Unveiling the Impact of Lean Leadership on Continuous Improvement Maturity: A Scoping Review

Correspondence: Oskar Roemeling, Department of Innovation, Management & Strategy, University of Groningen, P.O. Box 800, 9700 AV, Groningen, the Netherlands, Tel +31 05 363 2025, Email o.p.roemeling@rug.nl

This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php).

Abstract

Purpose

Lean Management (LM) is a process improvement approach with growing interest from healthcare organizations. Obtaining a culture of continuous improvement is a primary objective of LM, and a culture of continuous improvement indicates a mature LM approach, and here leadership plays a central role. However, a comprehensive overview of leadership activities influencing LM maturity is lacking. This study aims to identify leadership activities associated with continuous improvement and, thus, LM, maturity.

Methods

Following the PRISMA guidelines, a scoping literature review of peer-reviewed articles was conducted in twenty healthcare management journals. The search provided 466 articles published up until 2023. During the selection process, 23 studies were included in the review. The leadership activities related to continuous improvement maturity were identified using the grounded theory approach and data coding.

Results

The analysis highlighted a total of 58 leadership activities distributed across nine themes of LM leadership. Next, analysing leadership activities concerning the different maturity levels revealed three maturity stages: beginner, intermediate, and expert. Based on the findings, we propose a framework that guides suitable leadership activities at the various stages of LM maturity. The framework provides leaders in healthcare with a practical overview of actions to facilitate the growth of the LM approach, and the related propositions offer academics a theoretical basis for future studies.

Conclusion

This review presents the first comprehensive overview of LM leadership activities in relation to continuous improvement and LM maturity. To enhance LM maturity, leaders are encouraged to consider their leadership style, (clinical) stakeholder involvement, alignment with the organizational strategy, and their role in promoting employee autonomy.

Keywords: lean management, lean healthcare, continuous improvement, lean leadership, leadership activities, lean adoption

Introduction

Leaders in healthcare organizations (HCOs) are increasingly confronted with external pressures that require changes to become more efficient at lower costs whilst maintaining or improving the quality of care. 1 , 2 To cope with these pressures in the long term, HCOs apply quality improvement methods. 3 As care pathways and patient journeys are similar to a production process, with units creating value for the patient through multiple steps, lean management (LM) offers a framework to guide process improvement. 4 , 5 LM can be defined as a management practice aimed at enhancing organizational efficiency through a process of continuous improvement (CI) aimed at maximizing value-adding activities and eliminating waste. 6 LM has roots in the manufacturing environment and has been successfully applied by and adapted to HCOs in recent years. 7

LM is used to facilitate strategic change, to improve quality, and to reduce costs. 8 One of the main objectives of LM is to develop a culture of continuous improvement (CI). In such a culture, improvement activities are championed by employees and recognized as part of everyday work rather than being seen as discrete improvement-related projects. 9 CI is defined as the ongoing change process to improve quality and reduce waste for overall performance. 2 , 10 To better understand the depth of LM applications in HCOs, a structured assessment of the deployment of LM is required. 11 Liker 12 suggests that this application depth can be measured by the extent to which LM principles are present, known as the level of LM maturity. In addition, Bessant et al 13 developed a five-level CI-model to assess the degree of application of LM, in which LM maturity is recognized as full integration of CI. In our research, we use these ideas to establish if a culture of CI is present, which implies that we have reached LM maturity.

Prior research focused on LM in healthcare aimed to explore factors that influence LM maturity; studies recognize strong leadership and high commitment of managers and physicians, continuous training, and the hospital’s involvement in CI as examples of facilitators. 7 , 14 , 15 Examples that inhibit maturity are lack of knowledge by LM leaders, insufficient resource availability, and provision of training not tailored to the healthcare context. 15–18 In addition, the Center for Lean Engagement and Research in Healthcare (CLERH) recognized leadership, commitment, standard work, communication and a daily management system as overarching factors influencing LM maturity. 11 Moreover, leadership is important in LM approaches. 19–23 LM leaders are coaches who create the strategy, build the team, and help employees develop their skills within the LM initiative. 24 Hence, leadership is central to LM and, thus, LM maturity.

Previous studies on LM leadership in healthcare identified various leadership activities influencing LM maturity, such as adopting a hybrid leadership style, empowering employees to become Lean leaders, involving them in decision-making processes, and establishing LM as a long-term CI program. 25–30 The previous studies underline the importance of leadership in LM maturity. Yet, a clear overview of LM leadership activities in relation to LM maturity and the culture of CI has come to pass. To the best of our knowledge, this research is the first to systematically review the literature on LM in the healthcare setting to address this gap. Our work relates to the study of Aij et al, 24 who reported on the role of LM leadership and servant leadership in relation to LM transitions.

The primary objective of this study is to develop a growth model that connects leadership activities identified in the literature to specific LM maturity phases. By doing so, the model offers a guideline for organizational leaders to spur the adoption, and thus maturity, of LM within HCOs. In line with these objectives, this study seeks to answer the following research question: “How do leadership activities facilitate a culture of continuous improvement and, thus, lean management maturity?”

Identifying leadership activities in relation to LM maturity can contribute to the success of LM initiatives. The proposed framework guides leaders in the transition to a mature LM approach. From an academic perspective, this study contributes to existing research within the LM leadership domain by aggregating empirical LM leadership activities in relation to the levels of CI maturity and furthering our understanding through the development of propositions.

Methods

This scoping literature review has been conducted using empirical research that reported on LM in health care. We identified leadership activities influencing LM maturity, and we related these LM leadership activities to different levels of maturity. 14 A literature review focuses on identifying, evaluating and synthesizing literature systematically, reproducibly and comprehensively, 31 argued appropriately to answer the research question. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines 32 were followed to report on the literature selection and guide the review process. The search strategy was three-pronged: 1) defining inclusion and exclusion criteria; 2) composing a search string; and 3) assessing remaining articles on eligibility through full-text review. Ultimately, this resulted in the final set of 23 articles included in this review. Coding supported the analysis of the included studies. In the remainder of this section, we further elaborate on the applied methodology.

Databases

As LM is a popular approach in various domains (eg, manufacturing, services), and we were explicitly interested in healthcare management, we required a focused approach for our data selection. Moreover, we aimed to arrive at a diverse dataset that offers a global perspective on leadership and avoids ethnocentrism. To that end, we follow Meese et al, who asked healthcare management or public health academic experts from all high-income Organisation for Economic Co-operation and Development (OECD) countries to list the most influential journals in the healthcare management domain. 33 For this review, we selected the 20 top journals on the Meese-ranking. The resulting list is of highl quality, geographically diverse and differs substantially from pre-existing US or European rankings. This approach ensures the relevance of our findings for healthcare, and conducting the literature review on this subset of journals reduces possible viewpoint biases. 33 In addition, it enhances the validity and accuracy of the current study. 34 The specific databases were directly accessed for the identification and collection of articles, an overview of the included journals is added to Supplementary Table 1 .

Inclusion and Exclusion Criteria

Following the research objectives, initial inclusion and exclusion criteria were established to include relevant articles ( Table 1 ). Exclusively, English-written articles were included, as this is the most common language of LM healthcare research, 7 and it is common amongst review articles to be limited to English. 35 Only empirical studies reporting on LM in a healthcare context were included. We searched for articles that reported on the application of LM in the broadest sense, as we are interested in identifying relevant leadership activities in all the possible LM stages. Moreover, we did not apply any specific leadership inclusion criteria in order to be able to search as broadly as possible within the articles for leadership activities during later screening. In other words, we were careful not to exclude articles that might not specifically mention leadership but did report on activities that could be related to leadership.

Table 1

Inclusion and Exclusion Criteria to Assess Eligibility Through Abstract Screening

Keywords

LM is known by multiple names; therefore, several literature reviews on LM in healthcare were consulted to establish a comprehensive set of LM search terms. An overview of the various LM terms based on these literature reviews is presented in Table 2 . Consequently, we applied the following search terms to identify as many LM studies as possible: lean thinking, lean management, lean healthcare, lean philosophy, continuous improvement, lean methods, and lean principles. We used no specific keywords concerning leadership activities, as we did not want to rule out studies that might not explicitly report on leadership but did report valuable activities that could be attributed to leadership.

Table 2

Lean Search Terms Based on Lean in Healthcare Literature Reviews

As the selected journals (mainly) publish healthcare management research, 33 the concept of healthcare was not included in the search string. However, during some preliminary search trials, we observed that the Academy of Management Journal and BMJ Quality & Safety did not exclusively publish articles within the healthcare domain. Hence, this resulted in an arguably inflated number of potential articles. Consequently, the search string for these two journals was adjusted slightly to obtain articles in the healthcare domain. The search strings in Table 3 were directly applied to the twenty journals, which led to the identification of 466 unique articles. The search was conducted in April 2023, ensuring that articles published until this month are included in the identification phase of this review.

Table 3

Applied Search Strings

Screening and Selection

Four hundred and sixty-six unique articles were taken to the screening phase, aiming to assess articles that relate to the research objective: identifying leadership activities relevant to reaching LM maturity. The abstracts of these 466 articles were screened with the inclusion and exclusion criteria, resulting in 45 eligible articles. Access to 40 of these articles was obtained via the journals and for five articles via direct request to authors. To determine the final set of articles included in this study, the 45 articles were assessed through a full-text review to determine if they matched the inclusion criteria and if leadership activities could be identified. The full-text review highlighted eleven articles found to be in an inappropriate study setting, six articles did not report on or link with leadership, four did not report on empirical research, and one did not report on LM, amounting to the exclusion of 22 articles. Following the PRISMA guidelines, our final set consisted of 23 articles, as shown in Figure 1 . The 23 articles hold information on 34 unique HCOs that applied LM, as four reported on multiple case settings.

Data Extraction and Analysis

The descriptive information was obtained using a data extraction form based on Okoli and Schabram (2010). The form was piloted before data extraction and aggregated after completion. The overview has been added to Supplementary Table 2 . The collected descriptive information comprised the author(s), year of publication, journal, study context, research objective, and main findings. We applied the grounded theory approach to obtain the data that indicated the level of LM maturity and infer the leadership activities that were relevant in obtaining this level of maturity. 40 To establish the LM maturity level, the articles were thoroughly read and categorized into one of the five maturity levels. 13 To facilitate this process, we applied a maturity decision tree, which we added to the overview of the classification in Supplementary Table 3 and Supplementary Figure 1 .

The extraction of LM leadership activities was supported by the software program Atlas.ti. Here, we proceeded as follows: articles were scanned to understand the concept of LM leadership. 11 , 21 , 23 , 24 , 26 , 41 Through axial coding, excerpts of LM leadership activities were retrieved from the articles. New codes emerged during this inductive coding process, leading to the establishment of the codebook, which has been added in Supplementary Table 4 . After completion of the coding, the coded excerpts were transferred to Excel. The excerpts indicating leadership activities were reviewed to merge similar activities. This resulted in a total of 58 different identified leadership activities. Subsequently, these activities were reviewed and adjusted to create LM leadership themes, resulting in the emergence of nine LM leadership themes.

Results

In this section, we provide the results of our literature review, and we begin with the presentation of the PRISMA-diagram, depicted in Figure 1 , that shows the literature selection process.

Characteristics of Included Studies

In total, 23 unique articles were included in this review. An overview of the journals in which the studies were published is presented in Table 4 , and the distribution of studies over countries is presented in Table 5 . Supplementary Table 5 provides an overview of the descriptive information of the articles, the assessed level of LM maturity, including justification for this classification and other descriptive information deemed relevant. Through the included studies, we were able to identify 34 unique HCOs. As one of the HCOs 39 reported on two stages of the LM implementation process, which were found to be in different levels of LM maturity, the two stages of LM implementation were considered as separate instances (labelled HCO 1a and 1b). This implies that we identify 35 unique cases taken to the analysis phase. An overview of the countries in which the 34 HCOs are based is shown in Table 4 . The publication years of the studies are shown in Figure 2 . The years of publication vary from 2010 to 2022, in which no identifiable trend was observed. The observation that HCOs from the United Kingdom (UK) and the United States (US) both account for one-third part of this literature review is in line with the finding that the UK and the US account for the largest number of publications on Lean healthcare. 42

Table 4

Distribution of Articles by Journal