Increasing Competitiveness through the Implementation of Lean Management in Healthcare

Round 1

Reviewer 1 Report

See Attached 

Comments for author File: Comments.pdf

Author Response

Thank you very much for your interesting suggestions and comments. We have included them in this new version of the paper.

In this new version, we have restructured particularly the methodological and discussion sections, including new references and new design of figures, improving the explanation of how to achieve the internal transformation linked to the Lean Culture. We have highlighted in yellow the main changes.

We have checked the paper style with a native English professional.

Particularly:

• We have mentions new Lean tools and skills (for examples in lines 205-208).
• In the application of the methodology we justify in more detail the explanation for using some tools and no others (lines 211-212; 307-309) and the process of learning in the organization for achieving the cultural transformation (lines 375-377; 384-393; 651-653; 721-726; 779-786).

Reviewer 2 Report

The authors propose a novel participative methodology to implement Lean Management in healthcare. The aim of the method is to redesign processes and, as a result, minimize waste and improve selected KPIs. After a detailed description of the proposed approach, the authors test their methodology on an example Spanish hospital and compare KPIs before and after the implementation. The results show that this methodology may improve the hospital performance and can be reused across other healthcare facilities.

The paper is well-written and well-structured. The authors provide a clear description of the methodology and include results of their analysis on a real example. I suggest some minor corrections/adjustments:

• It would be good to mention some other parcticipative/participatory approaches, e.g. to business process modeling.
• The diagram in Fig. 3 could be prepared in a certain notation for process modeling to improve its understandability.
• Table 2 can be more clear - consider adding a horizontal line between Productivity and Quality, as the numbers are difficult to read.

Author Response

Thank you very much for your interesting suggestions and comments. We have included them in this new version of the paper.

In this new version, we have restructured particularly the methodological and discussion sections, including new references and new design of figures, improving the explanation of how to achieve the internal transformation linked to the Lean Culture. We have highlighted in yellow the main changes.

We have checked the paper style with a native English professional.

Particularly:

• We have mentioned other participative approaches as you have suggested (for example in lines 234-237).
• We have changed the figure 3 and the table 4 as you have suggested.

Reviewer 3 Report

It is not clear, for this research, what is an "action research", and how it generates a significant impact on the proposal. I suggest to define clearly the concept/construct of action research in the introduction. Autor research is mentioned twice but no defined.

Figure 1 is confused. In lines 100-101 authors wrote: the authors propose a methodology. I see Figure 1 as a recursive diagram. I suggest adding the phases in the diagram. It is clear that the conceptual phase is "phase 1" and the applied phase is "phase 2", just mention in Figure 1.

Check a typo in Figure 1: Departmentr.

I suggest, if possible, to design a figure to describe/explain the sequence of phase 1 and insert at the beginning of phase 1. I´m not sure if figure 2 has the objective to explain phase 1, it seems not. Including a new figure helps to understand better the first part os the proposal.

In the results section (testing the methodology), I suggest the same as methodology. Try to describe how every point was developed during the the application.

The same comment for the second phase: implementing the methodology.  In the "applied phase" of Figure 1, I can see three stages: preliminary, launch and consolidation, but what items are considered within these themes. Figure 3 shows the patient flow but is not the methodology.

Lines 73-77 should be structured The first, the second, the third, and the last to avoid confusing.

I hope these comments help tp improve the article.

Author Response

Thank you very much for your interesting suggestions and comments. We have included them in this new version of the paper.

In this new version, we have restructured particularly the methodological and discussion sections, including new references and new design of figures, improving the explanation of how to achieve the internal transformation linked to the Lean Culture. We have highlighted in yellow the main changes.

We have checked the paper style with a native English professional.

Particularly:

• We have included a definition of Action Research approach in the Introduction Section.
• We have redesigned the figure 1, according to your suggestions.
• We have redesigned the figure 2, according to your suggestions, restructuring the content of the methodology section.
• We have restructured the applied and discussion sections for improving the readiness.
• We have changed the paragraph explaining the structure of the paper as you have suggested.

Reviewer 4 Report

Dear Authors,

Thanks for the opportunity to review the manuscript titled: “Increasing competitiveness through the implementation of Lean Management in healthcare".

The manuscript addresses an issue of implementation of Lean Management in healthcare . The topic itself is interesting and within ta scope of IJERPH.

In my opinion, the paper is interesting, well written and The subject matter presented in it is up to date. I especially appreciate the practical value and the possibility of implementing the presented results.

However, there are some shortcomings that need to be corrected in order for the paper to be acceptable:

1. I suggest extending literature review. Additional bibliographic references are necessary. Especially concerning lean management in a healthcare. I have found some interesting papers:

Mousavi Isfahani, H., Tourani, S. and Seyedin, H. (2019), "Lean management approach in hospitals: a systematic review", International Journal of Lean Six Sigma, Vol. 10 No. 1, pp. 161-188. https://doi.org/10.1108/IJLSS-05-2017-0051

Vinaytosh Mishra, Cherian Samuel & S. K. Sharma (2019) Lean, agile and leagile healthcare management – A case of chronic care, International Journal of Healthcare Management, 12:4, 314-321, DOI: 10.1080/20479700.2018.1428520

Rotter, T., Plishka, C., Lawal, A., Harrison, L., Sari, N., Goodridge, D., … Kinsman, L. (2019). What Is Lean Management in Health Care? Development of an Operational Definition for a Cochrane Systematic Review. Evaluation & the Health Professions, 42(3), 366–390. https://doi.org/10.1177/0163278718756992

In my opinion the authors should refer to these papers in the discussion and indicate the distinguishing points of their study.

2. The limitation section needs to be expanded considerably to reflect the ongoing changes and emerging new challenges.

In my opinion, the manuscript  needs minor revision. In conclusion, this paper need revision and some improvements are necessary for the final publication.

Author Response

Thank you very much for your interesting suggestions and comments. We have included them in this new version of the paper.

In this new version, we have restructured particularly the methodological and discussion sections, including new references and new design of figures, improving the explanation of how to achieve the internal transformation linked to the Lean Culture. We have highlighted in yellow the main changes.

We have checked the paper style with a native English professional.

Particularly:

• We have checked and included new references throughout the paper as you have suggested (highlighted in yellow in the references section), commenting them in relation with our proposal.
• We have included, in the Discussion section, two specific parts: one for new challenges; one for presenting the limitations of the paper.

Reviewer 5 Report

Applying lean management to healthcare is interesting and relevant. The chosen Application Research approach is relevant and innovative. The authors describe a valuable case study and share their insights and experiences from applying lean management in a project in the context of a hospital unit. The scientific approach and the work carried out is described and detailed. The participatory and involvement of actors in the innovation and improvement approach is valid and important.  What can be improved from my perspective, is the Action Research approach by refering to more current approaches as well as Design Science paradigm e.g. Hevner et al., or Sein et al, Gregor et al., etc. The focus on lean management and related methods and techniques is adequate, however, lacks consideration and reflection of business process management (e.g. BPMN), only limited information is available concerning how processes have been documented (value flows, information flows, patient flows, material flows, etc.) and the degree of change can be visualized and communicated. For further digitization solutions such as content management, data quality and integration of information and communication systems are relevant. Probably a use case based approach is interesing, however, the authors to not further explicate on this. Links to agile paradigms and approaches are visible but are not further explored by the authors. As well, the relationship between KPI and process / tasks activities can be further developed and described. For healthcare, service quality and service productivity are relevant, but it is not made explicit, how the authors refer to these concepts, and where they see limitations and constraints to apply production-oriented approaches to a service case. The service perspective in general is kept rather vague, as value is not well elaborated. It can be controversely discussed when a treatment is successful, because there are various perspectives and intentions of actors which need to be moderated. From my perspective, KPIs should be selected oriented towards common goals and strategies, for this, approaches such as balanced score card are interesting, as they balance the various interests, and from my experience are traditionally popular and common to be installed in hospitals. Further problem, are applied DRG catalogues for cases which predefine the available financial budget and applicable resources, medical treatments are often based on recommendations from evidence-based studies, which characterize maturity levels. None of this influencing factors have been addressed or discussed. I hope this helps to further improve the presentation of the research results.

Author Response

Thank you very much for your interesting suggestions and comments. We have included them in this new version of the paper.

In this new version, we have restructured particularly the methodological and discussion sections, including new references and new design of figures, improving the explanation of how to achieve the internal transformation linked to the Lean Culture. We have highlighted in yellow the main changes.

We have checked the paper style with a native English professional.

Particularly:

• We have included, in the methodological section, a mention to other more common approaches, such as Design Science Paradigm (lines 96-102).
• We have reinforced, in the methodology section, the connection between Lean Management and other process redesign approaches, such as, Business Process Management or Modelling (lines 234-237).
• We have included, in the methodological section, a wide proposal of Lean tools (for examples in lines 205-208), explaining that some of these tools can be selected depending on the complexity of the process and the level of maturity of the organization towards cultural transformation (for examples, lines 211-212; 307-309; 375-377; 384-393; 651-653; 721-726; 779-786).
• We pay attention to the role of the information system design in the hospital (now and in the future) (for example, lines 413-415; 812-821).
• We have connected the specific targets of Lean Management (with their KPIs) with the general targets of the organization (including Stakeholders´needs), in terms of costs, services, flexibility, agility or sustainability (for example, lines 37-42; 222-224; 324-326; 436-437).
• We have mentioned specifically the importance of resources for implementing improvements and changes (not always available) (for example, lines 411-415; 812-821).