Does lean improve efficiency or effectiveness from the patient perspective?

doi:10.21203/rs.3.rs-1528352/v1

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Does lean improve efficiency or effectiveness from the patient perspective?

https://doi.org/10.21203/rs.3.rs-1528352/v1

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Background: The purpose of this paper is to assess the impacts of lean healthcare on patient satisfaction and determine whether it improve the efficiency or effectiveness in the eyes of the patient after lean interventions.

Methods: A multi-method, systematic review of the English literature researching the relationship between lean healthcare and patient satisfaction was conducted from September to November 2021. From the initial identification of over 621 papers, 51 studies that met the search criteria were selected. We did a thematic content analysis of the 51 papers.

Results: 41 out of 51 studies clearly reported that the application of lean would lead to improved patient satisfaction, one study sated that satisfaction remained unchanged, two studies reported a decrease and one stated that the impact is unclear. The factors, impacting the relationship between lean healthcare and patient satisfaction, were classified into 7 categories: medical staff service, service process, service outcome, hospital facilities and equipment, hospitalizations, patient complaints, respondents’ characteristics. Most studies have verified the impact of the improvement of service process factors caused by lean implementation on patient satisfaction, and only 7 studies have verified the impact of lean improved service results on patient satisfaction.

Conclusion: Most of the research on lean improvement on patient satisfaction focuses on efficiency, not effectiveness—the effect of patient treatment. Although the efficiency improvement in lean improvement itself also starts from the patient, the improvement of effectiveness still needs more attention, and the focus of lean healthcare needs to return to the essence of medical treatment.

lean

lean healthcare

patient satisfaction

systematic review

Medical services are facing the challenge of [1] improving the quality of care, improving efficiency and ultimately providing more value to patients [2]. Since the 1990s, healthcare providers have been seeking inspiration and guidance from other industries to solve quality and cost problems [3]. In this regard, lean healthcare has become a service strategy to reduce or eliminate waste and non-value-added activities in medical services. It is also an important management concept to improve hospital efficiency and quality around patients' needs.

Lean originated from Toyota production system (TPS) [4], and the focus of lean management activities is to create value for end customers by continuously improving efficiency and eliminating waste [5]. Womack and Jones were the first authors to propose the application of lean production to health care. They believe that the first step in implementing lean production is to formulate the nursing process according to the patient's point of view, focusing on shortening the delivery time and adding value [6]. According to a national survey conducted by the American Hospital Association in 2017, about 70% of hospitals use lean or related methods [7]. The application of lean has made great achievements in improving efficiency and service quality and reducing costs. Defining value from the perspective of patients is the core concept of lean healthcare [6].The value of lean for patients is to complete their care and treatment from the perspective of efficiency and effectiveness: with the best results, no errors, on time, and no delays [8].

The National Quality Forum ranks patient experience assessment as a top priority and is often assessed using patient surveys [9]. Patient satisfaction is a key index to evaluate the quality of medical service [10–13], is also an influencing factor of medical practice [13]. Patients play the role of contributor, target and reformer in quality improvement. The results of patient satisfaction survey allow health care providers to determine the service content that needs to be improved [12]. It also enables decision makers to understand the needs of patients, so as to make strategic plans more effectively [14, 15]. On the other hand, the higher the satisfaction of patients, their behavioral intentions will change, such as following the treatment recommended by doctors, resulting in better health outcomes [16, 17]. Therefore, from the perspective of creating value for patients, how the application of lean medicine affects patient satisfaction is an interesting topic.

Therefore, from the perspective of creating value for patients, how the application of lean medicine affects patient satisfaction is an interesting topic. According to Mathon's early research [18], she proposed eight defining attributes of patient satisfaction, namely the art of care, technical quality of care, access, finances, physical environment, availability of providers, continuity of care and efficacy. Based on Mahon's research, Wagner and bear [19] divided the attributes of patient satisfaction into affective support, health information, decisional control, and professional competencies. Janet and Bronya [20] studied it in a broader context of health care based on previous experience, and believed that patient satisfaction can be divided into two dimensions and four attributes: human dimension includes provider's attitude and technical capability, while system dimension includes accessibility and efficiency. Through four years of efforts, Carey [21] developed an inpatient and outpatient questionnaire called quality of care monitors. The inpatient questionnaire consists of 8 scales: physician care, nursing care, medical outcome, courtesy, food Service, comfort and cleanliness, admission / billing, and religious care. The outpatient questionnaire has 7 scales: physician care, nursing care, medical outcome, facility characteristics, waiting time, testing services, and registration process.

Many scholars have proposed that implementing "lean healthcare" can help improve patient satisfaction. According to the case of Weinstock [22], Lean Healthcare does not focus on layoffs and assets, but on improving patient satisfaction by improving actions and processes. However, some scholars questioned this, for example, Moraros et al [23] suggest that there is a little significant correlation between the effectiveness of lean implementation and patient satisfaction.

In recent years, although many scholars have begun to conduct research in this field, research on the impact of lean healthcare on patient satisfaction is still in its infancy. This study attempts to provide a comprehensive understanding of the current state of research on improving patient satisfaction through lean medicine through a systematic review.

We searched published articles on the relationship between lean improvement and patient satisfaction. The research design and results of these studies were reviewed. We also analyzed the impact of each study on patient satisfaction outcomes.

Data sources and search Strategy

We searched PubMed, Web of Science, SCOPUS, Google Scholar, September 2021 for studies on the impact of lean improvement on patient satisfaction. At the same time, we supplemented other studies by citing the articles retrieved from the search, and conducted a study of the combined literature before proceeding to the final analysis.

Inclusion and Exclusion Criteria

Inclusion criteria

The article takes the main tools of lean production as the main method, and introduces the specific application of lean production in detail; introduces its improvement goals and improvement effects; qualitative or quantitative analysis of changes in patient satisfaction.

Exclusion criteria

The article mentions Lean Medicine, but does not describe specific tools and application processes; mentions patient satisfaction, but does not measure it qualitatively or quantitatively.

Data Extraction

The searched literature is exported to EndNote. Then, by screening the titles, abstracts, full text, etc., the included studies are input into the excel according to the literature title, year, department, problems, intervention, results, patient satisfaction measurement, and conduct data statistical analysis and make statistical form. (Fig. 1)

Statistical methods

Using the Excel 2010 version of the extracted content for data analysis and statistical chart drawing, mainly describing the publication time, improvement issues and other indicators. Bibliometrics is expressed by the number of literature articles.

Patient Satisfaction Scale

This study employed Carey et al.’s "Quality of Care Monitors" questionnaire for inpatients and outpatients [21]. This questionnaire was first used during 1988 and 1989, it is still widely used by many scholars.

Figures 2 and 3 show that the majority of studies were conducted in the United States (n = 25), and that earlier studies on the effect of lean medicine on patient satisfaction appeared to appear in 2009, but increased significantly after 2015. (Fig. 2–3)

In all the studies, most of the studies adopted descriptive research, only ten studies used comparative studies. In the measurement of patient satisfaction after lean implementation, 39 studies used quantitative methods, 6 studies used qualitative methods, and 6 studies did not carry out specific measurement for the time being. Quantitative measurement methods are mainly self-made questionnaires and third-party survey, and a small part comes from national surveys. Qualitative measurement mainly adopts interview method. In the self-designed questionnaire, some questionnaires did not test for reliability and validity, and it is difficult to determine how much the improvement in satisfaction is due to the lean implementation in using the national survey research.

Of the intervention approach, out of 51 studies, 37 used lean intervention and 14 used Lean Six Sigma.

The purpose of lean implementation

From Table 1, we can see that the purpose of implementing lean in most studies is to improve efficiency through lean improvement, and only three studies aimed to improve quality through lean implementation.

The change of patient satisfaction after lean implementation

In the evaluation of satisfaction after the lean implementation, 41 studies clearly showed increased patient satisfaction after intervention, instead, one study showed that patient satisfaction was unchanged, two studies showed decreased patient satisfaction, and one study shows that the effect of lean implementation on patient satisfaction is unclear. In addition, among the four hospitals implementing lean management mentioned in one study, the satisfaction of three hospitals increased and that of one hospital decreased. Another study mentioned that after the implementation of lean management, the satisfaction of patients with the overall nursing experience increased, but the satisfaction with the interaction with doctors and nurses decreased.

Influencing factors of patient satisfaction

Since Carey's et al.’s [21] questionnaire is mainly from the perspective of hospital management, comprehensive consideration of medical care, nursing, and medical environment, and lack of consideration for patients themselves, based on this reason and analysis on the basis of incorporating the literature, we come up with our influencing factor model of patient satisfaction, involving medical staff service (technology, attitude), service process, service outcome, hospital facilities and equipment (medical facilities, environmental facilities) and hospitalizations. According to our research results, patient complaints and respondent characteristics have been added. These 7 dimensions may all affect patient satisfaction.

Medical staff attitude can has a positive impact on patient satisfaction, for example, professional and skilled technical service, good service, and providing help for patients will improve patient satisfaction to a certain extent [24–30]. Service processes may have a negative effect on patient satisfaction, all eliminate unnecessary waste, simplify cumbersome processes, and increase value-added processes help to increase patient satisfaction [9, 24, 29, 31–40]. Quality of medical services may have a positive role on patient satisfaction, the higher the quality of the medical service, the higher the patient satisfaction [29, 41, 42]. Logistics services may also have positive effects on patient satisfaction. Good dining experience and logistics personnel solving problems in time will improve patient satisfaction [43, 44].

Although, some studies even show that environmental factors are not significantly associated with patient satisfaction [25, 26, 34], it is worth mentioning that environmental factors may add value to improve patient satisfaction [1]. However, these factors should not come at the expense of affecting the quality of care, such as the time of doctor-patient interaction. One study also found that 95% of patient complaints contrary to patient satisfaction were care-independent [35]. In addition, this study found that respondents' characteristics (e. g., gender, age, occupation, property status, etc.) would also affect patient satisfaction [45]. (Table 1)

Table 1

Influencing factors of patient satisfaction
Factors	Specific Description	Number
Medical Staff Service	Technology, Attitude, etc.	9
Service Process	Waiting time, Length of hospital stay, Length of inspection, Duration of patient-doctor interaction, etc.	39
Service Outcome	Safety, Quality of care Throughput, Consultation quality, Accessibility (such as doctors, care, medicines, etc.), etc.	7
Hospital Facilities and Equipment	Medical equipment, Environmental facilities, etc.	4
Patient Complaints	Complaints about communication, cleanliness, parking, food, staff attitude, waiting time, wrong billing, etc.	2
Respondents’ Characteristics	Gender, age, occupation, income, etc.	1

Increase or decrease in patient satisfaction

The purpose of this systematic review was to evaluate the impacts of lean implementation on patient satisfaction in the healthcare services. In this study, we found that most of the reviewed studies reported increased patient satisfaction after lean implementation, and the view is consistent with those mentioned earlier in Weinstock [22].But our study also found that satisfaction remains [46] and satisfaction declines after intervention [6, 47]. The reason may be that if the satisfaction baseline is already very high, there will be relatively little room for improvement of patient satisfaction brought by the implementation of lean medicine. In addition, another reason may be that it takes more time to improve patient satisfaction [48].

Two studies conducted in primary care organizations found that patient satisfaction decreased after lean implementation. The study points out that the patient doctor meeting is the most important occasion to jointly create patient value and to evaluate the quality of nursing function. Lean implementation improves the operation efficiency of medical institutions, and the most immediate effect is an increase in patient throughput. Then the doctor spends less time on every patient, the patient noticed this change [6, 47]. While in primary care, patients seem to be more likely to notice this change, and therefore show dissatisfaction, which is consistent with our previous point of view that "patient-doctor interaction time" will affect patient satisfaction [49].

Thus, the impact of the lean on patient satisfaction cannot be precisely determined with certainly, which is consistent with the views of Suzan Hammoudeh et al [50]. In addition, there is a potentially important reason that most studies use researcher-defined parameters to measure patient satisfaction. The effectiveness of this research tool is questioned because the focus of patient satisfaction should be on the patient, using predetermined parameters instead of exploring the potential value held by the patient [6].

Factors affecting patient satisfaction

In terms of factors affecting patient satisfaction, our study found that external factors such as the environment were not significantly associated with patient satisfaction, which is consistent with the research of Larkins et al [25] and McEntire, et al [26]. In the department regarding patient complaints, 95% of the complaints are non-medical aspects, such as communication, cleanliness, food, parking, staff attitude, waiting time, wrong bills, et al [35]. This reminds us that first, improving patient satisfaction requires more starting from internal hospital activities, and secondly, the survey of satisfaction should involve weight issues. Otherwise, although the logical relationship between the patient's personal characteristics and satisfaction has not been demonstrated, it is certain that there is a certain connection between them [45].

Satisfaction measurement

In terms of satisfaction measurement, although most of the included literature use some tools to draw quantitative or qualitative conclusions that patient satisfaction is improved, there is no unified evaluation standard. Most of the evaluation tools are designed by the project implementers or rely on the national satisfaction survey. Among them, the reliability and validity self-designed questionnaire in some studies still need to be tested, and it is difficult to determine the extent to which the improvement in satisfaction is due to the lean implementation in the satisfaction measurement that relies on the national survey, so the value of the research results is limited.

In the dimension of satisfaction, patient expectations are less considered in measurements of patient satisfaction. Since lean production was originally designed to improve the efficiency of the production system. While in the medical field, it is generally believed that value is created by healthcare providers, and the contribution from patients’ perspective is limited. Therefore, healthcare institutions only focus on internal activities within the organization without thinking too much about the role of patients in the value creation process. However, patients have their own preferences and experience requirements (functional quality). In order to achieve more timely and efficient care and more patient-centered care, the patients’ perspective needs to be better integrated into current lean applications [6].

Regarding the follow-up issues, only four studies have adopted follow-up. In fact, a change in patient satisfaction can be appreciated only after a while and not immediately after the launch of Lean initiatives [51]. Secondly, follow-up time (accountability and continuous estimation of the effectiveness of changes in implementation [52, 53]) is short, which makes it difficult to confirm the sustainability of the improvement. In fact, through continuous follow-up research on patient satisfaction, the changes in patient satisfaction can be dynamically revealed, so as to evaluate the effect of lean implementation on satisfaction and formulate the most effective action strategy.

Purpose of lean implementation

Analysis the problems of lean implementation and improvement in the searched studies, most of them are concentrated in the medical service process, and uses the time comparison before and after the application of the lean method to evaluate the improvement degree of this method. Non-medical activities concern little in the selection of departments, for example with only one direction of literature research in improving the patients’ diet. This may be because of the hospital nature. The main function of the hospital to treat diseases and save people, which determines that these departments become the main department of the hospital. With the increasing number of patients, the hospital is more urgent to improve these departments, but in fact, the hospital is a comprehensive organization that encompasses many different types of departments, and there must be varying degrees of waste in the operation of these departments and opportunities to improve, but did not give full attention.

Regarding the continued improvement of the results, our study found that most of the current studies are one-off studies, and the satisfaction evaluation is limited to twice before and after implementation. Only two studies mentioned that the lean improvement and patient satisfaction assessment continued after the completion of the project, and maintained the results of the improvement. Lean methods are iterative [27]. Lean is never a one-time solution, it is based on continuous improvement [33]. But apparently, maintaining these results is challenging [28].

The essence of lean healthcare

Lean management creates value by focusing on patients and meeting patients' needs for the essence of medical services, which includes creating value for patients in service process and medical results. This study found that in lean practice, the core factor to solve the medical needs of patients has been ignored. For medical institutions, the application of lean can provide maximum services at the least cost. Reducing costs through the implementation of lean is the initial purpose of many medical institutions to implement lean. Therefore, it is not surprising that efficiency priority has become the primary choice of medical institutions. In this study, 51 cases, most of the original intention of implementing lean is to improve efficiency to improve satisfaction, and only cases propose to improve quality to improve patient satisfaction.

Lean medical emphasizes creating value for patients, and the definition of value is also from the perspective of patients. In the whole medical service process, eliminate waste in all links, realize value flow and achieve zero harm. However, in lean practice, we often focus on the service process, and the essential needs of patients for medical services, that is, the treatment effect and results, are lack of sufficient research.

For patients, coming to the hospital is to solve their own diseases. This process includes service process and service results. Both are very important to patients, but the latter is the most fundamental. No patient is expected to be hurt when he comes to the hospital. Therefore, lean emphasizes zero harm more from the perspective of hospital managers. The perception of patients' satisfaction with medical services should not be just efficiency factors such as process, service attitude and waiting time compression. The treatment effect, that is, effectiveness, should be the core value of medical services.

Suggestions on the future study of patient satisfaction

Therefore, through the literature review, we suggest future research can seek inspiration from the following aspects to better explore the impact of lean implementation on patient satisfaction. First of all, before the lean improvement, set up the experimental group and the control group to control the relevant variables.

Second, the evaluation dimension of patient satisfaction should be patient-centered and fully consider the needs of patients. To this end, the concept of "patient expectations" can be introduced, that is, what kind of services and treatment patients expect before entering a hospital or a certain department for treatment. The degree of satisfaction of the patient’s relevant expectations by the time the treatment is completed and leaving the hospital or department; at the same time, the evaluation of satisfaction should be evaluated in different dimensions, and should not be limited to an overall and general evaluation.

Third, the survey methods should be a combination of qualitative and quantitative. Quantitative research mostly uses questionnaires. In order to obtain a more accurate relationship between lean intervention and patient satisfaction, a questionnaire that match this item should be set up, and the questionnaires should be tested for reliability and validity; qualitative interviews should be used as a supplement to quantitative research. Sometimes you receive unexpected answers, and you can more accurately get the patient’s true thoughts through non-verbal information. At the same time, all the above surveys are best conducted by third-party agencies or personnel to avoid the influence of participants, and it can also exclude patients from making tendentious choices due to concerns about the effect of treatment and the authority of doctors. Finally, after the project is over, follow-up should be conducted to continuously track the effect of impact on patient satisfaction, follow-up changes in real time, and pay attention to the long-term impact of lean implementation on patient satisfaction.

This study discovered the several problems existing in the research of hospital lean practice on patient satisfaction. Firstly, most of the studies are observational before and after design. Therefore, the lack of matched control groups, the existence of potential variables, and the lack of randomization make the causal relationship between the improvement of results and the lean intervention unclear. Secondly, the absence of follow-up and short follow-up time in the middle and late stages cannot well reflect the continuity of improvements, and longer tracking performance indicators are needed to assess sustainability of lean. Thirdly, for the measurement of patient satisfaction, there is no unified evaluation criteria, and most of the satisfaction parameters are defined by the researchers, ignoring the focal role of patients in satisfaction, which is known as "patient expectations."

There is no generalization and exploration of the potential value of patients, which makes the effectiveness of the satisfaction measurement in the research questioned. In order to achieve more timely, more efficient, and patient-centric care, the patients’ perspective needs to be better integrated into current lean applications. Methods such as focus groups, diaries, and patient blogs can be used to co-create patients value. Finally, lean is never a one-time solution. It is a continuous improvement, but most of the studies are one-time studies, lack of continuous tracking and evaluation.

While most of the reviewed studies show that lean implementation can improve patient satisfaction by improving processes and outcomes, the evidence is insufficient to support this claim that the exact impact of lean implementation on patient satisfaction is not clear, and more systematic, scientific and rigorous research is needed to determine the relationship.

Most of the studies found in this study focus on efficiency rather than effectiveness. Although efficiency itself starts from patients, patients with only efficiency but no effectiveness are not necessarily satisfied. For example, in the case of primary health care, the optimization of process and the improvement of efficiency have no meaningful impact on patient satisfaction. For patients, effectiveness is more important. This is the essence of medical treatment. Lean improvement needs to return to the essence of medical treatment.

TPS: Toyota production system.

Ethics approval and consent to participate：Not applicable

Consent for publication：Not applicable

Availability of data and material：The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests：The authors declare that they have no competing interests.

Funding：Not applicable

Authors' contributions：Xianjin and Tian Gao collaborated in drafting the study design. Xianjin Xing, Jian Wang, Jinyang Liu, Jinming Han and Ge Qu conducted the data collection and performed the analysis and interpretation of data. Xianjin Xing and Tian Gao drafted the manuscript. Tian Gao contributed to the theoretical and conceptual focus of the study. All authors read and approved the final manuscript.

Acknowledgements：Not applicable

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No competing interests reported.

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You are reading this latest preprint version

Does lean improve efficiency or effectiveness from the patient perspective?

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Version 1

Abstract

Figures

Background

Methods

Data sources and search Strategy

Inclusion and Exclusion Criteria

Inclusion criteria

Exclusion criteria

Data Extraction

Statistical methods

Patient Satisfaction Scale

Results

The purpose of lean implementation

The change of patient satisfaction after lean implementation

Influencing factors of patient satisfaction

Discussion

Increase or decrease in patient satisfaction

Factors affecting patient satisfaction

Satisfaction measurement

Purpose of lean implementation

The essence of lean healthcare

Suggestions on the future study of patient satisfaction

Conclusions

Abbreviations

Declarations

References

Additional Declarations

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