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Article history:
Available online 13 July 2010
This paper presents an ethnographic account of the implementation of Lean service redesign methodologies in one UK NHS hospital operating department. It is suggested that this popular management
technology, with its emphasis on creating value streams and reducing waste, has the potential to
transform the social organisation of healthcare work. The paper locates Lean healthcare within wider
debates related to the standardisation of clinical practice, the re-conguration of occupational boundaries and the stratication of clinical communities. Drawing on the technologies-in-practice perspective
the study is attentive to the interaction of both the intent to transform work and the response of
clinicians to this intent as an ongoing and situated social practice. In developing this analysis this article
explores three dimensions of social practice to consider the way Lean is interpreted and articulated
(rhetoric), enacted in social practice (ritual), and experienced in the context of prevailing lines of power
(resistance). Through these interlinked analytical lenses the paper suggests the interaction of Lean and
clinical practice remains contingent and open to negotiation. In particular, Lean follows in a line of
service improvements that bring to the fore tensions between clinicians and service leaders around the
social organisation of healthcare work. The paper concludes that Lean might not be the easy remedy for
making both efciency and effectiveness improvements in healthcare.
2010 Elsevier Ltd. All rights reserved.
Keywords:
UK
Lean healthcare
Service re-conguration
Organisation
Management
Introduction
In the current global economic climate, governments look for
ways to contain or reduce public healthcare spending, while
simultaneously assuring levels of service and, in some cases,
extending provision to marginalised groups. Policy makers and
service leaders are therefore attracted to management philosophies
that, for other industries, offer more productive and cost-effective
ways of organising and delivering services. One prominent example
is the popular application of process re-engineering methodologies,
such as Lean Thinking and Six Sigma (Radnor & Boaden, 2008).
These are characterised as reducing waste and adding customer
value through re-conguring organisational processes (Womack &
Jones, 2003). Over the last decade there has been growing international interest in the idea of Lean Healthcare, exemplied by the
q The research was funded by the Economic and Social Research Council
[RES-061-25-0040].
qq The authors would like to thank reviewers for their comments and suggestions in developing this work.
* Corresponding author. Tel.: 44 (0)115 8231275.
E-mail address: justin.waring@nottingham.ac.uk (J.J. Waring).
0277-9536/$ e see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2010.06.028
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that were explicitly based on the philosophy of Lean and TPS. Our
research found, however, variations in these projects encouraging
us to be attentive to different ways Lean is translated into and
impacts upon clinical practice. This paper focuses on the reconguration of two surgical lists (vascular and arthroscopy)
within one hospital setting.
The papers ndings were collected over 12 months in one
hospital operating department carried out between 2008 and 2009.
This included non-participant observations of clinical activities,
including ward areas, operating theatres, recovery rooms, clinics and
assessment rooms; and participant observations in other non-clinical
settings, including management meetings, team briengs, and rest
areas. Our observations focus on a series of meetings to dene and
design departmental strategy for Lean; team briengs to introduce
Lean to clinical groups; workshops and problem-based activities such
as mapping existing activities; and other activities where service
changes were introduced. Our role within these processes ranged
from being an external academic observer to becoming more
involved in group discussions related to service change. During our
observations we engaged staff in numerous informal conversations to
clarify issues, and conducted 42 semi-structured one-to-one interviews with nurses, operating department practitioners (ODPs),
healthcare assistants, surgeons, anaesthetists and managers. The
study received ethical approval through standard NHS procedures. In
line with this, all clinical staff were notied in writing and through
staff briengs of the study aims and methods in advance of
conducting the research, observational activities required verbal
consent from participants and interviews required written consent.
Our observations were recorded in individual eld journals
comprising rich descriptions of events, interactions and statements, together with personal reections. The research team met
weekly to reect upon observations and identify emergent
themes, whereby a common electronic record was compiled that
catalogued interpretative codes, categories and themes with
corresponding extracts of data. Interviews were transcribed and
coded through close reading by the authors. This involved
developing a common coding frame that related to our observational categories and themes. We draw upon this data to tell
the unfolding story of Lean within this operating department.
Clearly, there are limits to the detail of ethnographic analysis we
can give; as such our paper moves between empirical settings,
levels of analysis and conceptual categories to explore social
practice in the context of this organisational change (Nicolini,
2010).
Lean-in-clinical practice
Rhetoric
Our rst analytical theme foregrounds the role of rhetoric
within organisational practice or the way language is used in an
interactive space to persuade others (Farrell, 1999). Classical principles of rhetoric include the appeals to reason (logos), emotion
(pathos) and values (ethos), but more broadly it is attentive to
where, how and when arguments are articulated. A focus on
rhetoric highlights the contribution of persuasion to the negotiation of social order, the social construction of knowledge, and the
dynamics of social power (Foucault, 1980). For example, scholars of
epistemology highlight the rhetorical use of concepts such as
objectivity when scientists seek to legitimise their discoveries; yet,
ultimately, such knowledge remains shaped by the values and
ideology of the given epistemic community (Knorr-Cetina, 1983;
Scott, 1999). In the context of our study, we were attentive to the
way service leaders interpreted and articulated Lean to persuade
others as to its relevance to service improvement. In this sense, we
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The checklist is a great idea, I just dont see why we have to do.
Its really for nursing issues, about instrumentation and equipment. We have our own checks that work really well and frankly
it is a waste of my time. (Clarke, Anaesthetist)
When asked about the lasting impact on their practice, clinicians typically suggested that what might look like a good idea in
theory was often difcult to put into practice. Somewhat ironically, the primary resistance to change related to additional time
demands made on clinical work. However, in many instances staff
simply found it more convenient to return to their customary ways
of working, simply ignoring new guidelines for handovers, recordkeeping or clinical roles.
One particularly strong and public act of resistance was the
defacement of a large poster that graphically illustrated the new
arthroscopy and vascular care pathways. A few days after this had
been displayed in the staff lounge we found numerous, grafti-like,
handwritten comments had been added to the chart. For example, the
diagrams Legend had been sufxed in pencil with Fairy Tale; Work
of Fiction. In areas where it designated times for certain tasks, such as
thirty second for patient checks somebody had written staff need
more than thirty seconds, what we need here are more well trained
and motivated staff. In another area staff had written why dont you
tell the surgeons not to use email all the time during lists. These
comments revealed some of the frustrations staff felt about the
proposed changes and the potential for mischief to act as a form of
resistance to management change (Ackroyd & Thompson, 1999).
The lines of resistance to Lean were multidimensional, and in
our experience there was no single issue that galvanised staff into
open confrontation with the working group. Rather clinicians tended to nd fault with different aspects of the process. This
dispersed form of resistance led to simmering conict within daily
practice, whereby staff often acted defensively when new changes
were presented, but publically remained open to the possibility
that they might improve working practice.
Conclusions
At the outset we suggest Lean healthcare might represent a new
development in the reorganisation of healthcare work. In this paper
we have investigated its implementation in one operating department and found that in several ways it has the potential to contribute
to the three lines of change outlined above, including the use of
evidence-based guidelines, the re-conguration of occupational
boundaries and new forms of clinical leadership. Firstly, Lean
emphasises the importance of determining evidence of waste and
inefciency through the use of audits, process maps and PDCA
cycles. Although these may not be perceived as credible or scientic
as other methods of generating evidence-based guidelines, such as
randomised-control trials, these are articulated as a purportedly
rational and legitimate basis for generating evidence and persuading
clinicians as to their appropriateness. Secondly, this evidence is
directed towards the re-conguration of clinical practices to
produce more productive and value-adding processes. This
frequently centres on the re-alignment of established clinical roles
and boundaries to create ow or more streamlined work, as illustrated by new routines and rituals in the form of checklists, booking
systems or delineated clinical duties. Thirdly, the implementation of
Lean requires the development of leaders, both at senior management and local departmental levels. These are concerned with
dening the problems of waste and inefciency that undermine the
values of the services, as well as with enrolling other clinicians into
Lean thinking. Accordingly, we nd evidence of occupational restratication as individuals are recruited as champions of Lean. In
this way, the introduction of Lean healthcare contributes to and cuts
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