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Table 1 Characteristics of the 22 articles included in the systematic review grouped by the level of context

From: Benchmarking outcomes on multiple contextual levels in lean healthcare: a systematic review, development of a conceptual framework, and a research agenda

Study type/ Overall quality Country/ region
Department/ specialty
Setting for benchmarking Benchmarking measures Lean methods
Intra-organizational level
Abdelhadi A [43]
Multiple case study/ Low Saudi-Arabia
Comparing two ED sections (male/female) within the same public hospital •Takt time Lean manufacturing principles to identify and eliminate waste and improve workflows
Abdelhadi A, Shakoor M [44]
Multiple case study/ Low Saudi-Arabia
Comparing inpatient and outpatient pharmacies at one large public regional hospital •Takt time Lean manufacturing principles to identify and eliminate waste and improve workflows
•Spaghetti diagrams
New S et al. [60]
Controlled interrupted time series/ High UK
Orthopedic OR
Comparing orthopedic trauma theater and an elective orthopedic theatre in the same trust Primary intervention:
•WHO-checklist compliance
•"Glitch count” (intraoperative process disruptions)
•Clinical outcomes (90D):
Secondary intervention:
•1st operation start time
Primary intervention: Lean training in
•Process mapping
•Philosophy of continuous participative experimental improvement
•Genchi Genbutsu
•Respectful cooperation
Secondary intervention:
•Improving start time
Raab SS et al. [47]
Controlled interrupted time series/ Intermediate US/Pennsylvania
Histopathology laboratory
Comparing two sister histopathology sections in one University Medical Center in Pittsburgh •Productivity ratio (work units/FTEs) •PPC system
•Current state and ideal state identification
Robertson E et al. [61]
Controlled interrupted time series/ High UK
Comparing a specialist elective orthopedic hospital’s plastic surgery team with an orthopedic theater team •NOTECHS II (non-technical skills)
•”Glitch rate” (technical skills)
•WHO checklist compliance
•Patient safety outcomes:
-Complication rate (90D)
-Readmission rate (90D)
-LOS in hospital
A combination of teamwork training and lean process improvement training including:
•Genchi Genbutsu
•Respect and teamwork
•Process mapping
•Philosophy of continuous improvement
Venkateswaran S et al. [48]
Controlled interrupted time series/ Intermediate US/Louisiana
Hospital warehouses
Comparing three hospitals’ central warehouses in one health system •Monthly inventory turnovers
•5S audit scores (non-conformities)
Traditional 5S (control group):
•Prework (5S team selection and training, baseline data collection and analysis)
•Implementation (performance of 5S)
•Post-analysis (evaluating outcome of the improvements)
Hybrid 5S (intervention group):
•Kaizen structure:
-Observation and preparation (identifying problem areas, VSM)
-Planning lean initiatives
-Implementation (performance of first 4 S’s + developing an inventory model)
-Measurement of improved process (evaluating effectiveness, efficiency, relevance, and impact)
Regional level
Culig MH et al. [49]
Case study with regional benchmarks/ Intermediate US
Cardiac surgery
Comparing results of a program with regional rates from the Society of Thoracic Surgeons National Adult Cardiac Surgery Database •Preoperative demographics
•Surgery type (off-pump, urgent, emergency, emergency salvage)
•Total LOS
•Post procedure LOS
•Use of blood products
•Complications (mortality, any complications, any infection, atrial fibrillation, cardiac arrest, heart block requiring permanent pacemaker, prolonged ventilation > 24 h, pneumonia, renal failure, reoperations, stroke, readmission within 30 days)
•ICU stay
•Mean total ventilation
•Vision and values
•Defined metrics (balanced scorecard)
•Pull methodology
•Daily huddles
•A3-problem solving
•Ongoing mentoring of frontline staff
•Visual management
•Standardization (standard work)
•One-by-one processing
•Leveling the workload
•Root cause analysis
Ieraci S et al. [62]
Case study with regional benchmarks/ High Australia/New South Wales
Benchmarking the ED of a single hospital against New South Wales Department of Health benchmark waiting times •Compliance with NSW Department of Health benchmark for waiting times in each of the five Australasian Triage Scale (ATS) categories in Fast Track and Standard ED groups. •Physical space reallocation
•Creating two distinct patient tracks (low-complexity patients “fast track”, high-complexity patients “normal track”)
Kielar AZ et al.[45]
Case study with regional benchmarks/ Low Canada/Ontario
Benchmarking the performance of radiology units against provincial acceptable wait times defined by Ontario government •Compliance with acceptable wait times for CT/MRI scans (28 days) set by the province •Rapid Improvement Event
Vermeulen MJ et al. [50]
Controlled interrupted time series/ Intermediate Canada/Ontario
Benchmarking EDs in Ontario, Canada Primary outcomes
•Length of stay
•Median time to physician
•Percentage of admitted and nonadmitted patients missing provincial ED LOS targets
Secondary outcomes
•Left without being seen rate
•30-day mortality
•30-day readmission rate among admitted patients
•72-hour revisit rate among discharged patients
A lean improvement approach, specific tools not described
National level
Ahmed S et al. [51]
Cross-sectional/ Intermediate Malaysia
Whole hospitals
Random sample of 16 hospitals in peninsular Malaysia; comparisons by respondents’ gender, type of hospital and working experience Six Lean constructs:
•Continuous quality improvement
•Lean management initiatives
•Six Sigma initiatives
•Patient safety
•Quality performance
Perceptions of Lean and quality improvement
Allaudeen N et al. [63]
Controlled interrupted time series/ High US
Benchmarking one VA ED against other similar VA facilities in the US •ED LOS •Root cause analysis
•Developing standard work
•Managing standard work: daily management system with huddles, visual management, Pareto charts, PDSA cycles
Boronat F et al. [52]
Case study with national benchmarks/ Intermediate Spain/Catalonia
Comparing one Urology department with national benchmarks in Catalonia, Spain •Risk-adjusted complications index RACI by IASIST® •Risk-adjusted mortality index RAMI by IASIST® •Risk-adjusted readmission index RARI by IASIST®
•Risk-adjusted length of stay index RALOS by IASIST®
•Identification of value for the client
•Identification of the value chain
•Creation of continuous value flow
•Elimination of the superfluous
•Search for perfection by continuous improvement (PDCA)
•Reduction of variability
Dickson EW et al.[53]
Multiple case study/ Intermediate US
Comparing four ED departments (2 academic, 2 community) •Global patient LOS
•Percentage of patients that left unseen (2/4 EDs)
•Patient volume
•Patient satisfaction (Press Ganey or Gallup surveys)
Kaizen events:
•Current state and future state
•Value stream map
•Testing ideas
•Continuous improvement
•Pursuit of perfection
Holden RJ et al. [54]
Cross-sectional/ Intermediate Sweden
Whole hospitals
Three hospitals, comparisons by hospital, unit acuity, and professional role •Attitude toward lean
•Commitment toward lean
•Perceived justice of lean implementation
•Perceived flow improvement due to lean
•Project-based lean implementation
•Change agents and educators (internal/external)
Lee JY et al. [55]
Cross-sectional/ Intermediate US
Whole hospitals
Comparing hospitals using Six Sigma vs. Lean Six Sigma in a national sample of 215 hospitals in the US •Responsiveness capability
•Patient safety
•Process mapping
•Redesign for continuous flow (cell design, pull system)
•Just-in-time process management or inventory management
Pluimers DJ et al. [46]
Cross-sectional/ Low The Netherlands
Colorectal cancer care pathways
Benchmarking colorectal cancer pathways in 8 hospitals •Flowchart for rectum (yes/no)
•Flowchart for colon (yes/no)
•Operational focus:
-Medical content, operational content, both
-Mean number of patient visits
•Autonomous Work Cell
-Multidisciplinary outpatient clinic
-Use of dedicated sessions
•Physical layout
-Safety, cleanness and order
-Visual management system
-Number of staff involved with diagnosis
-One stop shop for diagnosis
•Non-value adding activities
•Operational focus
•Autonomous work cells
•Physical layout of resources
•Multi-skilled teams
•Pull planning
•Elimination of non-value adding activities.
Poksinska BB et al. [56]
Controlled interrupted time series/ Intermediate Sweden
Primary care
Comparing Lean and non-Lean groups in a national sample of health centers (primary care) National Patient Satisfaction survey (2009, 2011, 2013), 5 subject categories:
•Accessibility and waiting
•Patient involvement
•Communication and information sharing
•General impression
•Lean group (23 health centers) : at least 3 years experience working with lean
•Non-lean group: no lean activities (23 health centers)
Shortell S et al. [31]
Cross-sectional/ High US
Whole hospitals
Benchmarking hospitals that reported doing Lean in a national sample of US hospitals according to ownership, membership in a system or network, area type, teaching status, and bed size •Self-reported Lean maturity
•Number of years doing Lean
•Number of units doing Lean
•Number of tools reported as High or Very High
•Overall Lean leadership commitment index
•Daily management system index
•Education and training scale
•Self-reported performance index
A 63-item survey addressing the self-reported •Engagement in Lean, Lean Six Sigma or RPI
•Duration, extent, and maturity of lean implementation
•Use of tools and methods
•Lean behaviors
•Performance improvements
Simons P et al. [57]
Case study with national benchmarks/ Intermediate The Netherlands
Benchmarking one radiotherapy institute against Dutch Society for Radiotherapy and Oncology national norms •Percentage of patients exceeding the national norms for waiting times (palliative and curative patients) •5S
•Multidisciplinary team based projects
International level
van Lent WAM et al. [58]
Case study with international benchmarks (baseline only)/ Intermediate The Netherlands, US, Europe
A Dutch CDU benchmarked with two other CDUs Baseline characteristics
•Patient case mix
•Services offered
•Total patient visits in 2004
•Estimated total patient visits in 2005
•Indexed average number of patients treated per bed per month
•Indexed average number of patient visits per month per total CDU staff
•Indexed average number of patient visits per nurse per month
•Root-cause analysis
•Elimination of waste
•Rapid-Plan Assessment
•Reorganization of inventory
•Visual management
Van Vliet EJ et al. [59]
Multiple case study/ Intermediate UK, US, The Netherlands
Comparing 3 cataract pathways •Lead time
•Access time
•Waiting time for surgery
•Number of hospital visits
•Number of patients receiving their care in autonomous cataract work cells
•Average number of physical patient transfers
•Number of different staff functions
•Number of one-stop diagnosis, preassessments, and surgeries
•Number of decoupling points
•Number of patients who did not receive any additional preassessments
•Number of patients who did not revisit the hospital for a first review by an ophthalmologist
•Number of average coordination actions per patient
•Operational focus
•Autonomous work cell
•Physical layout of resources
•Multi-skilled team
•Pull planning
•Elimination of wastes
  1. Abbreviations: CDU Chemotherapy Day Unit; ED Emergency Department; LOS Length of Stay; OR Operating Room; PDCA Plan-Do-Check-Act; PDSA Plan-Do-Study-Act; PPC Perfect Patient Care; RPI Robust Process Improvement; VA Department of Veterans’ Affairs; VSM Value Stream Mapping