Unveiling the Impact of Lean Leadership on Continuous Improvement Maturity: A Scoping Review

Figures & data

Table 1 Inclusion and Exclusion Criteria to Assess Eligibility Through Abstract Screening

Included	Excluded
Articles published in the twenty high-quality healthcare management journals (the list has been added in Supplementary Table 1)	Articles published in any other journal
English written articles	Articles not written in English
Empirical studies	Non-empirical studies, editorials
The article contains a term that refers to Lean	The article does not contain a term of Lean
The article reports on the application of Lean in a healthcare setting	The article reports on the application of Lean in settings other than healthcare
Articles obtained with the search string (Table 2)	Articles not obtained with the search string

Table 2 Lean Search Terms Based on Lean in Healthcare Literature Reviews

Lean Term	Articles
Lean thinking	[6,20,24,26,36,37]
Lean healthcare	[20,26,36,37]
Lean management	[6,26,38]
Lean philosophy	[6,20,24,26]
Continuous improvement	[6,20,24,26]
Lean methods	[6,39]
Lean principles	[6,20,24,26,36]

Table 3 Applied Search Strings

Search String	Journals Applied
“Lean thinking” OR “Lean management” OR “Lean healthcare” OR “Lean philosophy” OR “Continuous improvement” OR “Lean methods” OR “Lean principles”	HCMR, HA, SSM, HSR, HP, JHM, MQ, HSMR, NEJM, JAMA, JHSRP, MCRR, The Lancet, JHOM, BMC, HR, VH, BMJ
“Lean thinking” OR “Lean management” OR “Lean philosophy” OR “Continuous improvement” OR “Lean methods” OR “Lean principles” AND “Healthcare” OR “Health care”	AMJ, BMJ Q&S

Figure 1 PRISMA Diagram.

Table 4 Distribution of Articles by Journal

Journals	# Articles
Journal of Health Organization and Management	11
Journal of the American Medical Association	3
Health Care Management Review	2
Social Science and Medicine	2
BMJ Quality & Safety	2
Academy of Management Journal	2
Human Relations	1
Total	23

Table 5 Distribution of HCOs by Country

Country	# of HCO
United Kingdom	10
United States of America	10
Brazil	5
Canada	3
Sweden	2
The Netherlands	2
Australia	1
Denmark	1
Ireland	1
Total	34

Figure 2 Distribution of publications over the years.

Table 6 Overview of LM Leadership Themes and Underlying Leadership Activities

Leadership Themes	Underlying Leadership Activities
	Activities that are Positive or Present (n=38)	Activities that are Negative or Absent (n=20)
Motivation, engagement, support and trust	Engaging the entire workforce; Visible engagement and support by top/senior management team; Using achieved results to demonstrate LM’s abilities; Leaders legitimizing their expertise to gain trust.	Lack of trust in leaders; Employees feeling jeopardized; Creation of resistance among the workforce; No initiatives to avoid scepticism; Leaders not fostering engagement and involvement.
Workforce involvement	LM is infused throughout the system of care; Flexibility/freedom in participation; Including relevant stakeholders.	Lack of departmental managers and directors included; Lack of frontline involvement.
Leadership style	Hands-on management style; Visible leadership (Gemba); Bottom-up approach; Hierarchical leadership (top-down); Pull-based authority.
Focus and vision	Focus on alignment in the organization; Quick wins; Focus on multiple silos at a time; Alignment between organizational strategy and LM deployment; Shared responsibility; Awareness of CI as cultural development; Making the workforce aware that CI is everyone’s job.	Failing to include the whole chain of care; Lack of alignment between LM deployment and the organization’s strategy; LM is not seen as a culture of CI.
Learning	Learning through visual management; Enhancing autonomous problem-solving; Weekly meetings for discussing problems; Checking and coaching for improvement; Enhancing experimenting.	Lack of shared knowledge/shared learning.
Training	Organization-wide training in LM and tools; Local training in LM; Learning programs tailored to projects.	Staff often unavailable during training and LM practices; Not preparing the workforce before deploying LM; Smaller proportions of staff participating in LM training.
Collaboration	Enhancing discussions and learning in teams; Establishing clear roles in teams; Agreeing upon shared goals of projects; Involving clinical management; Mid-level and frontline leaders leading LM practices; Relevant team assembling to gain support for change.	Employees required to adopt multiple roles in a team.
Deployment and management:	Standardization of LM management; Employment of full-time process improvement specialists; Managerial consistency.	Lack of managerial consistency; Projects not being standardized; Inexperienced LM leaders; Lean was viewed as an add-on to work, rather than a way of working.
Facilitating leadership	Minimize disruptions to clinical work of staff; Facilitating adequate resources to support LM training and deployment of LM experts.	Insufficient facilitation of resources, time, money and IT.

Figure 3 Lean Maturity Framework.

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