This study aims at developing an improvement framework of warehouse processes by improving process cycle efficiency using lean six sigma (DMAIC) approach. A case study method was used to illustrate the evaluation of the existing processes in the warehouse of a third party logistics company with a focus on productivity using warehouse lean tools. Data were collected based on warehouse operational areas of suppliers, customers and internally related with a focus on warehouse core processes. The optimization of the warehouse processes was based on established lean tools. Based on the warehouse evaluation, high non-value added activities were observed leading to a low process cycle efficiency of 40%. After the implementation of the lean six sigma approach, the process cycle efficiency improved of up to 70%. An improvement framework was also established for productivity across the warehouse processes to minimise waste. Lean warehousing has been used to illustrate solutions to a real-time problem of productivity which has negatively impacted on management and customer satisfaction. The study has added to lean warehousing focusing on all the warehouse processes using six sigma DMAIC approach, unlike most literature which concentrates on a specific process. Also develop a framework for the improvement of the processes.

Lean methodologies have been used successfully in both industry and healthcare to reduce waste. The operating room (OR) and central supplies department (CSD) are areas associated with high hospital costs. The aim of this study was to employ Lean methodologies to support the rationalisation of surgical trays in paediatric inguinoscrotal surgery in order to reduce instrument wastage, processing times and overall costs in a European setting.
This was a prospective, pilot observation and implementation study using Lean methodology including DMAIC (Define, Measure, Analyse, Improve and Control) cycles. Relevant tray set-up included trays for boys ≥12 months age undergoing open elective inguinoscrotal surgery. A comparative analysis of two phases, pre and post-standardization was then carried out with respect to operating times, instrument set-up times, tray weights, and costs. Instruments that were used <40% of the time were eliminated from the surgical tray.
Rationalization of the inguinoscrotal tray led to a 34.7% reduction in tray size, with a concomitant time-reduction of >2 min per case. The average overall instrument utilisation rate increased from 56% to 80% across users. Cost savings were projected at €5380.40 per annum based on current changes. There were no differences in operative time, or adverse outcomes.
At the hospital level, the reduction in variation, and rationalisation of this single surgical tray could lead to both operational (Tray assembly process; Operating rooms; Ergonomic functionality) as well as economic (Sterilisation; Instrument repair; Purchases) financial and ergonomic improvements for the healthcare system. The reduction in time taken to count and sterilise instruments can lead to a potential manpower saving involving a redistribution of activities to other areas which may require them.
Surgical tray rationalisation is emerging Lean concept with overlap across a number of specialities, and represents a technique by which to manage costs, and improve supply chain efficiency without any adverse effect in patient healthcare outcomes.

As end-users, employees appropriate technologies. Technology appropriation is generally conceived as a covert phenomenon. In particular, alternative ways and new purposes for which employees deploy technologies tend to remain hidden. Therefore, the potential of technologies as a source of organizational improvements may remain undisclosed. Continuous improvement (CI) programs, in contrast, are explicitly oriented at disclosing organizational improvements. In essence, CI programs encourage employees to openly discuss how to improve their work practices. Such continuous movements towards novel, often better, ways of working may be perfectly suited to bring the covert nature of technology appropriation into the open. Based on a case study on a personal digital assistant (PDA) in a Belgian nursing home with such a CI program in place, we document and analyze to what extent and why functionalities of the PDA were discussed and further developed. We distinguish between the functionalities that, upon implementation, intended to improve particular work practices, and those that surfaced after the technology had been introduced. To conclude, we point at employees\' perceived usefulness of their work practices and their willingness to improve these, rather than only the technology itself, to further the debate on technology appropriation.

UNASSIGNED: Clinical decision support (CDS) generates excessive alerts that disrupt the workflow of clinicians. Therefore, inefficient clinical processes that contribute to the misfit between CDS alert and workflow must be evaluated. This study evaluates the appropriateness of CDS alerts in supporting clinical workflow from a socio-technical perspective.
METHODS: A qualitative case study evaluation was conducted at a 620-bed public teaching hospital in Malaysia using interview, observation, and document analysis to investigate the features and functions of alert appropriateness and workflow-related issues in cardiological and dermatological settings. The current state map for medication prescribing process was also modelled to identify problems pertinent to CDS alert appropriateness.
RESULTS: The main findings showed that CDS was not well designed to fit into a clinician\'s workflow due to influencing factors such as technology (usability, alert content, and alert timing), human (training, perception, knowledge, and skills), organizational (rules and regulations, privacy, and security), and processes (documenting patient information, overriding default option, waste, and delay) impeding the use of CDS with its alert function. We illustrated how alert affect workflow in clinical processes using a Lean tool known as value stream mapping. This study also proposes how CDS alerts should be integrated into clinical workflows to optimize their potential to enhance patient safety.
CONCLUSIONS: The design and implementation of CDS alerts should be aligned with and incorporate socio-technical factors. Process improvement methods such as Lean can be used to enhance the appropriateness of CDS alerts by identifying inefficient clinical processes that impede the fit of these alerts into clinical workflow.

Academic literature and practitioners acknowledge that there is a need to improve efficiency and service quality in the healthcare industry. In Spain, osteoporotic fractures represent a great cost in socio-economic and morbi-mortality terms, hip fracture being the surgical pathology with the second highest consumption of resources. The research questions that govern this study concern the use of Lean principles to identify waste, and an evaluation of the application of an innovative approach in the hip fracture surgery process. A research design based on a case study and action research was developed. Findings relate to (i) the identification of the main types of waste or muda (being the most frequent delay, transportation, over-processing and defects); (ii) the analysis of existing processes based on a Lean approach (identifying opportunities for improvement as a reduction of the number of steps and participants, improving communication, automation, standardization, etc.); and (iii) the application of an innovative process based on the Lean approach and action research in the healthcare industry. This research provides insights for academia, practitioners, management, and society: waste identification and process redesign helps to continue the improvement of operations, increase efficiency, reduce costs, and enhance services, providing benefits to patients, families, hospital employees, and the healthcare system.

Hospital quality improvement initiatives that focus on the patient experience are increasingly gaining attention. One of the known improvement methodologies is patient journey mapping. Central to this methodology is the mapping process, resulting in a patient journey map: a visual presentation of the complete route a patient follows during all stages of a care trajectory and the patients emotional experience during this journey: the patient journey map. Currently, there is no standard approach on how to perform the steps in the mapping process and evidence is lacking on the most effective and efficient way. As a result, the adoption of the methodology by healthcare professionals is hindered, more time than necessary is spent on the mapping and a lot of significant variation exists in the quality of the resulting patient journey maps. The Lean methodology has a proven track of record to optimize and standardize processes. Hence, by performing a Lean analysis onto the patient journey mapping process, opportunities to optimize and standardize the process may be identified. This study aimed to assess the value of Lean methodology to optimize patient journey mapping in a hospital setting. Observations and interviews were performed to identify the process for patient journey mapping in a Dutch academic hospital. Lean was used to visualize the process and identify inefficiencies. An expert panel reviewed the improvement suggestions. We conclude that Lean can provide value for aligning different views on the process, for structuring the process steps and phases and for identifying optimization actions in the mapping process.

OBJECTIVE: The purpose of this paper is to define a clinical pathway for total joint replacement (TJR) surgery, estimate the effect of delays between steps of the pathway on wait time for surgery and to identify factors contributing to more efficient operations and challenges to their implementation.
METHODS: This is a case study with a mixed methods approach. The authors conducted interviews with hospital staff. Data collected in the interviews and through on-site observation were analyzed to map the TJR process and identify the steps of the care pathway. The authors extracted and analyzed data (time stamps) from 60 hospital patient records for each step in the pathway and ran a regression on the duration of the whole trajectory.
RESULTS: There were wide variations in the delays observed between the seven steps identified. The delay between Step 1 and Step 2 was the only significant variable in predicting the total wait time to surgery. In one hospital, one delay explained 50 percent of the variation. There was misalignment between findings from the qualitative data in terms of strategies implemented to increase efficiency of the clinical pathway to the quantitative data on delays between the steps.
CONCLUSIONS: The study identified the clinical pathway from the consultation with an orthopaedic surgeon to the surgery. However, it did not go beyond the surgery. Future research could investigate the relationship between specific processes and delays between steps of the process and patient outcomes, including length of stay, mobilization and functionality in activities of daily living, as well as potential complications from surgery, readmission and the services required after the patient was discharged.
CONCLUSIONS: Wait times can be addressed by implementing strategies at the health system level or at the organizational level. The authors found and discuss areas where there could be efficiency gains for health care organizations.
CONCLUSIONS: Stakeholders in care processes are diverse and they each have their preferences in how they practice (in the case of providers) and how they perceive and wish to respond adequately to patients\' needs in contexts that have different norms and approaches. The approach in this study enables a better understanding of the processes, the organizational culture and how these may affect each other.
CONCLUSIONS: Our mixed methods enabled a process mapping and the identification of factors that significantly affected the efficiency of the TJR surgery process. It combines methods from process engineering with health services and management research. To some extent, this study demonstrates that although managers can define and enforce processes, organizational culture and practices are harder to influence.

Hospital care is the single, largest contributor to health spending, yet evidence to guide value transformation is lacking. The large, real-world studies required to fill this void are challenging to conduct in the complex and fast-paced acute care environment. To address these challenges, we created a framework that combines Lean manufacturing methodology and Applied Research principles. We deployed this framework to design, pilot, and iteratively improve a study protocol testing the effectiveness of an innovative care pathway for patients hospitalized with acute exacerbations of Chronic Obstructive Pulmonary Disease. Over a three month period, the protocol was successfully piloted and refined at a single site, subsequently becoming the basis for a large system-wide randomized controlled trial. This framework combining Lean and Applied Research methods resulted in synergies that neither method could accomplish alone and may serve as a template for learning healthcare systems to efficiently generate real-world evidence in the acute care setting.

Delays in first cases contribute to multiple operating room (OR) inefficiencies and decreases in OR productivity.
Lean process improvement methods were used to redesign the existing workflow for elective first cases of the day in a large, urban, public hospital. First case start times were prospectively recorded from May 2, 2016 through December 29, 2017.
Data from 415 operating days were examined, 86 days prior to, 35 days during, and 294 days after implementation of interventions in the pre-operative holding area. During this time, of 23,891 operations performed, 14,981 were elective procedures, 5963 (39.8%) of which were first cases of the day. The mean rate of elective first case on-time starts per week went from 23.5% before and during to 73.0% after implementation of lean interventions (p < 0.0000001).
Implementation of lean interventions in the pre-operative holding area was associated with significantly improved rates of elective first case on-time starts.

Background Lean practices have been widely used by health care organizations to meet efficiency, performance and quality improvement needs. The lean health care literature shows that the effective implementation of lean requires a holistic system-wide approach. However, there is still limited evidence on what drives effective system-wide lean implementation in health care. The existing literature suggests that a deeper understanding of how lean interventions interact with the organizational context is necessary to identify the critical variables to successfully sustain system-wide lean strategies. Purpose and methodology: A multiple case study of three Italian hospitals is conducted with the aim to explore the organizational conditions that are relevant for an effective system-wide lean implementation. A conceptual framework, built on socio-technical system schemas, is used to guide data collection and analysis.
The analysis points out the importance to support lean implementation with an integrated and coordinated strategy involving the social, technical, and external components of the overall hospital system.