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Brief analytical summaries or syntheses #36

How does lean work in emergency care ?

A case study of a lean-inspired intervention at the

Astrid Lindgren Children’s Hospital, Stockholm, Sweden


This study published in BMC Health Services investigates how a package of “lean-like” changes translated into better care process management in a health care setting. The authors studied an intervention in a children’s hospital’s emergency department in Stockholm. Improvements in wait and lead times were sustained following changes to employee staffing, scheduling, and problem solving.


There is growing interest in applying lean thinking in health care, yet there is still limited knowledge of how and why lean interventions succeed (or fail). Emergency departments (EDs) all over the world are challenged with problems of overcrowding and excessive waiting times. Overcrowding and delays correlate with increased patient mortality, decreased patient and staff satisfaction, and inefficient use of resources. Moreover, as EDs are considered to be the heart of hospitals, problems there may affect the whole organization. Process and flow problems are factors that contribute to delays and overcrowding.
Hoping to overcome the limitations of function-based organization, many healthcare organizations are adopting approaches such as lean thinking to better integrate health care delivery. The term lean thinking (hereafter referred to as “lean”) is based on a production philosophy originally developed by Toyota Motor Corporation. It consists of principles and practices that focus on minimizing the total time and resources needed to produce and supply goods or services to a customer, thus increasing efficiency. Reductions in time and resource use are achieved by focusing on value-adding steps and eliminating non-value-adding steps in the production process. Literature reviews show that lean has been applied with success to a wide range of clinical situations.

Analysis and results

Improvements in waiting and lead times were achieved and sustained in the two years following lean-inspired changes to employee roles, staffing and scheduling, communication and coordination, expertise, workspace layout, and problem solving. These changes resulted in improvement because they:

(a) standardized work and reduced ambiguity;

(b) connected people who were dependent on one another;

(c) enhanced seamless, uninterrupted flow through the process; and

(d) empowered staff to investigate problems and to develop countermeasures using a "scientific method".

Contextual factors that may explain why not even greater improvement was achieved included: a mismatch between job tasks, licensing constraints, and competence; a perception of being monitored, and discomfort with inter-professional collaboration.


Rather than merely arguing that “lean works” in health care, as most recent studies have done, the authors demonstrated how and why performance improvement resulted from a package of lean-inspired changes. They did this by applying four theoretical lean principles to demonstrate specific ways in which lean-inspired changes transformed work and improved performance in an ED. The adapted lean principles offered here may enable healthcare organizations and managers to pick the right components of a lean program and to better understand the reasons behind lean’s success (or failure).

Implications and recommendations

Standardize work
Before the hospital-initiated improvement efforts, different actors assumed their roles and responsibilities based on spheres of expertise. While this approach is common in healthcare, it has been claimed to yield ambiguity about who should do what, when, and how. The lean intervention brought new roles and responsibilities (flow managers, team nurse and nurse’s aide, and team physician), which were further formalized in job descriptions.
Connect people that are dependent on one another
Before lean, there was no explicit expectation concerning who should provide a service, to whom, and when. Thus, for example, any nurse available would act on a physician’s order when they were free and felt ready to take on a new task. In addition, communication between caregivers was asynchronous, mainly handled through paper charts left at the nursing station. In contrast, the team-based organization created clearer, synchronous connections between the caregivers involved in the process. Coordination between caregivers was also facilitated by the new workstation arrangement, with care team members sitting together.
Create seamless uninterrupted flow through the process
Before the hospital-initiated improvement efforts, caregivers shared responsibility for all patients at the ED, in a rather implicit manner. Moreover, there was not explicit expectation for the timing of care providers’ actions. With the changes, flow managers were explicitly assigned overall responsibility for work and patient flow at the ED.
Empower staff to investigate problems with the process and to develop, test, and implement countermeasures using a "scientific method”
The team approach to problem solving brought together members from different professions and helped them to understand how their work related to others and to patient needs. It also empowered people on the floor to manage processes and to come up with suggestions for improvement. 


How does lean work in emergency care ? A case study of a lean-inspired intervention at the Astrid Lindgren Children’s Hospital, Stockholm, Sweden