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Antecedents and Characteristics of Lean Thinking Implementation in a Swedish Hospital: A Case Study

Ulhassan, Waqar MSc, PhD Candidate; Sandahl, Christer PhD; Westerlund, Hugo PhD; Henriksson, Peter PhD; Bennermo, Marie MD, PhD; von Thiele Schwarz, Ulrica PhD; Thor, Johan MD, MPH, PhD

doi: 10.1097/QMH.0b013e31827dec5a
Original Articles

Despite the reported success of Lean in health care settings, it is unclear why and how organizations adopt Lean and how Lean transforms work design and, in turn, affects employees' work. This study investigated a cardiology department's journey to adopt and adapt Lean. The investigation was focused on the rationale and evolution of the Lean adoption to illuminate how a department with a long quality improvement history arrived at the decision to introduce Lean, and how Lean influenced employees' daily work. This is an explanatory single case study based on semistructured interviews, nonparticipant observations, and document studies. Guided by a Lean model, we undertook manifest content analysis of the data. We found that previous improvement efforts may facilitate the introduction of Lean but may be less important when forecasting whether Lean will be sustained over time. Contextual factors seemed to influence both what Lean tools were implemented and how well the changes were sustained. For example, adoption of Lean varied with the degree to which staff saw a need for change. Work redesign and teamwork were found helpful to improve patient care whereas problem solving was found helpful in keeping the staff engaged and sustaining the results over time.

Medical Management Centre, Karolinska Institutet, Stockholm, Sweden (Mr Ulhassan, Drs Sandahl and Thor); Stress Research Institute, Stockholm University, Stockholm, Sweden (Dr Westerlund); Department of Cardiology and Department of clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden (Dr Henriksson); Departments of Cardiology and Clinical Sciences, Danderyd Hospital, Stockholm, Sweden (Dr Bennermo); Department of Psychology, Stockholm University, Stockholm and Medical Management Centre, Karolinska Institutet, Stockholm, Sweden (Dr Schwarz); Medical Management Center, Karolinska Institute, Stockholm, Sweden and Jönköping Academy for Improvement of Health and Welfare, Jönköping University, Jönköping Sweden (Dr Thor).

Correspondence: Waqar Ulhassan, MSc, PhD Candidate, Medical Management Centre, Plan 5, Berzelius väg 3, Karolinska Institutet, SE-17177 Stockholm, Sweden (

The authors thank Richard Fletcher, MD, for his assistance in setting up the study.

The first author is currently receiving a stipend from Higher Education Commission of Pakistan. The involvement of US was supported with grants from AFA Insurance. For the remaining authors, none were declared.

©2013Lippincott Williams & Wilkins, Inc.