Table 3 CMOcs from realist interview findings

CMOc 1: ‘Ripple- effect’: The funded, mandated, top-down, externally led nature of Lean implementation

The early stages of Lean implementation were funded, mandated, and top-down in nature (C), driven by an external consultancy firm that initially focused on training senior leadership (C). Frontline staff did not feel involved in Lean changes, and they felt pressured to adopt Lean (M). The lean language used did not make sense to staff (M). Training failed to demonstrate a connection between Lean and healthcare, this led to misunderstandings and negative perceptions of Lean. There was a resistance to Lean, a lack of support for Lean and potential staff retention issues (O) which had a ‘ripple-effect’ on contexts for sustainability.

CMOc 2: Lack of fit between Lean and healthcare and a lack of customization to context

The complexity and dynamic nature of healthcare and the unique needs of pediatric patients (C), was perceived as incongruent with the nature of Lean. The translation of Lean to patient care did not make sense for many staff and Lean efforts felt impersonal. Lean training failed to make the connection between Lean and healthcare clear for staff (M) and early stages of implementation led by the consultancy company failed to customize Lean to the local context, this triggered pitfalls to the success of Lean, such as feelings of disconnect and negative perceptions of Lean (M), resulting in a resistance and a lack of support for Lean continuation (O).

CMOc 3: Rapidly evolving healthcare contexts overtime – “innovation fatigue”

Lean was implemented in areas that experience constant change (C), early-stages of implementation involved multiple Lean events for training purposes (C), frontline staff felt overwhelmed from the constant change, they were unsure what changes were due to Lean and felt that Lean was the latest fad (M), this led to negative perceptions of Lean, resistance and lack of support by frontline staff (O).

CMOc 4: Process of Lean customization to context- positive and negative effects

The contract of the external consultancy leading Lean implementation ended (C), placing the continuation of Lean on internal senior leaders and unit managers (C). This led to a process of customization of Lean to local context, through a variety of ways (drop Lean language, less Lean activities, greater involvement of frontline staff). This customization of Lean and shift in implementation triggered positive and negative responses for frontline staff, unit managers and senior leaders (M). As a result, only some Lean efforts became embedded. However, there was variation and discrepancy between senior leaders and unit managers compared to frontline staff on perceptions of how embedded Lean efforts are and the degree to how much they support the continuation of Lean (O).

CMOc 5: Shared values and sense-making processes for normalization

The context of early-stages of implementation (C), failed to trigger sense-making processes necessary for staff to understand Lean and potentially engage and begin to embed Lean into their practice (O). Shared values were evident between Lean principles and staff professional values as healthcare providers. However, value congruency without clear sense-making processes resulted in lack of adoption of Lean behaviours as part of normalized frontline practice. Sense-making processes were hindered by a failure of initial Lean training efforts to translate the principles of Lean into the context of healthcare that would resonate with staff (M). Lean language and the lack of staff involvement in Lean changes also hindered sense-making processes and feelings of engagement. This resulted in negative perceptions of Lean, a lack of buy in and support for the continuation of Lean from frontline staff (O).