A Realist Investigation of Lean Sustainability in Pediatric Healthcare

Abstract

Background: Lean is a management system aimed at maximizing value by reducing waste and reconfiguring organizational processes that originated from the Toyota manufacturing industry. Lean is increasingly implemented as a quality improvement management system for healthcare. We conceptualize Lean as a complex intervention when implemented in the context of healthcare. Research has been conducted on the implementation of Lean in healthcare, however no evidence has been gathered on the sustainability of Lean efforts. The contextual factors and mechanisms that influence the sustainability of Lean in healthcare have not been well studied. Purpose: The purpose of this dissertation was to develop, test and refine an initial program theory on Lean sustainability in pediatric healthcare. Sustainability is an important yet understudied implementation outcome. Methods: This dissertation was underpinned by scientific realism, using the context (C) + mechanism (M) = outcome configuration (Oc) (CMOcs) heuristic to explain under what contexts, for whom, how and why Lean efforts are sustained or not sustained in pediatric healthcare. It consisted of three research phases and four related papers: (I) a conceptual debate paper on the potential for nurses to contribute to and lead improvement science; (II) a debate paper on the complexity of Lean and implications for research designs and methods; (III) research phases 1 and 2, initial program theory development and a realist review to further develop and refine the initial program theory; (IV) a realist evaluation using case study research design to test the program theory developed and refined during research phases 1 and 2. Thirty-two qualitative realist interviews were conducted with multiple stakeholder groups across four pediatric units in the context of the Saskatchewan Lean Management System, Canada. Findings: The following findings were identified and addressed in this dissertation: Phase 1 Seven CMOc hypotheses underpinned the initial program theory. Phase 2 Five CMOc hypotheses from the initial program theory were substantially supported after synthesis: 'sense-making’, ‘value congruency’, 'staff engagement’, ‘empowerment' and the ‘ripple effect’ or causal pathway between Lean implementation outcomes that then served as facilitating or hindering contexts for sustainability. Overall, there was variation with the conceptualization and measurement of sustainability. Phase 3 Five CMOcs emerged from the realist interview data, two of which were substantiated from Phase 2 'sense-making and value congruency' and the ‘ripple effect’ from early implementation. The remaining three CMOcs addressed a ‘lack of fit between Lean and healthcare and a lack of customization to context’, ‘innovation fatigue’ and the ‘positive and negative effects of Lean customization to context’ on sustainability. Conclusions: These dissertation findings depicted the complex nature to sustaining Lean efforts and the differences in the perceptions and degrees of adoption across the hierarchy of the organization. The approach and nature of implementation was also critical to shaping contexts for sustainability. Customization to context was also important to Lean sustainability. These findings have important implications for sustainability research, in understanding the determinants of sustainability for complex health interventions.