“Lean thinking” words appeared for the first time in 1988 after a MIT comparative research of the automotive industry.[1, 2] This term is based on the innovative production model called Toyota Production System (TPS).[1, 2]. TPS focused the attention of the entire production on the value for the customer. “Just in time” and “jidoka” are the two main pillars of TPS. The first one ensure to product “what is needed, when it is needed, and in the amount needed” whereas the latter is “the automation with a human touch”. These principles help the organization to detect, prevent and consequently solve problems. Liker highlighted that the lean enterprise is simply “the end result of applying the Toyota Production System to all areas of your business”.
In other words Radnor et al. defined the “Lean as a management practice based on the philosophy of continuously improving processes by either increasing customer value or reducing non-value adding activities (muda), process variation (mura), and poor work conditions (muri)”.
Ohno identified seven kind of muda categorized in transportation, inventory, motion, waiting, overproduction, overprocessing and defects. These muda are present also in the healthcare sector. Subsequently, Lean management has been exported to this sector.[8, 9] This application has been described in so many different ways such as strategy, philosophy or way of working and several efficiency results (i.e. time saving or cost reduction) have been achieved over time.[11–15] However, few results on the improvement of the outcome have been published.
Although, a protocol for a Cochrane Review on the effect of lean on the patient outcomes has been reported, the specific impact of LEAN application on healthcare-associated infections (HAIs) has not still extensively investigated.
Lean and Six Sigma can be applied to several aspects of health care including finance, inventory management, information processing, outpatient clinics, and inpatient setting.
HAIs are recognized worldwide as an important public health problem, and they are of increasing interest to politicians, patients, and the public.
Up to 2,609,911 new cases of HAIs occur every year in the European Union and European Economic Area (EU/EEA). Multiple research studies report that in Europe hospital-wide prevalence rates of HAIs range from 4.6–9.3%. In particular HAIs have impact on critically ill patients with around 0.5 million episodes of HAIs being diagnosed every year in intensive care units (ICUs) alone, including central line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and ventilator-associated pneumonia (VAP).
The problem of nosocomial infection is increased by the spread of multiresistant microorganisms.[22–28] Since the 1970s, the selective pressure exerted by antibiotics has given rise to bacterial species that are increasingly resistant, and the last 20 years have seen a dramatic rise in the number of multi-resistant pathogenic strains; the attributable deaths in the EU due to antimicrobial resistant microorganisms were estimated to be 33,110 per year.
At present, the monitoring and prevention of HAIs is a priority for the healthcare sector, and reducing the incidence of HAIs is used as an indicator of the quality of service provided.
Several identified causes of HAIs have been identified such as the lack of standardized procedures[31–34] or inadequate sanitation procedures that can contribute to the spread of cross-infections.
Some estimate that 20–30% of HAIs are preventable through an extensive infection prevention and control programme.
The reduction of HAIs is considered a quality indicator of the healthcare provided. Lean and six sigma supported by change management are important tools, renamed Robust Process Improvement (RPI), to address those problems by the Joint Commission Center for Transforming Healthcare. In fact, The Joint Commission reported one example of reduction or Surgical Site Infection through RPI. In 2012 a review of the literature focused on the quality improvement in the surgical healthcare showed how different tools (lean, six sigma and statistical process control or PDCA) can decrease the infection rate.
Several lean applications have been described over the years with the purpose of improving healthcare quality,[8, 40–43] nonetheless, to the best of our knowledge, no systematic reviews and meta-analysis have been selectively focused on the lean application for reduction of HAIs.
The aim of this systematic review and meta-analysis of prospective studies is to provide high-level evidences about the lean application for HAIs reduction. The purpose of this study is to analyze if the lean application can reduce the healthcare-associated infections rate.