Qual Saf Health Care 19:376-382 doi:10.1136/qshc.2009.037986
  • Original research

Lean thinking in healthcare: a realist review of the literature

  1. Johan Thor1
  1. 1Medical Management Centre, Berzelius väg 3, Karolinska Institutet, Stockholm, Sweden
  2. 2Department of Public Health, University of Helsinki, Helsinki, Finland
  3. 3Department of Management and Engineering, Linköping University, Linköping, Sweden
  1. Correspondence to Pamela Mazzocato Medical Management Centre, Berzelius väg 3, Karolinska Institutet, SE-17177 Stockholm, Sweden; pamela.mazzocato{at}
  1. Contributors PM, MB, CS and JT were involved in the original conception and design of the article. PM designed an initial search strategy with inclusion criteria which was refined with help from CS and JT. PM performed the systematic search and, when needed, conferred with CS and JT. PM, CS and JT developed, piloted and then refined the standardised abstraction form. PM, CS, JT, MB and HA shared the responsibility for reading and analysing the full text articles. PM reviewed all the data abstracted, organised the data and collected the data in an Excel spreadsheet by topic. An MS Access database was developed and queried by PM. PM, CS, JT and HA piloted the categorisation together. PM completed the analysis and conferred with CS, JT and HA regarding any uncertainties. PM and CS drafted the article. JT, MB and HA critically revised it. All authors have approved the final version of the paper. PM, CS and JT act as guarantors of the paper.

  • Accepted 1 May 2010
  • Published Online First 19 August 2010


Objective To understand how lean thinking has been put into practice in healthcare and how it has worked.

Design A realist literature review.

Data sources The authors systematically searched for articles in PubMed, Web of Science and Business Source Premier (January 1998 to February 2008) and then added articles through a snowball approach.

Review methods The authors included empirical studies of lean thinking applications in healthcare and excluded those articles that did not influence patient care, or reported hybrid approaches. The authors conducted a thematic analysis based on data collected using an original abstraction form. Based on this, they articulated interactions between context, lean interventions, mechanisms and outcomes.

Results The authors reviewed 33 articles and found a wide range of lean applications. The articles describe initial implementation stages and emphasise technical aspects. All articles report positive results. The authors found common contextual aspects which interact with different components of the lean interventions and trigger four different change mechanisms: understand processes to generate shared understanding; organise and design for effectiveness and efficiency; improve error detection to increase awareness and process reliability; and collaborate to systematically solve problems to enhance continual improvement.

Conclusions Lean thinking has been applied successfully in a wide variety of healthcare settings. While lean theory emphasises a holistic view, most cases report narrower technical applications with limited organisational reach. To better realise the potential benefits, healthcare organisations need to directly involve senior management, work across functional divides, pursue value creation for patients and other customers, and nurture a long-term view of continual improvement.


  • All authors had full access to all of the data in the study and take responsibility for the integrity of the data and accuracy of the data analysis.

  • Funding This study was performed as part of a project on innovation implementation in healthcare, funded by the Swedish Vinnvård programme. PM and HA's salaries were covered by the project funding. The other authors were supported by their respective employers in conducting this research as part of their work.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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