Ginsburg, P. B., McKenzie, K., & Milstein, A. (2007). Redesigning

PT
care delivery in response to a high-performance network: the Virginia Mason

Medical Center. Health Affairs, 26(4), w532-w544.

RI
39. Phillips, R. (2003). Stakeholder theory and organizational ethics. Berrett-Koehler

SC
Publishers.

40. Piercy, N., & Rich, N. (2009). Lean transformation in the pure service environment:

U
the case of the call service centre. International journal of operations & production
AN
management, 29(1), 54-76.

41. Poksinska, B. (2010). The current state of Lean implementation in health care:
M

literature review. Quality Management in Healthcare, 19(4), 319-329.

D

42. Qi, Y., Huo, B., Wang, Z., & Yeung, H. Y. J. (2017). The impact of operations and

supply chain strategies on integration and performance. International Journal of

TE

Production Economics, 185, 162-174.

EP

43. Radnor, Z. & Boaden, R. (2008), “Editorial: lean in public services-panacea or

paradox?”, Public Money & Management, 28(1), 3-7.

C

44. Radnor, Z. (2010). Transferring lean into government. Journal of Manufacturing

AC

Technology Management, 21(3), 411-428.

45. Radnor, Z. (2011). Implementing lean in health care: making the link between the

approach, readiness and sustainability. International Journal of Industrial

Engineering and Management, 2(1), 1-12.

42
 ACCEPTED MANUSCRIPT

46. Radnor, Z., & Bucci, G. (2007). Evaluation of Pacesetter: Lean, Senior Leadership

and Operational Management within HMRC Processing. London: HM Revenue &

Customs, 86.

47. Radnor, Z., Holweg, M., & Waring, J. (2012). Lean in healthcare: the unfilled

PT
promise?. Social science & medicine, 74(3), 364-371.

48. Sachs, S., & Rühli, E. (2011). Stakeholders matter: A new paradigm for strategy in

RI
society. Cambridge University Press.

SC
49. Sánchez, A.M., & Pérez, M.P. (2001). Lean indicators and manufacturing strategies.

International Journal of Operations & Production Management, 21(11), 1433-1452.

U
50. Saurin, T. A., Marodin, G. A., & Ribeiro, J. L. D. (2011). A framework for assessing
AN
the use of lean production practices in manufacturing cells. International Journal of

Production Research, 49(11), 3211-3230.

M

51. Spear, S. J. (2005). Fixing health care from the inside, today. Harvard business
D

review, 83(9), 78.

52. Thelen, M. (2016). Why Lean Manufacturing Fails. Available at

TE

https://www.isixsigma.com/methodology/lean-methodology/why-lean-
EP

manufacturing-fails/ (last accessed on 3 October 2016).

53. Toussaint, J. (2009). Writing the new playbook for US health care: lessons from
C

Wisconsin. Health Affairs, 28(5), 1343-1350.

AC

54. Triantaphyllou, E., & Lin, C. T. (1996). Development and evaluation of five fuzzy

multiattribute decision-making methods. International Journal of Approximate

reasoning, 14(4), 281-310.

55. Tsasis, P., & Bruce-Barrett, C. (2008). Organizational change through lean

thinking. Health Services Management Research, 21(3), 192-198.

43
 ACCEPTED MANUSCRIPT

56. Wang, Y. J., & Lee, H. S. (2008). The revised method of ranking fuzzy numbers

with an area between the centroid and original points. Computers & Mathematics

with Applications, 55(9), 2033-2042.

57. Wang, Y. M., & Elhag, T. M. (2006). Fuzzy TOPSIS method based on alpha level

PT
sets with an application to bridge risk assessment. Expert systems with applications,

31(2), 309-319.

RI
58. Weiner, B. J., Amick, H., & Lee, S. Y. D. (2008). Review: Conceptualization and

SC
Measurement of Organizational Readiness for Change A Review of the Literature in

Health Services Research and Other Fields. Medical Care Research and Review,

U
65(4), 379-436.
AN
59. Wilson, L. (2013). Wanna Sabotage Your Lean Implementation Effort? Try This.

Industry Week. Available at http://www.industryweek.com/lean-sabotage?page=1

M

(last accessed on 3 October 2016).

D

60. Womack, J. P., & Jones, D. T. (2009). Lean solutions: how companies and

customers can create value and wealth together. Free Press, Simon and Schuster,
TE

New York.
EP

61. Yang, M. G. M., Hong, P., & Modi, S. B. (2011). Impact of lean manufacturing and

environmental management on business performance: An empirical study of

C

manufacturing firms. International Journal of Production Economics, 129(2), 251-

AC

261.

62. Zadeh LA. 1965. Fuzzy sets. Information and Control, 8, 338–353.

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Appendix

Appendix I – Description of sub-elements within an element in the proposed stakeholder-based lean readiness framework

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Element Sub-element Description of Sub-element

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Leadership and Strategic agenda alignment To begin with, leadership and executive team has to consider aligning their healthcare
executive team institution’s strategic agenda (vision and mission) in line with the objective of implementing

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lean. This will inform other stakeholders of the healthcare institution that they are getting ready
to begin the lean transformation.

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Lean knowhow To align their strategy, the executive team has to be first trained on the basics of lean and have
to concretize their lean knowhow to understand what can be realistically expected from

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implementing lean and how important is their role in achieving the expectations. Healthcare
institution’s leadership and executive team has to have knowledge of culture, principles and

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practices of lean and the procedure for its implementation to extract the targeted benefits.
Top management Knowledge of lean at the executive level will signal to the physicians, nurses, and other

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commitment medical staffs of the healthcare institution that the top management is committed, serious and

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dedicated to succeed in the transformation. It has to also arrive at a common understanding on
defining what lean means to them and communicate it to the entire healthcare institution. Long-
term commitment of credible and charismatic executives is required for regularly attending
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lean meetings, recruiting lean consultants, developing process improvement teams, agreeing for
training and retraining, and investing infrastructure (e.g. office space) and financial resources.
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Instituting lean positions To achieve the lean knowhow, leadership and executive team have to approach consultants of
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lean with expertise in healthcare, also known as lean sensei. Depending upon the availability of
funds, the healthcare institution can invest on a permanent in-house lean sensei team or can
gather services from an external lean consulting team. In either case, leadership and executive
team has to institutionalize dedicated lean positions (such as lean sensei, lean champions, etc.)

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with the responsibility of introducing the healthcare institution to lean concepts and supporting
them in the lean journey.
Organic structure & Open The readiness of the leadership and executive team can be determined by the organization

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culture structure (mechanistic or organic). True adoption of organic structure with open culture by
making all the employees feel significant is an important aspect of readiness for lean

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implementation. Healthcare institution’s structure needs to have least power differentials to
ensure inclusion, encourage innovation and sustain new work routines. Strong cohesive

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leadership engaging both senior and middle managers needs to exist. Devolution of authority to
the teams led by frontline employees such as nurses has to be initiated by the leadership team.

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Culture to openly share the key successes and failures with all leaders and staffs have to exist.

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Transition from the culture of firefighting to that of cause and effect has to be initiated.
Employees should not have hesitation to reveal the mistakes committed and should have the
mindset of learning from the errors to ensure that same mistakes are not repeated.

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Job security Employee job security (no fire policy) is one of the important readiness aspect of the leadership
and executive team. Leadership and executive team of the healthcare institution can be

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considered better ready for lean implementation if there is no fear of termination among the

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employees for cutting costs or for revealing the inefficiencies in the process.
Systems approach Mature readiness of the leadership and executive team is determined by its ability to adopt
systems approach in solving problems and taking decisions. Healthcare institution’s leadership
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and executive team has to take a wider view of improvement by crossing the functional
boundaries and by breaking the departmental silos. Lean should not be considered as a
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technique for ad-hoc problem-solving and cost elimination. Changing mindset from measuring
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progress in terms of the absolutes of success or failure to consistently meeting expected

outcomes has to be achieved.
Frontline Customized hands-on Customized hands-on training has to be provided to all physicians, nurses, and other medical
management training staffs on prerequisites lean through pilot projects to help them in understanding what lean

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team transformation looks like. A key focus of these training sessions has to be on the soft aspects of
going for lean implementation such as overcoming the resistance for change, systems thinking,
constructive culture, unlearning the traditional ways of thinking, etc. Feedback on training can

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be used to restructure the modules to suit the needs of the team being trained. This customized
hands-on training will prepare the frontline management team of the healthcare institution for

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easily getting onboard to the actual lean training which focusses on different lean elements
such as tools, techniques, principles, practices, and performance measures.

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Knowledge of the existing Entire frontline management team including the physicians, nurses, and other medical staffs
systems has to be knowledgeable on the existing systems. They should have a complete understanding

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of all the activities and functional areas within and across the process and be capable of

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proposing suggestions for redesigns in future. Each one of them should be aware of healthcare
institution’s floor map, patient pathway for different diagnosis/treatments, job description,
scope and accountability of all designations, and reporting structures. All the employees have

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to be able to communicate the importance and value of their current job.
Multi-skilled physicians, Physicians, nurses, and other medical staffs have to be trained and experienced with multiple

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nurses, and other medical skills to work in different positions within and across processes in the healthcare institution.

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staffs
Team culture among Physicians, nurses, and other medical staffs have to be experienced in working in teams with an
physician, nurse, and other objective to improve the patient satisfaction and overall team performance than the
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medical staffs performance of individuals involved. As it is the frontline management team which is under
pressure in completing the tasks, they have to work together to see how activities can be
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exchanged to reduce the pressure and thereby focus on better utilizing the available working
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hours.
Respect for peers and sub- Respect for peers and subordinates with least solidarity between different departments and
ordinates across employee positions have to be inculcated. As lean philosophy follows a bottom-up
approach in its frontline implementation, it is necessary that all employees irrespective of their

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positions are given equal respect and recognition. Ideas for improvement can come from any
employee and empowering all the employees is necessary to make them open up with their
ideas.

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Least resistance to change Frontline management team is considered to be ready when they do not exhibit resistance to
change. Acceptance towards reallocation or expansion of roles and/or processes is a necessary

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prerequisite for succeeding in the lean journey. Frontline management team should exhibit the
ability to quickly learn/unlearn from the experience to improve the efficiency of the processes.

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Frontline management team has to be convinced that the culture (prevailing norms,
assumptions, and beliefs) at the healthcare institution is going to change and it has to be

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welcomed.

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Physician, nurse, and other Meaningful involvement and engagement of medical staff, nurse and physicians including
medical staff involvement healthcare institution’s senior doctors have to be inculcated. Frontline management team has to
and engagement be affectively committed with their job and has to exhibit minimum employee turnover and

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absenteeism. Nurse and other medical staff have to own the processes to identify and
recommend improvements in their day to day job and associated processes. Involvement and

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engagement can be further enhanced by acknowledging frontline management team’s

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suggestions and insights before starting the lean journey and appreciating them that their efforts
are worthy of continuance. Reward systems have to be installed for recognizing innovative
ideas and improvement suggestions from the frontline management team. The culture for
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celebrating successful improvement initiatives has to be in place.
Lean sensei and Expertise of sensei and Lean sensei and team should have expertise in lean implementation for successfully guiding the
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team team healthcare institution in its lean journey. Lean sensei should be adopting functional (not
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authoritarian) and coaching (not policing) approach for buying the commitment of frontline
management team. Using their past expertise, lean sensei and team have to inculcate
willingness to change than resistance and fear to change among the frontline management
team. Usually the lean sensei recruited is highly experienced in implementing lean in the

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context of manufacturing and might have recently moved to the service context with an
objective of adapting the concepts of lean to services and in specific to healthcare. In such
cases, the lean team has to comprise of employees (nurses, medical staffs, and also physicians)

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from the healthcare institution to bring in the contextual knowledge of healthcare. Lean sensei
has to form the team such that the members complement each other’s expertise and holistically

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have the adequate expertise to start the lean journey.
Lean journey roadmap Complete details on how the lean implementation will be rolled out in the healthcare institution

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called as lean journey roadmap needs to be planned in detail by the lean sensei and team. The
team has to capture the micro-level details including the tasks to be done on the daily, weekly

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and monthly basis, the number of employees required, training modules, etc. The roadmap has

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to also capture the changes associated with job description, HR processes and policies. Keeping
in mind the roadmap planned, lean sensei and team have to get the necessary resource
requirements approved by the executive team.

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Comfort with lean team Comfort with lean team captures how comfortable are the frontline management team in
interfacing with the lean sensei and team. Frontline management team has to be comfortable

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with necessary willingness to change while getting facilitated by the lean sensei and team. Lean

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sensei has to create a climate of encouragement and urge the frontline management team to
work in hands with lean sensei and team for improving the experience of patients. A structured
procedure such as workforce planning can be used to change employee’s role or rotate
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employees across teams or functions to ensure that they don’t perceive the value of their work
to be in flux.
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Traveling together attitude Lean sensei and team have to impart traveling together attitude among all the stakeholders of
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the healthcare institution to synchronize all their viewpoints and ensure that everyone is on the
same page for the lean journey to be started. Lean sensei and team can achieve this attitude by
setting a very broad objective, say improving patient’s clinical and experiential quality, towards
which all the stakeholders have to travel by making improvements at their end. In addition,

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lean sensei and team should be cautious of conflicting objectives that can arise with progress
during implementation of lean and once identified has to be sought at the earliest.
Process-learning metrics Lean sensei and team have to identify process-learning metrics which has to be relevant,

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recognizable, and easy to implement before proceeding with the lean journey. Equal emphasis
and weightage have to be given for both process metrics and employee learning. These metrics

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can assist in understanding the progress made by employees in learning the lean philosophy
and also the efficiency attained by processes with the implementation of lean.

SC
Patients and other Knowledge of customer Healthcare institution has to have the knowledge of both internal and external customer groups.
customer groups groups Value for these customer groups has to be well-defined such that they can be linked to different

U
improvement initiatives that will be taken up in future. Pathway of these customer groups along

AN
with their associated data has to be documented in detail.
Patient respect, Respecting, involving and engaging patients and other customer groups in the treatment
involvement and process is an essential readiness aspect for succeeding in the lean journey. Customers who

M
engagement experience the entire process pathway of receiving care will have potential insights and
feedback for improving the process to increase the value received by them. For instance, need

D
for hospital layout change can be identified by analyzing the pathway taken by patients for

TE
receiving care from the hospital. Patient has to be respected, involved and engaged to assess if
the value required by them is same as that is understood by the healthcare institution. By
involving and engaging customers, healthcare institution confirms the respect and importance it
EP
gives to its patients and their family.
Patient’s knowledge of Patient’s knowledge of “end to end” process pathway indicates how much the healthcare
C

“end to end” process institution has involved and engaged the patient and has informed them about their processes.
AC

pathway This can be achieved only by making the end to end process from patient entry to exit highly
simple. Patient’s knowledge of “end to end” process pathway can be expected to also deliver
insightful improvement suggestions that can improve the satisfaction of patients in receiving
care.

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Supplier groups Supplier collaboration and Supplier collaboration and partnership increase the readiness for lean implementation at the
partnership healthcare institution as it increases the ability to monitor and share real time information by
collaborating and partnering with suppliers. It also facilitates the necessary technological

PT
assistance to and from the suppliers.
Supplier involvement and Supplier involvement and alignment can be achieved by aligning the supplier’s vision and

RI
alignment mission to the healthcare institution. Healthcare institution has to involve in developing a lesser
number of strategic and qualified suppliers.

SC
Supplier service quality High supplier service quality achievement by delivering consistently good quality product and
service is also an important characteristic of a supplier who is ready for lean implementation.

U
Healthcare Data measurement system Accurate data measurement system has to be in place to monitor the processes in the healthcare

AN
institution institution. Data compatibility across processes and departments has to be ensured before
attributes beginning the lean journey. Frontline management team has to understand the output of
measurement system and how such measurement can contribute to the improvement of

M
processes in the healthcare institution. Training needs to be provided to frontline management
team on how the collected data using the measurement system can be analyzed to draw

D
inferences.

TE
Capacity and demand Capacity and demand matching efforts have to be put in by the healthcare institution to
matching efforts optimally utilize its fixed and variable resources to achieve maximum efficiency. Healthcare
institution has to work towards understanding the trends in demand and think of solutions to
EP
enable smooth process flows. The procedure needs to be in place to measure and reassess
demand and arrange processes and activities as per the demand to attain a maximum value.
C

Past change experiences Past change experiences of the healthcare institution with different initiatives other than lean
AC

needs to be relooked. Outcomes of these past experiences influences how stakeholders of the
healthcare institution, especially frontline management team, will perceive the currently
planned change initiative using lean philosophy. Frontline management team needs to be made
aware of the similarities and differences (if any) between the past initiatives and the current

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initiative of lean implementation. Learnings from the past experience need to be incorporated
in the current initiative to avoid repetition of mistakes. Based on the past experience, forecasted
plans have to be developed for succeeding in the lean initiative.

PT
Patient and employee Ensuring patient and employee safety is a key prerequisite before any change initiative. Safe
safety environment to prevent injuries and strain on both patients and frontline management team are

RI
mandatory. Attention on the safety aspects conveys how much the healthcare institution cares
about its frontline management team and patients.

U SC
AN
M
D
TE
C EP
AC

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Tables

Table 1 - Snapshot of literature review on implementation of lean in healthcare institutions

Author Year Healthcare Institution Name Research Question Results

PT
Bushell & 2002 Progressive Healthcare How lean can help to improve Lean forces staff to stop and look at simple things that
Shelest primary care delivery processes? impact their daily work, find and address the issues,

RI
develop a team spirit, and give a feeling of control over
their own lives.

SC
Jimmerson 2005 Intermountain Health Care Whether and how the principles The implementation of lean tools accelerated problem
et al. of Toyota Production System solving, facilitated communication and buy-in across

U
(TPS) might apply to health care departments.
services?

AN
King et al. 2006 Flinders Medical Centre, How the concepts from Lean The total duration of the stay and waiting time for
Adelaide, South Australia thinking can be applied to patients can be significantly reduced by streaming the

M
establish streams for patient flows flows. The streaming is carried out in relation to their
in a teaching general hospital predicted outcome.

D
emergency department (ED)?

TE
Pham et 2007 Virginia Mason Medical Center How to redesign care delivery to Factors contributing to the success of Virginia Mason
al. improve the performance while Production System (VMPS) were committed leadership
reducing costs? to redesign care delivery, integrated system with an
EP
exclusively affiliated and salaried medical group, a
cohesive culture, information technology to facilitate
C

problem identification and implement change

AC

Toussaint 2009 Theda Care ,Wisconsin How lessons from lean Improved care and reduced cost can be achieved through
manufacturing can help to small cross-functional teams, collaborative care, patient's
improve care and lower costs in input, changing physician culture, and use of electronic
healthcare? health records
Chand 2011 Akron Children’s Hospital How to implement Lean Six The rounding process was studied to identify waste and
Sigma Methodology to eliminate the aspects of the activity that does not add value were
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Author Year Healthcare Institution Name Research Question Results

waste and variation in resident found out
rounding?
Radnor 2011 1.Pottery General Hospital NHS How organizations approach lean There is a direct relationship between the approach taken,

PT
Trust, 2.Iron Hospital implementation? Do they focus the conditions of readiness and the service improvement
NHS Trust, 3.Ring Mental only on tools of implementation activity in the organization
Health Trust and neglect organizational

RI
readiness?

SC
Díaz et al. 2012 Aravind Eye Care How principles of early triage and The main driver for Aravind's efficiency is an embedded
Lean practices can be applied to set of lean services practices facilitated by an early triage
provide better healthcare process, and that a better understanding of these can bring

U
operations? improvements in the healthcare sector.

AN
Garcia 2014 University of New Mexico How Lean management Using lean methodology and implementing PDSA (Plan,
principles can be used to improve Do, Study, Act) cycle have significantly reduced
patient satisfaction score and procedure cycle time and improved patient satisfaction.

M
reduce wait time?

D
TE
C EP
AC

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Table 2 - Snapshot of stakeholder based grouping of lean practices and performance measures implemented in healthcare institutions

Authors Year Practices Performance Measures

Bushell & 2002 Patients and other customer groups - Self check-in by patients using Healthcare institution attributes - Patient waiting time,

PT
Shelest smart cards for entry into exam room; Distance travelled by nurse;
Lean Sensei and Team - Value Stream Mapping, Standardized
operations, Visual/audio controls;

RI
Leadership & Executive Team - Workplace organization,
Information sharing;

SC
Jimmerson 2005 Healthcare institution attributes - Eliminating schedule Healthcare institution attributes - Backlog in
et al. incongruities, Moving transcriptionists out of the work area to pharmacy, Postage cost per year;

U
eliminate interruptions and clutter; Patients and other customer groups - Time to

AN
Patients and other customer groups - Issue or problem is stated treatment;
through the eyes of the customer; Lean Sensei and Team - Number of steps in getting
Lean Sensei and Team – VSM, 5 Whys method, Use of technology order to pharmacy, Accuracy and time to billing;

M
for real time information sharing, A3 problem solving approach,
Aligning flow paperwork with flow of the specimens,

D
Leadership & Executive Team -Relentlessly pursue for ideal state of

TE
error free work, Problems be taken in small and doable chunks,
Consistent work processes;
King et al. 2006 Patients and other customer groups - Seeing patients in the order of Patients and other customer groups - Overall time
EP
arrival rather than to prioritize to triage category; spent by the patient in the department; Time spent by
Lean Sensei and Team - Value Stream Map (VSM), Segmenting or patient waiting for review;
C

separating out care processes and managing each value stream Lean Sensei and Team - Average number of patients in
AC

separately, Continuous one piece flow; the ED at any time, Number of patients who do not wait;
Pham et 2007 Healthcare institution attributes - Identifying services that were not Healthcare institution attributes - Costs per migraine
al. useful; episode, Imaging costs;
Patients and other customer groups - Detailed review of individual
cases;
Frontline Management Team - Feedback to individual physicians on
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Authors Year Practices Performance Measures

cost performance;
Lean Sensei and Team - Online order entry or preprinted order forms
to automate restrictions on the number of pills on initial prescriptions

PT
and allow more pills on refills, Using published treatment guidelines;
Toussaint 2009 Frontline Management Team - Small cross-functional teams; Healthcare institution attributes - Defect free
Lean Sensei and Team - Kaizen, VSM, Collaborative care, Standard admission medication reconciliation, Preterm babies

RI
work, PDSA delivered, Mortality rate, Costs for a coronary bypass,
Healthcare institution attributes - Locked and stocked medicine Average cost per case;

SC
cabinets installed in each room (to give nurses extra time that could be Patients and other customer groups - Same day
spent at the bedside), Electronic health records; appointments in every office, “Door-to-balloon” time

U
(the minutes between a heart attack patient's entering a

AN
hospital and receiving a lifesaving angioplasty), Patient
satisfaction, Case-mix-index;
Lean Sensei and Team - Patients average time spent in

M
hospital, Quality bundle compliance;
Chand 2011 Patients and other customer groups - Patient data recording in the Patients and other customer groups - Value-added

D
online system; time per patient, Total rounding time per patient, Time

TE
Frontline Management Team - Multidisciplinary team, Balance of my physicians will take to see my child and me, Time
workload, Coach residents and provide timely feedback on their taken to answer my questions each day, Length of stay;
EP
physical examination, Receive adequate coaching and feedback from Frontline Management Team - Residents walking
attendings, Autonomy to manage patients, Writing single collaborative distance;
note; Lean Sensei and Team - Number of adverse events;
C

Lean Sensei and Team - DMAIC, Value stream map (VSM),

AC

Continuous one-piece flow, Built-in quality, Standardized work;

Radnor 2011 Healthcare institution attributes - Effective monitoring of Healthcare institution attributes - Direct savings;
implementation, outcomes and impact, Freeing the time of key Patients and other customer groups - Recording
resources, Reduction of time between two departments; patient details in multiple places, Patients being moved
Frontline Management Team - Visible leadership, Dedicated lean before beds are available, Length of stay, Number of
project teams, Dedicated local lean experts based in local offices, patients being moved from one ward to another, Death
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Authors Year Practices Performance Measures

Central lean experts rotated over three-month periods between sites rate for patients;
supported by external consultants, Senior managers to ‘Lead Lean’, Frontline Management Team - Excessive waiting for
Relevant training of staff, Internal team to support the lean activity, doctors and consultants, Staff walking distance,

PT
Improvement seen as part of their role, Communication of the changes, Manpower FTE;
Team working skills, More clarity around staff accountability, Lean Sensei and Team - Average turnaround time in
Lean Sensei and Team - Rapid Improvement Events (RIE’s) or a pathology, Time taken to process important categories of

RI
Kaizen event, Process mapping, Demand-capacity matching blood, Number of infections, Number of non-safety
incidents;

SC
Díaz et al. 2012 Healthcare institution attributes - Pokayoke (use of colored saris Not mentioned
and cards to identify patient sub-flows, use of simple brochures to

U
prepare patients for process), Transport and motion reduction (compact

AN
size of facilities and optimization evident in design of operating theatre
reduces motion waste), Waiting (streamlined processes facilitate
reduction of bottlenecks);

M
Patients and other customer groups - Use of software to assign
patients to OPD (to balance flow between units), Registration of

D
recurring patients directly at specialty clinic,

TE
Lean Sensei and Team - VSM, Variability reduction (triage
performed at the field, and at the beginning of process facilitate the
EP
classification of patients and capture data), Process simplification;
Supplier groups - Inventory optimization (vertical integration with
maker of critical supplies used to reduce costs and assure availability
C

of critical supplies);
AC

Garcia 2014 Frontline Management Team - Eliminate front staff involvement in Patients and other customer groups - Recovery cycle
procedure related questions and patients transportation; time;
Lean Sensei and Team - PDSA, Scheduling changes; Frontline Management Team - Staff overtime;
Lean Sensei and Team - Registration cycle time,
Procedure cycle time;

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Table 3 – Snapshot of implicitly stated lean readiness factors from the review of lean implementation in healthcare institutions literature

Author Year 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Bushell & 2002












Shelest

PT
Jimmerson 2005









et al.

RI
King et al. 2006









Pham et 2007






al.

SC
Toussaint 2009














Chand 2011

U
Radnor 2011

AN
Díaz et al. 2012










Garcia 2014

M
Implicitly Stated Lean Readiness Factors: 1 - Assessments of employee satisfaction; 2 - Barcode labelling for specimens; 3 - Capacity and demand matching efforts; 4 - Customized hands-on
training; 5 - Data measurement system; 6 - Expertise of sensei and team; 7 - Instituting lean positions; 8 - Job security; 9 - Knowledge of customer groups; 10 - Knowledge of the existing systems; 11 -
Lean journey roadmap; 12 - Comfort with lean team; 13 - Least resistance to change; 14 - Lean knowhow; 15 - Multi-skilled physicians, nurses, and staff; 16 - Organic structure & Open culture; 17 -

D
Past change experiences; 18 - Patient and employee safety; 19 - Patient respect, involvement and engagement; 20 - Patient’s knowledge of “end to end” process pathway; 21 - Physician, nurse, and staff
involvement and engagement; 22 - Process-learning metrics; 23 - Respect for peers and sub-ordinates; 24 - Strategic agenda alignment; 25 - Supplier collaboration and partnership; 26 - Supplier

TE
involvement and alignment; 27 - Supplier Service quality; 28 - Systems approach; 29 - Team culture among physician, nurse, and staff; 30 - Top management commitment; 31 - Traveling together with
a common objective.
C EP
AC

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Table 4 – Stakeholder-based lean readiness framework (LRF) for healthcare institutions

Healthcare Institution Lean S. No. Healthcare Institution Lean

Readiness Element (Stakeholder) Readiness Sub-Element
LRF1.1 Strategic agenda alignment
LRF1.2 Organic structure & Open culture
LRF1.3 Systems approach
LRF1. Leadership and Executive
LRF1.4 Instituting lean positions
Team
LRF1.5 Lean knowhow

PT
LRF1.6 Job security
LRF1.7 Top management commitment
LRF2.1 Customized hands-on training

RI
LRF2.2 Knowledge of the existing systems
LRF2.3 Multi-skilled physicians, nurses, and

SC
staff
LRF2.4 Team culture among physician, nurse,
LRF2. Frontline Management Team
and staff

U
LRF2.5 Respect for peers and sub-ordinates
LRF2.6 Least resistance to change
AN
LRF2.7 Physician, nurse, and staff
involvement and engagement
LRF3.1 Expertise of sensei and team
M

LRF3.2 Lean journey roadmap

LRF3. Lean Sensei and Team LRF3.3 Comfort with lean team
LRF3.4 Traveling together attitude
D

LRF3.5 Process-learning metrics

TE

LRF4.1 Knowledge of customer groups

LRF4.2 Patient respect, involvement and
LRF4. Patients and Other Customer
engagement
Groups
EP

LRF4.3 Patient’s knowledge of “end to end”

process pathway
LRF5.1 Supplier collaboration and partnership
C

LRF5. Supplier Groups LRF5.2 Supplier involvement and alignment

LRF5.3 Supplier service quality
AC

LRF6.1 Data measurement system

LRF6.2 Capacity and demand matching
LRF6. Healthcare Institution
efforts
Attributes
LRF6.3 Past change experiences
LRF6.4 Patient and employee safety

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Table 5 - Instrument for collecting data on healthcare institution’s lean readiness framework elements

S. No. Elements Description & Response

Leadership Healthcare unit needs to have high commitment and push from the top management to implement lean.
LRF1 and Executive Importance Not Least Somewhat Extremely Absolutely

PT
Important Mandatory
Team Weight important important important important critical
Frontline Frontline management team in healthcare unit needs to satisfy certain prerequisites before implementing lean.

RI
LRF2 Management Importance Not Least Somewhat Extremely Absolutely
Important Mandatory
Team Weight important important important important critical

SC
Oversight expert committee to coordinate the lean journey between leadership and frontline employees. Adaptation of
Lean Sensei manufacturing lean concepts to healthcare and in specific to the healthcare institution.
LRF3

U
and Team Importance Not Least Somewhat Extremely Absolutely
Important Mandatory

AN
Weight important important important important critical
Aspects related to customers, both internal and external, needs to be understood before proceeding with lean
Patients and
implementation.

M
LRF4 other customer
Importance Not Least Somewhat Extremely Absolutely
groups Important Mandatory
Weight important important important important critical

D
Supplier is key in implementing lean in the healthcare institution as they can have the capacity to increase or decrease

TE
Supplier waste in the focal organization.
LRF5
groups Importance Not Least Somewhat Extremely Absolutely
Important Mandatory
Weight important important important important critical
EP
Healthcare institution characteristics which needs to be made favorable for lean implementation. This involves primarily
Healthcare fixed resource investment which is independent of lean implementation, but having them in place makes lean
C

LRF6 institution implementation much smoother and impactful.

AC

attributes Importance Not Least Somewhat Extremely Absolutely

Important Mandatory
Weight important important important important critical

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Table 6 - Snapshot of instrument for collecting data on healthcare institution’s lean readiness framework sub-elements

Sub-
S. No. Description & Response
Elements
LRF1 Leadership & Executive Team

PT
Healthcare unit’s leadership team has to develop strategic actions to revise and associate lean with current agenda and
mission. It has to ensure common understanding on lean definition across the healthcare institution.

RI
Strategic
Importance Not Least Somewhat Extremely Absolutely
LRF1.1 agenda Important Mandatory
Weight important important important important critical

SC
alignment
Extent of Somewhat Fairly Extremely
Not ready Little ready Almost ready Ready
readiness ready ready ready

U
Healthcare organization’s structure needs to have least power differentials to ensure inclusion, encourage innovation and
sustain new work routines. Strong cohesive leadership by engaging both senior and middle managers needs to exist.

AN
Devolution of authority to the primarily nurse led teams has been initiated by leadership team to increase the degree of
Organic improvement. Culture to openly share the key successes and failures with all leaders and staff. Culture of moving from one

M
LRF1.2 structure & of fire-fighting and responding immediately to one of cause and effect.
Open culture Importance Not Least Somewhat Extremely Absolutely

D
Important Mandatory
Weight important important important important critical

TE
Extent of Somewhat Fairly Extremely
Not ready Little ready Almost ready Ready
readiness ready ready ready
Healthcare unit’s leadership team takes a wider view of improvement by crossing the boundaries of functions and by
EP
breaking the departmental silos. Lean is not just considered as a technique for cost elimination. Understanding to not
encourage adhoc problem-solutions that are not completely aligned with end-to-end Lean implementation. Changing
C

Systems mindset from measuring progress in terms of the absolutes of success or failure to consistently meeting expected outcomes.
LRF1.3
AC

approach Importance Not Least Somewhat Extremely Absolutely

Important Mandatory
Weight important important important important critical
Extent of Somewhat Fairly Extremely
Not ready Little ready Almost ready Ready
readiness ready ready ready

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Table 7 - Linguistic variables and their corresponding fuzzy numbers

Extent of Readiness Importance weights

Linguistic variable Fuzzy numbers Linguistic variable Fuzzy numbers
Not Ready [NR] 1 2 3 Not Important [NI] 0 0.05 0.15
Little Ready [LR] 2 3 4 Least Important [LI] 0.1 0.2 0.3
Somewhat Ready [SR] 3 4 5 Somewhat Important [SI] 0.2 0.35 0.5
Fairly Ready [FR] 4 5 6 Important [IT] 0.3 0.5 0.7
Almost Ready [AR] 5 6 7 Extremely Important [EI] 0.5 0.65 0.8

PT
Ready [RY] 6 7 8 Absolutely Critical [AC] 0.7 0.8 0.9
Fully Ready [FR] 7 8 9 Mandatory [MY] 0.85 0.95 1

RI
Table 8 - Snapshot of linguistic fuzzy values for Extent of Readiness and Importance weights of
sub-elements under the tenet “LRF1”.

SC
Lean Readiness Lean Readiness Extent of Readiness Importance Weight
Framework Framework Sub-
A1 A2 A3 A4 A5 A1 A2 A3 A4 A5
Element (LRFi) element (LRFij)

U
AC AC MY MY IT
AN
LRF1.1 FR SR AR RY FR EI EI EI AC AC
LRF1.2 AR SR SR FR SR IT AC AC EI MY
LRF1.3 RY LR LR LR FR EI AC IT EI SI
LRF1
M

LRF1.4 FR FR FR FR FR EI EI MY AC AC
LRF1.5 FR SR AR FR LR AC AC MY AC EI
LRF1.6 RY RY AR FR RY MY EI MY MY AC
D

LRF1.7 RY RY AR FR FR EI EI MY EI EI
TE

Table 9 - Conversion of linguistic fuzzy values of Extent of Readiness and Importance Weight
into fuzzy numbers for “LRF1.1”.
EP

Equivalent Equivalent
Assessors Extent of Readiness Importance Weight
Fuzzy Number Fuzzy Number
A1 Fairly Ready [FR] 4 5 6 Extremely Important [EI] 0.5 0.65 0.8
C

A2 Somewhat Ready [SR] 3 4 5 Extremely Important [EI] 0.5 0.65 0.8

AC

A3 Almost ready [AR] 5 6 7 Extremely Important [EI] 0.5 0.65 0.8

A4 Ready [RY] 6 7 8 Absolutely Critical [AC] 0.7 0.8 0.9
A5 Fairly Ready [FR] 4 5 6 Absolutely Critical [AC] 0.7 0.8 0.9
4.4 5.4 6.4 Fuzzy average 0.58 0.71 0.84
Fuzzy average Extent of Readiness
Importance Weight of
of LRF1.1
LRF1.1

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Table 10 - Readiness level and ranking scores of sub-elements of lean readiness framework

Average Readiness
Sub-element Average Extent of Readiness Readiness Value
Importance Weight Level
LRF1.1 4.40 5.40 6.40 0.58 0.71 0.84 2.55 3.83 5.38 3.92
LRF1.2 3.60 4.60 5.60 0.61 0.74 0.86 2.20 3.40 4.82 3.47
LRF1.3 3.20 4.20 5.20 0.44 0.59 0.74 1.41 2.48 3.85 2.58
LRF1.4 5.80 6.80 7.80 0.65 0.77 0.88 3.77 5.24 6.86 5.29
LRF1.5 3.60 4.60 5.60 0.69 0.80 0.90 2.48 3.68 5.04 3.73

PT
LRF1.6 6.00 7.00 8.00 0.75 0.86 0.94 4.50 6.02 7.52 6.01
LRF1.7 5.00 6.00 7.00 0.57 0.71 0.84 2.85 4.26 5.88 4.33
LRF2.1 3.80 4.80 5.80 0.36 0.53 0.70 1.37 2.54 4.06 2.66

RI
LRF2.2 5.00 6.00 7.00 0.40 0.56 0.72 2.00 3.36 5.04 3.47
LRF2.3 4.20 5.20 6.20 0.56 0.68 0.80 2.35 3.54 4.96 3.62
LRF2.4 5.80 6.80 7.80 0.55 0.68 0.80 3.19 4.62 6.24 4.68

SC
LRF2.5 6.60 7.60 8.60 0.68 0.80 0.90 4.49 6.08 7.74 6.10
LRF2.6 4.20 5.20 6.20 0.46 0.62 0.78 1.93 3.22 4.84 3.33
LRF2.7 6.60 7.60 8.60 0.72 0.83 0.92 4.32 5.81 7.36 5.83

U
LRF3.1 4.40 5.40 6.40 0.61 0.74 0.86 4.03 5.62 7.40 5.68
AN
LRF3.2 4.80 5.80 6.80 0.50 0.65 0.80 2.20 3.51 5.12 3.61
LRF3.3 4.60 5.60 6.60 0.36 0.53 0.70 1.73 3.07 4.76 3.19
LRF3.4 4.00 5.00 6.00 0.61 0.74 0.86 2.81 4.14 5.68 4.21
LRF3.5 4.80 5.80 6.80
M

0.69 0.80 0.90 2.76 4.00 5.40 4.05

LRF4.1 5.20 6.20 7.20 0.61 0.74 0.86 2.93 4.29 5.85 4.36
LRF4.2 4.00 5.00 6.00 0.72 0.83 0.92 3.74 5.15 6.62 5.17
D

LRF4.3 4.00 5.00 6.00 0.38 0.53 0.68 1.52 2.65 4.08 2.75
LRF5.1 3.40 4.40 5.40 0.28 0.47 0.66 1.12 2.35 3.96 2.48
TE

LRF5.2 4.20 5.20 6.20 0.54 0.68 0.82 1.84 2.99 4.43 3.09
LRF5.3 5.00 6.00 7.00 0.65 0.77 0.88 2.73 4.00 5.46 4.06
LRF6.1 4.20 5.20 6.20 0.52 0.65 0.78 2.60 3.90 5.46 3.99
EP

LRF6.2 4.40 5.40 6.40 0.36 0.53 0.7 1.51 2.76 4.34 2.87
LRF6.3 5.80 6.80 7.80 0.61 0.74 0.86 2.68 4.00 5.50 4.06
LRF6.4 3.80 4.80 5.80 0.68 0.8 0.9 3.94 5.44 7.02 5.47
C
AC

Table 11 - Readiness level and ranking scores of elements of lean readiness framework

Average Importance
Element Computed Extent of Readiness Readiness Level Readiness Value
Weight
LRF1 4.61 5.58 6.56 0.68 0.80 0.90 3.13 4.47 5.90 4.50
LRF2 5.27 6.21 7.16 0.55 0.68 0.80 2.90 4.22 5.73 4.28
LRF3 4.88 5.88 6.88 0.72 0.83 0.92 3.51 4.88 6.33 4.91
LRF4 4.79 5.76 6.73 0.51 0.65 0.78 2.44 3.74 5.25 3.81
LRF5 3.87 4.87 5.87 0.20 0.35 0.50 0.77 1.70 2.93 1.80
LRF6 4.95 5.92 6.89 0.41 0.56 0.70 2.03 3.31 4.82 3.39
HLRI 4.797 5.744 6.703 5.75

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Table 12 - Distance, closeness coefficients, and ranking of sub-elements using similarity to
ideal solution technique

Sub-element Lean Readiness Level D_FPIS (B+) D_FPIS (B-) CCi Rank
LRF1.1 2.552 3.834 5.376 3.99 3.03 0.43 16
LRF1.2 2.196 3.404 4.816 4.40 2.58 0.37 21
LRF1.3 1.408 2.478 3.848 5.26 1.77 0.25 28
LRF1.4 3.77 5.236 6.864 2.76 4.36 0.61 6
LRF1.5 2.484 3.68 5.04 4.14 2.82 0.40 17

PT
LRF1.6 4.5 6.02 7.52 2.12 5.05 0.70 2
LRF1.7 2.85 4.26 5.88 3.63 3.44 0.49 10
LRF2.1 1.368 2.544 4.06 5.20 1.89 0.27 27

RI
LRF2.2 2 3.36 5.04 4.45 2.66 0.37 20
LRF2.3 2.352 3.536 4.96 4.26 2.71 0.39 19
LRF2.4 3.19 4.624 6.24 3.30 3.78 0.53 8

SC
LRF2.5 4.488 6.08 7.74 2.11 5.16 0.71 1
LRF2.6 1.932 3.224 4.836 4.57 2.51 0.35 22
LRF2.7 4.32 5.81 7.36 2.28 4.87 0.68 3

U
LRF3.1 4.026 5.624 7.396 2.48 4.77 0.66 4
LRF3.2 2.2 3.51 5.12 4.30 2.76 0.39 18
AN
LRF3.3 1.728 3.074 4.76 4.72 2.41 0.34 23
LRF3.4 2.806 4.144 5.676 3.72 3.30 0.47 11
LRF3.5 2.76 4 5.4 3.84 3.13 0.45 14
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LRF4.1 2.928 4.292 5.848 3.59 3.45 0.49 9

LRF4.2 3.744 5.146 6.624 2.83 4.22 0.60 7
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LRF4.3 1.52 2.65 4.08 5.10 1.94 0.28 26

LRF5.1 1.12 2.35 3.96 5.39 1.79 0.25 29
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LRF5.2 1.836 2.992 4.428 4.77 2.23 0.32 24

LRF5.3 2.73 4.004 5.456 3.84 3.15 0.45 13
LRF6.1 2.6 3.9 5.46 3.93 3.10 0.44 15
EP

LRF6.2 1.512 2.756 4.34 5.01 2.10 0.30 25

LRF6.3 2.684 3.996 5.504 3.85 3.16 0.45 12
LRF6.4 3.944 5.44 7.02 2.60 4.53 0.64 5
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FPIS (B+) 7.74 7.74 7.74

FNIS (B-) 1.12 1.12 1.12
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Table 13 - Distance, closeness coefficients, and ranking of sub-elements within an element
using similarity to ideal solution technique

Element Sub-element Lean Readiness Level D_FPIS (B+) D_FPIS (B-) CCi Rank
LRF1 LRF 1.1 2.552 3.834 5.376 3.78 2.77 0.42 4
LRF 1.2 2.196 3.404 4.816 4.19 2.33 0.36 6
LRF 1.3 1.408 2.478 3.848 5.04 1.54 0.23 7
LRF 1.4 3.77 5.236 6.864 2.56 4.08 0.61 2
LRF 1.5 2.484 3.68 5.04 3.93 2.55 0.39 5

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LRF 1.6 4.5 6.02 7.52 1.95 4.77 0.71 1
LRF 1.7 2.85 4.26 5.88 3.42 3.17 0.48 3
FPIS (B+) 7.52 7.52 7.52

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FNIS (B-) 1.408 1.408 1.408
LRF2 LRF 2.1 1.368 2.544 4.06 5.20 1.70 0.25 7
LRF 2.2 2 3.36 5.04 4.45 2.44 0.35 5

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LRF 2.3 2.352 3.536 4.96 4.26 2.49 0.37 4
LRF 2.4 3.19 4.624 6.24 3.30 3.54 0.52 3
LRF 2.5 4.488 6.08 7.74 2.11 4.92 0.70 1

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LRF 2.6 1.932 3.224 4.836 4.57 2.29 0.33 6
LRF 2.7 4.32 5.81 7.36 2.28 4.63 0.67 2
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FPIS (B+) 7.74 7.74 7.74
FNIS (B-) 1.368 1.368 1.368
LRF3 LRF 3.1 4.026 5.624 7.396 2.20 4.19 0.66 1
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LRF 3.2 2.2 3.51 5.12 3.97 2.23 0.36 4

LRF 3.3 1.728 3.074 4.76 4.39 1.92 0.30 5
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LRF 3.4 2.806 4.144 5.676 3.40 2.74 0.45 2

LRF 3.5 2.76 4 5.4 3.51 2.56 0.42 3
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FPIS (B+) 7.396 7.396 7.396

FNIS (B-) 1.728 1.728 1.728
LRF4 LRF 4.1 2.928 4.292 5.848 2.56 3.08 0.55 2
EP

LRF 4.2 3.744 5.146 6.624 1.87 3.84 0.67 1

LRF 4.3 1.52 2.65 4.08 4.01 1.62 0.29 3
FPIS (B+) 6.624 6.624 6.624
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FNIS (B-) 1.52 1.52 1.52

LRF5 LRF 5.1 1.12 2.35 3.96 3.20 1.79 0.36 3
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LRF 5.2 1.836 2.992 4.428 2.60 2.23 0.46 2

LRF 5.3 2.73 4.004 5.456 1.78 3.15 0.64 1
FPIS (B+) 5.456 5.456 5.456
FNIS (B-) 1.12 1.12 1.12
LRF6 LRF 6.1 2.6 3.9 5.46 3.25 2.74 0.46 3
LRF 6.2 1.512 2.756 4.34 4.31 1.78 0.29 4
LRF 6.3 2.684 3.996 5.504 3.18 2.80 0.47 2
LRF 6.4 3.944 5.44 7.02 2.00 4.15 0.68 1
FPIS (B+) 7.02 7.02 7.02
FNIS (B-) 1.512 1.512 1.512

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Table 14 - Distance, closeness coefficients, and ranking of elements using similarity to ideal
solution technique

Element Lean Readiness Level D_FPIS (B+) D_FPIS (B-) CCi Rank
LRF 1 3.13212 4.46517 5.90160 2.15 3.89 0.64400878 2
LRF 2 2.89745 4.22150 5.72754 2.35 3.69 0.61093441 3
LRF 3 3.51422 4.88213 6.33103 1.83 4.29 0.70123659 1
LRF 4 2.44323 3.74152 5.24820 2.77 3.25 0.53973331 4
LRF 5 0.77361 1.70370 2.93305 4.61 1.36 0.22735999 6

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LRF 6 2.02922 3.31306 4.82309 3.16 2.85 0.47478497 5
FPIS (B+) 7.52 7.52 7.52
FNIS (B-) 1.408 1.408 1.408

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Table 15 - Strong and weak Sub-elements of lean readiness framework in the assessed

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healthcare unit

Strong Sub-elements
LRF2.5 Respect for peers and sub-ordinates

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LRF1.6 Job security
LRF2.7 Physician, nurse, and staff involvement and engagement
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LRF3.1 Expertise and experience of sensei and team
LRF6.4 Patient and employee safety
LRF1.4 Instituting lean positions
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Weak Sub-elements
LRF5.1 Supplier collaboration and partnership
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LRF1.3 Systems approach

LRF2.1 Customized hands-on training
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LRF4.3 Patient’s knowledge of “end to end” process pathway

LRF6.2 Capacity and demand matching efforts
LRF5.2 Supplier involvement and alignment
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Table 16 - Strong and weak sub-elements within an element of lean readiness framework in
the assessed healthcare unit

Element Strong Sub-elements Weak Sub-elements

LRF 1 LRF 1.6 Job security LRF 1.3 Systems approach
LRF 1.4 Instituting lean positions LRF 1.2 Organic structure & Open
culture
LRF 2 LRF 2.5 Respect for peers and sub- LRF 2.1 Customized hands-on training
ordinates LRF 2.6 Least resistance to change

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LRF 2.7 Physician, nurse, and staff
involvement and
engagement

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LRF 3 LRF 3.1 Expertise of sensei and LRF 3.3 Comfort with lean team
team
LRF 4 LRF 4.2 Patient respect, LRF 4.3 Patient’s knowledge of “end

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involvement and to end” process pathway
engagement
LRF 5 LRF 5.3 Supplier service quality LRF 5.1 Supplier collaboration and

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partnership
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LRF 6 LRF 6.4 Patient and employee LRF 6.2 Capacity and demand
safety matching efforts
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Table 17 - Strong and weak elements of lean readiness framework in the assessed healthcare
unit
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Strong Elements Weak Elements

LRF 3 Lean Sensei and Team LRF 5 Supplier Groups
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LRF 1 Leadership & Executive Team LRF 6 Healthcare Institution Attributes

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Figures

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Figure 1 - Fuzzy Logic based healthcare institution lean readiness assessment procedure
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Figure 2 - Linguistic levels for matching HLRI
[HLR Member Set = {(Not Ready (1, 1, 3); Low Ready (1, 3, 5); Average Ready (3, 5, 7); Close to Ready (5, 7, 9); Ready (7, 9, 9)}]

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"AVERAGE
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READY"
5 Minimun 'D'
Best linguistic match

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Not Ready Low Ready Average Ready Close to Ready Ready

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HLR Member Set

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Figure 3 - HLRI Euclidean distance (D) from each member of HLR Set

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Figure 4 - Closeness coefficients of sub-elements and focus areas

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Figure 5 - Closeness coefficients of sub-elements and focus areas within an element
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Figure 6 - Closeness coefficients of elements and focus areas
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Highlights

1. We propose a stakeholder-based lean readiness framework for healthcare institution

2. We develop a procedure for assessing the readiness of a healthcare institution

3. We report experiences of deploying the framework in a US healthcare institution

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4. The readiness of stakeholders is quantified and ranked with future recommendations

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5. We discuss a lean readiness laboratory initiative for testing pilot lean projects

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