Health care is a complex multi-professional setting with a tradition of strong professional leadership and considerably conservative structures and managerial models (Reference Viitanen, Kokkinen, Konu, Simonen, Virtanen, Lehto and terveydenhuollossa1;Reference Antwi and Kale2). During past 2 decades, there has been a requirement for transformation of the leadership and management of healthcare organizations to improve efficacy and safety (Reference Viitanen, Kokkinen, Konu, Simonen, Virtanen, Lehto and terveydenhuollossa1;Reference Al-Abri3). Typically, the new managerial principles are adopted from the industry without a thorough consideration how these managerial models fit or should be implemented into health care. For healthcare professionals, who are used to evidence-based decision making, there are few if any systematic tools to analyze the benefits and usefulness of various leadership ideologies in advance. However, the principles of health technology assessment should be applicable to the systems and managerial processes, as well, and might provide better understanding about the skills and capabilities that are required to good leadership and management in healthcare organizations while aiming at continuous transformation as a response to the ongoing change of technologies and societies. Lean thinking is one of the recent leadership and transformation ideologies adapted from business and industry that should be assessed critically in the context of healthcare organizations.
Lean is a set of operating philosophies, leadership and management practices, and tools that can help create maximum value for patients, for example, by reducing the sources of waste in a process (Reference Drotz and Poksinska4–Reference Maijala, Eloranta, Saloniemi and Ikonen7). Lean health care can be described as a management philosophy to develop a hospital culture through continuous improvements, in which all employees actively participate in identifying and reducing non–value-adding activities (waste) (Reference Dahlgaard, Jostein and Dahlgaard-Park8). Health expenditure and the cost of treatments are expected to increase due to advances in medical technologies, population ageing, and rising public expectations (9). Lean is thought to be one solution in response to the efficiency and productivity demands to improve the quality of health services (Reference Joosten, Bongers and Janssen10–Reference Waring and Bishop17). In the same time, it seems that the concept of Lean has been misunderstood in the health care. Staff associate Lean with automotive applications and cost reduction. It would be fruitful for managers to develop a strategy for continual improvement and use vocabulary that is familiar with healthcare staff (Reference Savage, Parke, Von Konrring and Mazzocato18). In addition, the healthcare sector is going through technology-enabled changes. It has been suggested that it's possible to increase IT productivity in health care by 20 to 40 percent through the application of Lean (Reference Huskins, Van Kuiken and Velamoor19).
However, it is not clear that healthcare organizations generally carry out implementations systematically. Usually, Lean thinking is attempted by means of piecemeal applications and small-enclosed projects using Lean methods and tools, rather than creating a holistic cultural change that promotes the involvement of employees in daily improvements and behavioral changes (Reference Aij and Rapsaniotis20;Reference Andersen, Rovik and Ingebritsen21).
Recent studies have stated that leadership and management practices are critical to successful implementation of Lean thinking in health care (Reference Aij and Rapsaniotis20–Reference Lorden, Zhang, Lin and Cote22). Approximately 80 percent of the effort in Lean implementation is expended on changing the practices of leaders (Reference Mann23). Lean leaders are coaches who create the strategy, build the team, and help employees develop their skills (Reference Aij and Rapsaniotis20). Successful Lean interventions share some common features, such as management and leadership engagement (Reference Andersen, Rovik and Ingebritsen21).
Leaders need to act in two differing roles (Reference Aij, Aernoudts and Joosten24;Reference Aij, Visse and Widdershoven25). Lean management is rooted in two key principles: continuous improvement and respect for people. Both strive to eliminate waste and add value for customers or stakeholders (Reference Ljungblom26). Management is concerned with the organization of groups of people with a focus on providing work structures for individuals through controlling and coordinating activities. Leadership is concerned with motivating groups of people and suggests a social influence process, capable of facilitating change (Reference Aij, Aernoudts and Joosten24;Reference Aij, Visse and Widdershoven25). However, little is known about which facilitators are most important (Reference Andersen, Rovik and Ingebritsen21).
Lean management tools and techniques have many process management applications as regards health care and organizations that can improve quality, patient safety and cost-effectiveness (Reference Chiodo, Wilke, Bakshi, Craig, Duew and Hurwitz27;Reference Thomas28). These tools and techniques need to be related to the overall strategy and the principles of Lean health care to be successful (Reference Dahlgaard, Jostein and Dahlgaard-Park8). It has been stated that implementing Lean thinking and Lean tools into health care requires different skills from leaders than those required by traditional healthcare management (Reference Aij and Rapsaniotis20;Reference Thomas28). However, at the same time, there is a lack of complete understanding of the leadership/management practices that are necessary to achieve the successful widespread mobilization and sustainability of Lean thinking (Reference Aij, Simons, Widdershoven and Visse29;Reference Steed30).
The aim of this study was to review and analyze recent literature regarding Lean leadership and management, and to identify the characteristics of leadership and management that are associated with successful Lean thinking adaptation in health care. In addition, we tested the concept of the windshield (Reference Vanharanta31–Reference Reunanen and Kaitonen34) to analyze the skills and capabilities of Lean leadership and management that were described in the original studies, as to present a comprehensive overview of the managerial traits that are important for achieving successful Lean thinking in health care. Vanharanta describes that the management windshield metaphor is built from three different viewpoints: time, leadership and management. These viewpoints have been placed into a driver's windshield. The focus of the concept of the managerial windshield is to help decision makers in those situations where managers, leaders, and executives are at a conscious management and leadership “stage.”
Another purpose is to clarify some important management and leadership concepts. In the managerial windshield, the concept of being a manager is divided into two categories, leadership and management. Both managerial categories are further divided into four ontology dimensions: activities, style, focus, and purpose (Reference Vanharanta31). In this review, we did not use time-perspective. The model was chosen because it affected a systematic way of identifying and parsing leadership features.
DESIGN
Search Methods
Data were collected systematically. In February 2016, literature searches were carried out with the aid of an information specialist at Turku University Library for references published between January 2011 and February 2016. Search terms are presented in Figure 1. We conducted a computer search of published literature on the following electronic databases: PubMed, PubMed Systematic Review, ABI/INFORM, Business Source Complete, Emerald, JBI, and Cinahl. In all the searches, appropriate truncations and possible misspellings were included and the search terms were adapted for different databases. Other sources of information were examined by a hand search, such as reference lists of key articles identified through the search strategy. A full description of the review protocol and process for selecting studies can be obtained from the authors (Figure 1).
Figure 1. Process of data collection.
Inclusion and Exclusion Criteria
Articles had to satisfy the following inclusion criteria to be considered: (i) a description of Lean management or leadership in health care, (ii) a reference to Lean thinking, (iii) a peer-reviewed original research article or a literature review, and (iv) a full text article available in English. Exclusion criteria were: (i) an editorial article or (ii) a description or an evaluation of an educational framework or model (Figure 1).
Retrieval of the Studies for Review and Their Critical Appraisal
The selection of the studies was performed in three steps. First, one of the authors (R.M.) examined the titles and, second, three authors (R.M., S.E., T.I.) examined the abstracts. Third, all the authors reviewed the full text articles with regard to the inclusion criteria. Any disagreement between the authors was resolved by an additional review. We retrieved a total of 1,754 peer-reviewed articles of which 1,742 were rejected and twelve papers were included in the review. The critical appraisals were discussed between the authors and by consensus all twelve articles were accepted into the review. Nine studies were original articles. Three systematic reviews were included to widen the perspective and ensure that no essential qualitative information from earlier studies was missed (Figure 1).
Analysis of the Data
Deductive content analysis was used to analyze the data. One author performed a content analysis on each chosen study using open coding, category creation, and abstraction (Reference Burns and Grove35;Reference Frankfort-Nachmia and Nachmias36). After this, the constructions were discussed together by all the authors and a consensus was reached as to how the data were to be interpreted.
The analysis of nine original studies of adapting Lean thinking to health care was conducted by identifying the characteristics and traits related to the skills and capabilities mentioned as being associated with successful Lean adaptation. The traits were defined as four leadership and management dimensions: activities, style, focus, and the purpose of the concept of the windshield. Information was collected from the abstracts, results, including tables or figures, and conclusion sections of the original articles in a table format.
FINDINGS
Description of the Studies Reviewed
Of the twelve studies included in the review, nine were original studies and three reviews. The original studies were conducted in the United States (n = 5), the Netherlands (n = 3), and Canada (n = 1). A variety of data collection methods were used in the original studies: surveys/questionnaires (n = 2), interviews (n = 6), observations (n = 1), ethnographic case study (n = 1), and a combination of these (n = 2). One of the original studies did not describe the data collection methods in detail. Typically, the study settings consisted of patient treatment. Lean thinking was established within eight of the organizations and one was in the process of implementing Lean. In seven studies, the informants were positioned as managers in the organization. In eleven studies, both concepts of leadership and management were used, only one original study just used the concept of management (Table 1).
Table 1. Original Studies of Successful Lean Implementation, Their Healthcare Settings, Data Collection Methods, Informants, Study Objectives, and the Main Findings of the Study
CEO, chief executive officer; ED, emergency department; LTP, Lean Training Programme; OT/OR, operation theatre, operation room; QI, quality improvement.
Three of the review articles accepted in this review presented different perspectives of leadership and a successful implementation of Lean in health care. One of the review articles presented a comprehensive overview of the main issues highlighted by research on the implementation of Lean in a complex context such as health care (Reference D'Andreamatteo, Ianni, Lega and Sargiacomo37). Another review aimed at identifying and investigating the strength of the connection between two models, Lean health care and productive ward, and to explore the implications for leadership and implementation (Reference White, Wells and Butterworth38). The purpose of the third review was to determine the readiness factors that are critical to the application and success of Lean operating principles in healthcare organizations (Reference Al-Balushi, Sohal and Singh39).
D'Andreamatteo et al. (Reference D'Andreamatteo, Ianni, Lega and Sargiacomo2015) examined 243 articles. The results of the review were that the theoretical works have mainly focused on barriers, challenges, and success factors. They suggested that health professionals, managers, and policy makers should learn from the research as to how to play a pivotal role for a more effective implementation of Lean in different health contexts (Reference D'Andreamatteo, Ianni, Lega and Sargiacomo37). White et al. (Reference White, Wells and Butterworth2013) outlined the similar employee effects that exist between Lean-type improvement initiatives and the productive ward: empowerment, leadership, and engagement and exploration of the opportunities for leadership. They provided a list of reported employee impacts and the effects of value to healthcare leaders attempting to establish an environment and culture of improvement (Reference White, Wells and Butterworth38).
Al-Balushi et al. (Reference Al-Balushi, Sohal and Singh2014) investigated 170 articles which included additional references identified through citation analysis, including books, workshop materials, and conference papers. Their findings were that leadership, the organizational culture, communication, training, measurement, and reward systems are recognized as readiness factors throughout Lean literature. Directly related to the successful implementation of Lean in health care is that a setting is able to authorize a decentralized management style and undertake an end-to-end process view. However, these can be difficult initiatives in healthcare settings (Reference Al-Balushi, Sohal and Singh39) (Table 2).
Table 2. Selected Review Articles, Their inclusion and Exclusion Criteria, Number of Reviewed Studies, Studies on Whole System, Lean Implementation/Managerial Traits, Healthcare Settings and Countries, Study Objectives, and Main Findings
ED, Emergency department; OT/OR, Operation theatre, Operation room; QI, Quality improvement; RTC, releasing time to care.
Analysis of Managerial Dimensions
Activities
Leadership
Traits and skills related to handling conflicts, problem solving, and making change happen were mentioned in most articles. The authors emphasized an understanding of the complexity of the changes (Reference Aij, Aernoudts and Joosten24;Reference Steed30) and Lean (Reference Steed30), as well as an understanding of the system rules and changing power structures (Reference Steed30). It was also suggested that it is important that attention be paid to resistance to change (Reference Aij, Simons, Widdershoven and Visse29). In addition, it was mentioned that it is necessary to have an understanding of the company history of collaboration or conflict, and an understanding of how communication, leadership, and workload will affect the implementation (Reference Lorden, Zhang, Lin and Cote22).
Furthermore, the activities of leading, visioning, and especially empowering were considered essential for successful Lean leadership. Many of the studies (four of nine) referred to the fact that Lean leaders should have the abilities to empower, trust, and engage other team-members (Reference Aij, Visse and Widdershoven25;Reference Aij, Simons, Widdershoven and Visse29;Reference Steed30;Reference Hung, Martinez, Yakir and Gray40). In addition, many studies suggested a visible leadership of Lean was a recognizable feature of Lean leadership (Reference Aij, Simons, Widdershoven and Visse29;Reference Steed30;Reference Hung, Martinez, Yakir and Gray40;Reference Johnson, Smith and Mastro41). Visible leadership contains increasing transparency (Reference Aij, Simons, Widdershoven and Visse29) (Table 3).
Table 3. Results
Note. The features or activities recognized to indicate various success factors of Lean implementation or adaptation in nine original articles that describe and analyze healthcare systems or units with Lean activities, categorized according to the concepts of leadership and management in the windshield model. Aij et al. 2013 (Reference Viitanen, Kokkinen, Konu, Simonen, Virtanen, Lehto and terveydenhuollossa1), Aij et al. 2015 (a) (Reference Antwi and Kale2), Aij et al. 2015 (b) (Reference Al-Abri3), Goodridge et al. 2015 (Reference Drotz and Poksinska4), Hung et al. 2015 (Reference Kimsey5), Hwang et al. 2014 (Reference Lawal, Rotter and Kinsman6), Johnson et al. 2012 (Reference Maijala, Eloranta, Saloniemi and Ikonen7), Lorden et al. 2014 (Reference Dahlgaard, Jostein and Dahlgaard-Park8), Steed 2012 (9)
Management
The majority of the studies (seven of nine) referred to problem-finding, classifying, and solving activities (Reference Lorden, Zhang, Lin and Cote22;Reference Aij, Aernoudts and Joosten24;Reference Aij, Visse and Widdershoven25;Reference Aij, Simons, Widdershoven and Visse29;Reference Steed30;Reference Johnson, Smith and Mastro41;Reference Goodridge, Westhorp, Rotter, Dobson and Bath42). As an example, management activities consist of implementing techniques such as root cause analysis, and metric tools for measuring and monitoring the improvements (Reference Goodridge, Westhorp, Rotter, Dobson and Bath42). Gemba is an activity in which leaders go to the “shop floor” to examine processes and speak to workers, to see the situation for themselves, empower health-care employees, reinforce Lean practices and by doing so engages leaders in experiential learning about implementation (Reference Aij, Visse and Widdershoven25;Reference Aij, Simons, Widdershoven and Visse29;Reference Steed30). One of the key factors to finding problems is to understand functional and professional silos (Reference Aij, Visse and Widdershoven25) and the background that has caused the organization to initiate a Lean quality improvement project (Reference Lorden, Zhang, Lin and Cote22).
A3 problem solving is part of the problem solving techniques (Reference Steed30). Daily performance management using visual displays has also been mentioned, as well as communication huddles (Reference Hung, Martinez, Yakir and Gray40). Data walls collect and display locally relevant data (Reference Goodridge, Westhorp, Rotter, Dobson and Bath42). Visually displaying daily progress-technique is known more formally in Lean terminology as the use of a “daily management” or “daily engagement” system (Reference Aij, Visse and Widdershoven25;Reference Aij, Simons, Widdershoven and Visse29;Reference Hung, Martinez, Yakir and Gray40). Communication was one of the key factors referred to in most articles. As a part of management activities Hwang et al. (Reference Hwang, Hwang and Hong2014) emphasized that especially for a heavyweight manager it is important to communicate well both with top managers and project team members. In addition, Lorden et al. (Reference Lorden, Zhang, Lin and Cote2014) pointed out the necessity of two-way communication across the organizational hierarchy. The means of delivering information were also raised, such as monthly newsletters (Reference Johnson, Smith and Mastro41), a senior leadership newsletter, and house wide reports (Reference Steed30) (Table 3).
Style
Leadership
Facilitating, supporting, and functioning as coaches and mentors seemed to be the prevailing style for successful Lean leadership and was pointed out in all the original articles. These leadership styles mean that Lean leaders can increase their teams’ expertise both directly in their work and in quality improvement (Reference Aij, Visse and Widdershoven25;Reference Aij, Simons, Widdershoven and Visse29;Reference Steed30;Reference Hung, Martinez, Yakir and Gray40;Reference Goodridge, Westhorp, Rotter, Dobson and Bath42). Traits related to delegating decision making or power were also mentioned in some studies (Reference Aij, Visse and Widdershoven25;Reference Johnson, Smith and Mastro41;Reference Goodridge, Westhorp, Rotter, Dobson and Bath42).
Management
Features related to a democratic style of management were strongly indicated in the reviewed studies. Almost half of the studies (four of nine) referred to team-work concepts such as “team-oriented” and “understanding team dynamics” (Reference Steed30;Reference Hung, Martinez, Yakir and Gray40–Reference Goodridge, Westhorp, Rotter, Dobson and Bath42) Many studies emphasized the importance of having time for multidisciplinary collaboration (Reference Lorden, Zhang, Lin and Cote22;Reference Aij, Visse and Widdershoven25;Reference Aij, Simons, Widdershoven and Visse29;Reference Hung, Martinez, Yakir and Gray40;Reference Goodridge, Westhorp, Rotter, Dobson and Bath42). In addition, there were various other leadership and management styles that were mentioned in one or two studies, which are presented in Table 3.
Focus
Leadership
Most of the studies (five of nine) suggested that elementary to achieving transformation in Lean leadership is the leaders’ involvement and commitment to Lean and improvement (Reference Aij, Visse and Widdershoven25;Reference Aij, Simons, Widdershoven and Visse29;Reference Steed30;Reference Johnson, Smith and Mastro41;Reference Goodridge, Westhorp, Rotter, Dobson and Bath42). In addition, there were many demands concerning the leaders’ personal traits. For example, they should have the characteristic of being a high performer (Reference Steed30), and have several features that characterize being a servant, such as modesty and openness, ability to express uncertainty, being humble, and learning from others (Reference Aij, Visse and Widdershoven25). Signs of emotional intelligence were confirmed by features such as consistent and flexible, and having respect for others, being proactive and adaptive, agile, and resilient (Reference Aij, Visse and Widdershoven25;Reference Steed30) (Table 3).
Management
Many of the studies (four of nine) suggested that the utmost focus of Lean management is continuous learning, which was characterized by several expressions and examples such as learning from mistakes, learning by seeing and doing, and being committed to lifelong learning (Reference Aij, Visse and Widdershoven25;Reference Aij, Simons, Widdershoven and Visse29;Reference Steed30;Reference Goodridge, Westhorp, Rotter, Dobson and Bath42). Financial and manpower resource commitments were recognized as being required while implementing Lean (Reference Aij, Simons, Widdershoven and Visse29;Reference Hung, Martinez, Yakir and Gray40;Reference Goodridge, Westhorp, Rotter, Dobson and Bath42). Other focuses concerning results and assessing processes included evaluation according to real-time process performance, as well as end-of-the-reporting-period results (Reference Aij, Aernoudts and Joosten24) (Table 3).
Purpose
Leadership
The majority of the studies (five of nine) emphasized the communication of a clear vision and targets for improvement (Reference Lorden, Zhang, Lin and Cote22;Reference Aij, Simons, Widdershoven and Visse29;Reference Johnson, Smith and Mastro41–Reference Hwang, Hwang and Hong43). As an expression of purpose, top managers have been found to be aware of a long-term vision for the work (Reference Johnson, Smith and Mastro41). There were also several studies that mentioned the kind of features that emphasize organizational success, such as celebrating success (Reference Aij, Simons, Widdershoven and Visse29), fostering a culture of innovation, collaboration and creativity (Reference Hung, Martinez, Yakir and Gray40), a passion for excellence, and inclusive and collaborative team work (Reference Steed30) (Table 3).
Management
Some elements related to purpose were associated with management. Creating value for the patients (Reference Aij, Aernoudts and Joosten24) and enhancing customer value (Reference Hwang, Hwang and Hong43) were considered to be related to mission. Lean leaders should have an understanding as to who the customers are and what value means for them (Reference Aij, Visse and Widdershoven25;Reference Hung, Martinez, Yakir and Gray40;Reference Goodridge, Westhorp, Rotter, Dobson and Bath42). Two of the studies paid attention to sensitivity to professional values and the culture of health care (Reference Aij, Simons, Widdershoven and Visse29;Reference Hung, Martinez, Yakir and Gray40). Goal-related features were characterized by a clear, well-planned strategy (Reference Aij, Simons, Widdershoven and Visse29), as well as being goal and action oriented (Reference Steed30). Other objective related terms in the studies included adherence to evidence based practices (Reference Steed30) and “aligns the aims and objectives of health regions” (Table 3).
Other traits presented in the reviewed literature that could not be classified with windshield categories were related to learning and training of personnel: managers are developed primarily through in-company learning/mentoring, on-the-job training, and problem solving (Reference Aij, Visse and Widdershoven25).
CONCLUSIONS AND PRACTICAL IMPLICATIONS
The purpose of our study was to identify the characteristics of leadership and management that are associated with successful Lean thinking adaptation in health care by using a systematic literature review. This was done to identify from recently published original study sources a conceptual analysis of managerial traits.
Our main findings were that both leadership and management are required for successful Lean adaptation. In addition, we were able to classify the contents of the reviewed articles by using the four dimensions of leadership and management: activities, style, focus, and purpose. Various problem-solving techniques and skills, measuring performance, and various ways of communicating, including visible techniques, are the key activities of transformation for the healthcare organization to reach its goals (Reference Lorden, Zhang, Lin and Cote22;Reference Aij, Aernoudts and Joosten24;Reference Aij, Visse and Widdershoven25;Reference Aij, Simons, Widdershoven and Visse29;Reference Steed30;Reference Hung, Martinez, Yakir and Gray40;Reference Johnson, Smith and Mastro41). The role of leaders as mentors, coaches, or facilitators as well as their emotional intelligence were highlighted (Reference Aij, Visse and Widdershoven25;Reference Aij, Simons, Widdershoven and Visse29;Reference Steed30;Reference Hung, Martinez, Yakir and Gray40;Reference Goodridge, Westhorp, Rotter, Dobson and Bath42).
The signs of organizational democracy, such as team work and a multiprofessional collective perspective, were also emphasized as being significant styles of Lean leadership and management (Reference Lorden, Zhang, Lin and Cote22;Reference Aij, Visse and Widdershoven25;Reference Aij, Simons, Widdershoven and Visse29;Reference Hung, Martinez, Yakir and Gray40;Reference Goodridge, Westhorp, Rotter, Dobson and Bath42). Continuous learning has a significant role as a part of focus of Lean management (Reference Aij, Visse and Widdershoven25;Reference Aij, Simons, Widdershoven and Visse29;Reference Steed30;Reference Hung, Martinez, Yakir and Gray40;Reference Johnson, Smith and Mastro41). It is useful to notice that, in health care, it is significant to pay attention to sensitivity to professional values, and the culture of health care (Reference Aij, Simons, Widdershoven and Visse29;Reference Hung, Martinez, Yakir and Gray40). As an expression of Lean leadership's purpose is to communicate a clear vision and targets for improvement (Reference Lorden, Zhang, Lin and Cote22;Reference Aij, Simons, Widdershoven and Visse29;Reference Hung, Martinez, Yakir and Gray40–Reference Hwang, Hwang and Hong43). Part of this is to understand who the customers are and what value means for them (Reference Aij, Aernoudts and Joosten24;Reference White, Wells and Butterworth38;Reference Al-Balushi, Sohal and Singh39) (Figure 2).
Figure 2. Key findings of successful implementation of Lean as a managerial principle in health care.
Results were quite similar than previous study. Andersen et al have shown that a supportive culture, training, accurate data, physicians and team involvement were most frequent factors when enabling a successful Lean intervention (Reference Andersen, Rovik and Ingebritsen21). Leadership, organizational culture, communication, training, measurement and reward systems (Reference Al-Balushi, Sohal and Singh39), actions to improve the whole organization process-oriented, team-based performance (Reference D'Andreamatteo, Ianni, Lega and Sargiacomo37), and empowerment and engagement (Reference White, Wells and Butterworth38) are also the key traits in previous studies.
The researchers in this study made decisions on how the material was classified in accordance with the managerial windshield. The decisions were based on the contexts in which the results were presented in the material. The categorization for leadership and management was not always straightforward, and some features could fit into various categories. Nevertheless, looking at the results with windshield concepts clearly emphasizes the philosophy, principles, and tools of Lean thinking and the need for multiple skills and behavioral traits in the individuals responsible for change in their organizations before successful transformation of the system is achieved. Interestingly, strategic perspectives, mission and goal setting, as well as resource management were not stressed/highlighted as strongly as the skills and techniques of problem solving, activities related to empowerment, transformation, and continuous learning. The model of managerial windshield was well suited for structuring the features of Lean leadership and management.
Typically, the reviewed articles used both leadership and management to describe the managerial function, but the definitions of and differences between these two were seldom explained. It needs to be pointed out that the scope of our study was not to look into the professional job descriptions of managers as leaders. There is a variety of professional hierarchies in different healthcare systems as regards managers, leaders, or directors. Our intention was rather to look into the skills, activities, and behaviors of the two recognizable managerial concepts, that is, leadership and management.
Furthermore, one of our findings was that the description of Lean thinking was unclear in the majority of the studies, and there were few if any definitions of features that would differentiate Lean leadership and management from any other managerial or improvement settings. This is in accordance with a previous review which concluded that by reviewing the literature, everything it seems may be termed Lean (Reference Reunanen and Kaitonen34). Nevertheless, by analyzing the characteristics of managerial dimensions, we were still unable to obtain evidence as to whether Lean thinking had been adapted successfully in the studied organizations and whether the targets and goals had been reached or not; it was also not possible to determine the impact of the managerial function in the process of adaptation to Lean thinking.
Strong leadership and management are being considered critical to successful implementation of Lean thinking (Reference Maijala, Eloranta, Saloniemi and Ikonen7;Reference Aij and Rapsaniotis20;Reference Andersen, Rovik and Ingebritsen21;Reference Lorden, Zhang, Lin and Cote22;Reference Mann23;Reference D'Andreamatteo, Ianni, Lega and Sargiacomo37–Reference Al-Balushi, Sohal and Singh39). Leadership has been considered as a key to understand why, or why not, Lean interventions make contributions to health care (Reference Andersen, Rovik and Ingebritsen21). According to transformational leadership theory, leaders influence followers and, thus, are thought to be agents of change (Reference Bass44). Thus far, there has not been a complete picture of Lean management, Lean leadership attributes and Lean methods in health care (Reference Aij, Simons, Widdershoven and Visse29;Reference Steed30).
In addition, the analysis of the benefits and the criticality of Lean leadership/management in health care seems to have been undervalued (Reference Andersen, Rovik and Ingebritsen21). The concept of the windshield focus is to help managers and leaders in decision making and to clarify some important management and leadership concepts (Reference Vanharanta31). The results of our study can, on the one hand, be used in analyzing decision making related to Lean management in health care and, on the other hand, help to identify essential managerial concepts of Lean management and leadership in health care. The external validity of the findings could be strengthened by testing in an empirical study. In addition, there is insufficient knowledge about how Lean leadership and management is practically applied, which characteristics are emphasized at different levels of organization hierarchy, and whether the predominant characteristics of Lean leadership and management vary over a longer term in organizations. Appropriately tested instruments for modelling Lean adaptation are required.
The current study has some limitations. Although a careful search approach was used, some papers from the journals not indexed in the searched databases may have been overlooked. Another limitation was that the literature searches were carried out only for a 5-year period. Not to miss any important qualitative information, three systematic reviews were included to widen the perspective and ensure that no essential information was missed. Another shortcoming is that our review only included English-language studies; this precludes relevant insights stemming from papers published in languages other than English, and the fact that there might be cultural aspects that are overlooked by analyzing only English publications.
The trustworthiness of this study is demonstrated by describing the data selection process and by the involvement of three researchers in the selection and appraisal process. The PRISMA Checklist (Reference Moher, Liberati, Tetzlaff and Altman45) list was applied in study. The reliability and validity of the original articles were checked with the Consolidated Criteria for Reporting Qualitative Research (COREQ) study design and analysis/reporting checklist. This checklist consists of items specific to the reporting of qualitative studies and precludes generic criteria that are applicable to all types of research reports (Reference Tong, Sainsbury and Craig46). The criteria were variably met by the reviewed articles.
Scientific proof for Lean as an efficient and effective quality-improvement method is needed (Reference Andersen, Rovik and Ingebritsen21). Future research should be conducted to define experiences of Lean management and leadership models and the usefulness of these models when using the Lean system. Moreover, new leadership requires a new kind of role and competence from healthcare staff, and from this point of view, research data are also needed. The readiness factors identified from such data will enable healthcare leaders to be better prepared through learning and education as they begin or continue their journey toward Lean implementation.
CONFLICTS OF INTEREST
The authors have nothing to disclose.
