Abstract
Lean has been implemented in the health care sector for over a decade to address the challenges of lowering cost and improving quality. Its impact, however, has not been conclusive. Furthermore, the debate on its potential benefit has not been rigorous or systemic. This dissertation research fills this gap in literature. This dissertation is composed of three papers. In the first paper, I develop a reliable and valid instrument to measure the extent of lean implementation in hospitals. 1 theoretically derive a more robust set of lean principles for the hospital environment (patient focus, standardized care, seamless coordination, and continuous improvement) and use them as a primary platform for analyzing the use of lean in the health care environment. The results show that currently hospitals have implemented lean principles at relatively low level, compared to the possible maximum implementation level. Among the four principles, continuous improvement principle showed highest implementation level in hospitals. In the second paper, I assess the impact of lean principles implementation on quality and efficiency performance in hospitals by performing multivariate regression analysis with lean principles as independent variables and hospital performance as dependent variable. Multiple hospital performance indicators (adherence to evidence-based care processes, risk-adjusted mortality, patient satisfaction, and risk-adjusted cost) are used to measure process quality, outcome quality, perceived quality, and efficiency of each hospital. The results show that patient focus, standardized care, and continuous improvement principles are significantly associated with hospital quality, while seamless coordination principle is not. The result does not show any significant association between lean principles and hospital efficiency. In the last paper, I identify different lean implementation patterns in hospitals. Since lean is a multi-dimensional concept of four lean principles, which can be implemented individually or in combination, several lean implementation patterns are possible, depending on differing level of emphasis on lean principles. The results show that when lean is implemented holistically, lean is effective in improving quality performance in the health care environment, as in the manufacturing. The result does not show any significant association between lean implementation patterns and hospital efficiency.