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What is it and how can it help me?

Lean is an improvement approach to improve flow and eliminate waste that was developed by Toyota. Lean is basically about getting the right things to the right place, at the right time, in the right quantities, while minimising waste and being flexible and open to change.

Lean thinking focuses on what the customer values: any activity that is not valued is waste. If you remove the waste, the customer receives a more value added service.  For example, in healthcare this could mean any activity that helps patients get better and / or manages their symptoms and comfort. 

However, an organisation needs the flexibility to change and accommodate changes in their view of value, as it will evolve. For example, in healthcare we can imagine that we focus in on any activity that has strong evidence that it helps patients get better and / or manages their symptoms and comfort. This means that as our knowledge changes, our definition of value will change. In addition, we would also aim for high levels of patient satisfaction.

If your organisation undertakes a Lean transformation, you will usually move from understanding tools - to understanding systems - through to aligning all your work strategically. The strategic alignment focuses on aligning work along workflows or pathways that are interdependent. Healthcare systems are complex; there are a lot of stages in a patient pathway for example that cross organisational structures: this means that the work of one team is dependent upon the work of another. A Lean way of thinking would be to align the organisational structures along the workflows.

When does it work best?

This is a useful approach to designing or redesigning services to ensure that the work we do does add value to patient care. Where there is work or services that do not add value, you can divert resources to those that do add value. 

In Lean terms, time spent waiting is not value added so the approach has a strong focus on reducing waiting times. In addition, it helps you deliver a higher quality service to patients by reducing waste in the system.

How to use it

Lean thinking is specific to each organisation's underpinning values and beliefs and unique circumstances. However, Womack and Jones (1996) observed five generic elements which were present in all the Lean organisations which they studied. These are:

Principle 1 - Specify value
Understanding value is essential, otherwise you will design a service which no one wants or needs. The first Lean principle is to understand what the customer values. The opposite of this is waste. This simple analysis enables everyone to see if waste exists in an organisation.

The intention is to get staff and managers to see what the patient sees as the parts of their journey through healthcare. You will achieve optimum results if you understand patients' perspectives and include patients in any improvement activity as they will challenge professional boundaries.

Principle 2 - Identify and visualise the value stream
You now need to understand the sequence of events which make up the patient journey. This is known as
the value stream. You will start by asking staff to draw a 'where are we now' picture.

There are many ways other ways to visualise the current practices and activities which take place along the patient journey (see process mapping for an overview of approaches). No single approach is correct: select the right one for your problem.

Principle 3 - Making the value steps flow
Analyse all the obstacles that prevent the free flow of the patient on their journey. One by one, understand the root cause of these problems (see
5 whys and cause and effect diagrams) and remove the obstacles using tools like PDSA.  You should analyse the whole patient journey because doing work in one place may be more effective for the whole system rather than an individual organisation, department or function.

Principle 4 - Pulling patients along their journey
In healthcare, we often push patients from one queue to another. Pulling them from the end of one step to the beginning of the next, may be more effective.

Principle 5 - Perfection
Aim to continually improve the patient journey through ongoing development of the first four principles.

You can call this programme of improvement whatever you like, but if you follow these principles, you will have a Lean organisation.


Hereford Hospitals NHS Trust applies lean in pathology services.

What next?

Start with sort and shine,  PDSA or looking at reducing things that do not add value and seven wastes if your quality levels are poor.

To help you understand where to start and link to policy deployment, use value stream mapping.

Additional resources

'Lean Thinking in the NHS' - NHS Confederation report

'Overview of the Lean Approach to Business Management and its use in the Public Sector

The NHS Institute's Lean thinking home page


Lean thinking got its name from a 1990s best seller called 'The Machine That Changed the World: The Story of Lean Production'. 

Lean brings into many industries, including healthcare, new concepts, tools and methods that have been effectively utilised to improve process flow. Tools that address workplace organisation, standardisation, visual control and elimination of non-value added steps are applied to improve flow, decrease waste and exceed customer expectations.

The NHS Institute has defined Lean thinking as 'a philosophy that has been used widely in manufacturing industries, but is also very applicable to healthcare. It is essentially about simplifying processes, identifying which parts of a process add value to patient care, enabling care to flow more effectively and eliminating waste.'

Acknowledgements / sources

Anderson Consulting (1992) 'The Lean Enterprise Report'  London

Anderson Consulting (1994) 'World Wide Manufacturing Competitiveness Study: The Second Lean Enterprise Report'  London

Bicheno J (2004) 'The New Lean Tool Box'  PICSIE Books, Buckingham

Rich N, Bateman N, Esain A, Massey L and Samuel D, (2006) 'Lean' Evolutions' Cambridge University Press

Womack J, Jones D and Roos D (1990) 'The Machine that Changed the World' Simon and Schuster, New York

Womack J and Jones D (1996) 'Lean Thinking' Simon and Schuster, New York

Womack J and Jones D (2005) 'Lean Solutions' Simon and Schuster, New York


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