title: Effects of organizational context on Lean implementation in five hospital systems.
abstract: BACKGROUND
  Despite broad agreement among researchers about the value of examining how context shapes implementation of improvement programs and projects, limited attention has been paid to contextual effects on implementation of Lean.
  
  
  OBJECTIVE
  To help reduce gaps in knowledge of effects of intraorganizational context, we researched Lean implementation initiatives in five organizations and examined 12 of their Lean rapid improvement projects. All projects aimed at improving clinical care delivery.
  
  
  METHODS
  On the basis of the literature on Lean, innovation, and quality improvement, we developed a framework of factors likely to affect Lean implementation and outcomes. Drawing on the framework, we conducted semistructured interviews and applied qualitative codes to the transcribed interviews. Available documents, data, and observations supplemented the interviews. We constructed case studies of Lean implementation in each organization, compared implementation across organizations, and compared the 12 projects.
  
  
  RESULTS
  Intraorganizational characteristics affecting organization-wide Lean initiatives and often also shaping project outcomes included CEO commitment to Lean and active support for it, prior organizational capacity for quality improvement-based performance improvement, alignment of the Lean initiative with the organizational mission, dedication of resources and experts to Lean, staff training before and during projects, establishment of measurable and relevant project targets, planning of project sequences that enhance staff capabilities and commitment without overburdening them, and ensuring communication between project members and other affected staff. Dependence of projects on inputs of new information technology was a barrier to project success. Incremental implementation of Lean produced reported improvements in operational efficiency and occasionally in care quality. However, even under the relatively favorable circumstances prevailing in our study sites, incremental implementation did not readily change organizational culture.
  
  
  CONCLUSIONS
  This study should alert researchers, managers, and teachers of management to ways that contexts shape Lean implementation and may affect other types of process redesign and quality improvement.
authors.affiliation: Michael I. Harrison, PhD, is Senior Social Scientist, Agency for Healthcare Research and Quality, Rockville, Maryland. E-mail: Michael.Harrison@ahrq.hhs.gov. Kathryn Paez, PhD, RN, is Principal Researcher, American Institutes for Research, Washington, DC. Kristin L. Carman, PhD, is Vice President, American Institutes for Research, Washington, DC. Jennifer Stephens, MPH, is Senior Health Researcher, American Institutes for Research, Washington, DC. Lauren Smeeding, MHA, is Consultant, Kurt Salmon, Atlanta, Georgia. Kelly J. Devers, PhD, is Senior Fellow, Urban Institute, Washington, DC. Steven Garfinkel, PhD, is Institute Fellow, American Institutes for Research, Chapel Hill, North Carolina.
authors.forename: Michael I
authors.initials: MI
authors.lastname: Harrison
authors.forename: Kathryn
authors.initials: K
authors.lastname: Paez
authors.forename: Kristin L
authors.initials: KL
authors.lastname: Carman
authors.forename: Jennifer
authors.initials: J
authors.lastname: Stephens
authors.forename: Lauren
authors.initials: L
authors.lastname: Smeeding
authors.forename: Kelly J
authors.initials: KJ
authors.lastname: Devers
authors.forename: Steven
authors.initials: S
authors.lastname: Garfinkel
mesh_terms: D003695:Delivery of Health Care / Q000458:organization & administration; D017598:Efficiency, Organizational; D006739:Hospital Administration; D006801:Humans; D007407:Interviews as Topic; D007857:Leadership; D015279:Organizational Culture; D036301:Qualitative Research; D058996:Quality Improvement / Q000458:organization & administration*