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Lean thinking in healthcare: a realist review of the literature
  1. Pamela Mazzocato1,
  2. Carl Savage1,
  3. Mats Brommels1,2,
  4. Håkan Aronsson3,
  5. 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}


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.

  • Lean thinking
  • Toyota production system
  • literature review
  • realist review
  • health services research
  • continuous quality improvement
  • healthcare quality
  • management
  • qualitative research

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  • 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.