International Journal of

Environmental Research
and Public Health

Article
Implementation of Lean Management in a Multi-Specialist
Hospital in Poland and the Analysis of Waste
Agnieszka Zd˛eba-Mozoła 1, *, Anna Rybarczyk-Szwajkowska 1 , Tomasz Czapla 2 , Michał Marczak 1
and Remigiusz Kozłowski 3

1 Department of Management and Logistics in Healthcare, Medical University of Lodz, 6 Lindleya Street,
90-131 Lodz, Poland; [email protected] (A.R.-S.); [email protected] (M.M.)
2 Department of Management, Faculty of Management, University of Lodz, 90-237 Lodz, Poland;
[email protected]
3 Centre for Security Technologies in Logistics, Faculty of Management, University of Lodz,
90-237 Lodz, Poland; [email protected]
* Correspondence: [email protected]

Abstract: At the beginning of the 21st century, Lean Management (LM) tools were introduced into
the healthcare sector around the world. In Poland, there are still few LM implementations, and they
are not of a comprehensive nature. The aim of this article is to present the application of the LM
concept in a hospital in Poland as a tool for the identification and analysis of waste and its impact on
the process of organizing the provision of medical services on the example of improvements in the
process of patient admission. In the period from 1 July 2019 to 31 December 2019, a project of LM
implementation was carried out at the Provincial Specialist Hospital in Wroclaw. The project was





 based on the method of value-stream mapping and 5Why. Standardized interviews (before and after
Citation: Zd˛eba-Mozoła, A.; the project) were conducted with people from the hospital management and middle-level managers.
Rybarczyk-Szwajkowska, A.; Czapla, The implementation of LM tools resulted in the identification of a number of wastes, which have been
T.; Marczak, M.; Kozłowski, R. divided into groups. The most important waste was paper medical documentation. Its change to
Implementation of Lean an electronic form allowed for a better use of human capital resources; savings included 2.3 nursing
Management in a Multi-Specialist positions and 1.09 medical staff positions.
Hospital in Poland and the Analysis
of Waste. Int. J. Environ. Res. Public Keywords: lean management; lean healthcare; 5Why; value-stream mapping; waste
Health 2022, 19, 800. https://
doi.org/10.3390/ijerph19020800

Academic Editors: Paul

B. Tchounwou and Gabriel Gulis 1. Introduction
Lean Management (LM) was applied in the healthcare sector at the beginning of the
Received: 28 November 2021
Accepted: 10 January 2022
21st century. The main purpose of using Lean Management tools in this sector was to
Published: 12 January 2022
improve the quality of services provided to patients, to shorten the length of hospital
stay, and to minimize the frequency of medical errors. It has therefore become necessary
Publisher’s Note: MDPI stays neutral to implement solutions that improve efficiency, reduce cost, and engage employees to
with regard to jurisdictional claims in
introduce an innovative approach in the organization [1].
published maps and institutional affil-
The concept of Lean Management was developed and implemented in Toyota after
iations.
World War II. The solutions introduced there made it possible to improve productivity,
quality, and efficiency [2]. M. Graban defined a lean system as “a set of tools and a manage-
ment system, a method of continuous improvement and employee involvement, a way for
Copyright: © 2022 by the authors.
solving problems that are relevant to leaders and all levels of the organization” [3]. The
Licensee MDPI, Basel, Switzerland. overarching goal of Lean Management is to achieve the lowest cost, while maintaining
This article is an open access article the highest quality and in the shortest time [4]. The main task of LM is to “slim down”
distributed under the terms and the organization from unnecessary procedures, activities, and inefficiencies by eliminating
conditions of the Creative Commons waste (jap. Muda). Identification of wastes and their subsequent removal is supposed to
Attribution (CC BY) license (https:// improve the processes occurring in the organization while ensuring high quality of manu-
creativecommons.org/licenses/by/ factured products or services. An important element of the concept is the assumption of
4.0/).

Int. J. Environ. Res. Public Health 2022, 19, 800. https://doi.org/10.3390/ijerph19020800 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022, 19, 800 2 of 23

continuous improvement (kaizen), referring to continuous work on improving all elements

of the process [5,6].
The first mentions of Lean Management solutions used in healthcare units can be found
in publications from 1995 [7] and 1996 [8]. However, these were not structured activities, but
merely descriptions of using individual methods (e.g., just-in-time). Pilot implementations
in hospitals in the USA and Great Britain (in 2000 and 2002, respectively) [9] were aimed
at improving the flow of patients and brought positive observations both in medical and
non-medical areas [10]. The best known are the implementations at Virginia Mason Medical
Centre in Seattle, Flinders in Australia, and the Royal Bolton NHS Foundation Trust in
Farnworth (UK) [11].
The key principles of Lean Management primarily relate to two elements: values and
the pursuit of excellence (by eliminating waste). Value is understood both in relation to the
organization and to the client (patient) [12]. All activities undertaken in enterprises should
aim at generating value [13]. Waste, on the other hand, is any action or part of a process
that does not create value. There are seven types of waste in LM: transport, inventory,
motion, waiting, overproduction, excessive processing, and defects [14]. In the healthcare
sector, these are very visible, e.g., in the form of excessive movement of patients and staff,
delays in deliveries, or ineffective management of resources [15].
The implementation of Lean Management projects in healthcare faces a number of
barriers. The main obstacles are human barriers caused by the reluctance of healthcare
unit employees and the lack of faith in the possibility of applying solutions [16] that
have proved to be successful in production [17]. However, implementing lean thinking
in an enterprise requires understanding the basic principles of Lean Management and
adapting them to the specificity of a given unit, with particular emphasis on the diversity
of departments [9,18]. Qualified experts [19], who have extensive knowledge of Lean
Management implementation and are eager to get to know the hospital and familiarize
themselves with its structure, organizational culture, the processes inside, and the staff are
of key importance [20]. There is a view in the literature that LM can be used in any process
in a healthcare unit, bringing measurable benefits, such as reducing inventories, shortening
the duration of activities and processes, improving the quality of services, and increasing
the satisfaction of both patients and employees [15,21].
Currently, Lean Management solutions are being used for the first time in Polish
hospitals and outpatient clinics. One important project in the Polish healthcare system is
the project of the National Centre for Research and Development, carried out by the Polish
Society of Health Economics, and its partners, the aim of which is to develop national
standards for Value-Stream Mapping (VSM) that can be used in various medical entities
dealing with the treatment of patients with stroke [22]. However, these implementations
are still few, and only single units show interest in the new methods [5]. The reasons why
Polish hospitals use manufacturing industry solutions are the growing operating costs,
aging medical personnel, and the constantly deteriorating healthcare situation. In the Euro
Health Consumer Index report, in 2018, Poland was ranked 32nd out of 35 countries in
Europe, achieving one of the worst results in all areas, especially in terms of patient rights,
information, availability, and range and scope of operations [23]. The data of the Central
Statistical Office show, in 2019, the tendency of persistent negative changes in the age
structure of medical workers. The highest increase in the number of people authorized
to practice medical profession was recorded in the oldest age group—65 and over. In
2019, the share of doctors in this group among all medical practitioners and dentists was
24.5%. Moreover, no changes were noted in the age group of 35–44 years. In 2017–2019,
the size of this group remained the same, with the lowest level among all other groups
(the share of this group among all physicians was 14.6%). Similar trends also persist
among the nursing staff. In 2019, the largest number of nurses was in the age group of
45–54 years of age—99,000, while the least numerous group were nurses under 35 years of
age. In the group of 35–44 years of age, for 8 years, a constant decrease has been observed
in the number of people, with a constant annual increase in the group of 65 years and
Int.
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24

more.
trend This trend the
confirms confirms
agingthe
of aging of medical
medical personnelpersonnel in Poland,
in Poland, which which is becoming
is becoming a hugea
huge challenge for hospital managers [24]. A distribution of medical and nursing
challenge for hospital managers [24]. A distribution of medical and nursing staff in staff in
individual
individualage
agegroups
groupsisispresented
presentedininFigure
Figure1.1.

[in thousand]
120
number of medical personel 99
100 89

80

60
45
35 37
40 30 31 30 32
22
20

0
under 35 years 35–44 45–54 55–64 65 years of age
of age and more
age in years

Doctors Nurses

Figure1.1.Medical
Figure Medicaland
andnursing
nursingstaff
staffdivided
dividedinto
intoage
agegroups.
groups.Status
Statusfor
for2019.
2019.Source:
Source:Own
Ownstudy
study
based on the data of the Central Statistical Office.
based on the data of the Central Statistical Office.

Statisticalanalyzes
Statistical analyzes of ofthe
theCentral
CentralStatistical
Statistical Office
Officealso
alsoshow
showslight
slightchanges
changesin inthe
the
increaseof
increase of specialist
specialist doctors
doctors in in Poland
Polandper pertententhousand
thousandpeople.
people.Compared
Compared to to
thethe
data for
data
2019
for 2019andand2010,
2010,thethenumber
numberofofmedical
medicalpersonnel
personnelonly only slightly
slightly increased in the the areas
areasof of
radiodiagnostics,psychiatry,
radiodiagnostics, psychiatry,anesthesiology
anesthesiologyand andintensive
intensivecare,
care,family
family medicine,
medicine, surgery,
surgery,
andcardiology.
and cardiology. In In the
the other
other specialties
specialties analyzed
analyzed by by the
theCentral
CentralStatistical
StatisticalOffice,
Office,this
this
number remained at the same level, while it decreased in the area
number remained at the same level, while it decreased in the area of internal medicine [24]. of internal medicine
[24].Poland is the country with the last position in the European Union in terms of the
number Poland is the country
of doctors and nurses withpertheone
lastthousand
position inhabitants,
in the European Union in by
as evidenced termsthe of the
data
number of
presented bydoctors
the OECD andand nurses per one
presented in thousand
Figure 2. inhabitants, as evidenced by the data
Such aby
presented difficult
the OECD staffing
andsituation
presented inin
Polish
Figure hospitals
2. implies the need to improve the
efficiency
Suchofa processes, their improvement,
difficult staffing situation in Polishand elimination of unnecessary
hospitals implies the need to activities
improve[20]. the
Moreover, units of the healthcare sector operate in conditions of constantly
efficiency of processes, their improvement, and elimination of unnecessary activities [20]. increasing
demand
Moreover, for units
medical services;
of the this issector
healthcare especially
operate duein toconditions
greater patient awareness
of constantly and the
increasing
aging
demand of society [25]. Patients’
for medical services;needs
this isgrow, and thus
especially dueso todoes the patient
greater necessity to provide
awareness them
and the
with
agingsatisfaction with Patients’
of society [25]. treatmentneedsand services
grow, and [26].
thus so does the necessity to provide them
withThe aim of this
satisfaction witharticle is to present
treatment the application
and services [26]. of the LM concept in a hospital in
Poland as a tool for the identification and analysis
The aim of this article is to present the application of the of waste andLMitsconcept
impact on in athe process
hospital in
of organizing the provision of medical services on the example of
Poland as a tool for the identification and analysis of waste and its impact on the processimprovements in the
process of patient
of organizing theadmission.
provision of medical services on the example of improvements in the
process of patient admission.
Int.
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4 of 23

Figure 2.2.The
Figure Thenumber
number of doctors and and
of doctors nurses per one
nurses perthousand inhabitants
one thousand in individual
inhabitants EU countries.
in individual EU
Note: for Portugal and Greece, the data refer to all licensed doctors, resulting
countries. Note: for Portugal and Greece, the data refer to all licensed doctors, resulting in a significant
in a
overestimation of the number
significant overestimation of practicing
of the number ofdoctors (e.g.,doctors
practicing by around
(e.g.,30% for Portugal).
by around 30% forFor Austria
Portugal).
and Greece, and
For Austria the number
Greece, of
thenurses
number is underestimated as it only includes
of nurses is underestimated nurses
as it only working
includes in hospitals.
nurses working
in hospitals.
Source: Source: OECD/European
OECD/European Observatory Observatory on Healthand
on Health Systems Systems and
Policies Policies
(2019), (2019),Country
Poland: Poland:
CountryProfile
Health Health Profile
2019, 2019,
State of State
Health of Health
in the EU, OECDin the EU, OECD
Publishing, Publishing, Observatory
Paris/European Paris/European
on
Observatory
Health on and
Systems Health Systems
Policies, and Policies, Brussels
Brussels.

2. Materials and Methods

2.1.
2.1. Overview
Overview of
of the
the Background
Background of
of the
the Project
Project
In
In 2019,
2019, aa project
project was
was conducted
conducted to to identify
identify wastage using Lean
wastage using Lean Management
Management tools. tools.
The project was implemented at the J. Gromkowski Provincial Specialist
The project was implemented at the J. Gromkowski Provincial Specialist Hospital in Hospital in Wroclaw.
Subsequent stages of the project are shown in Figure 3.
Wroclaw.
The project started
Subsequent stages ofonthe
1 July 2019
project and
are lasted
shown inuntil
Figure313.December 2019. The first step
was to establish the project aim at the management
The project started on 1 July 2019 and lasted until 31 level (1),December
followed by the The
2019. appointment
first step
of a team (2). The team included: Deputy Director for Finance, Heads
was to establish the project aim at the management level (1), followed by the appointment of Departments
and Ward Matrons of Internal Medicine Department and Department of Gastroenterology,
of a team (2). The team included: Deputy Director for Finance, Heads of Departments and
Manager of the Organization and Supervision Department, Head of the Human Resource
Ward Matrons of Internal Medicine Department and Department of Gastroenterology,
Management Department, and external experts. The task of the team was to prepare the
Manager of the Organization and Supervision Department, Head of the Human Resource
project budget, obtain external funds for its implementation, prepare and organize training
Management Department, and external experts. The task of the team was to prepare the
courses for employees, set the project schedule, and then supervise its implementation.
project budget, obtain external funds for its implementation, prepare and organize
The team also identified the area that was designated to participate in the project. These
training courses for employees, set the project schedule, and then supervise its
included two internal medicine wards, a gastroenterology ward, and an admission room
implementation. The team also identified the area that was designated to participate in
and laboratory. The departments had a total of 137 hospital beds. A total of 6162 patients
the project. These included two internal medicine wards, a gastroenterology ward, and an
were admitted to the departments in 2019. The revenues of the departments amounted
admission room and laboratory. The departments had a total of 137 hospital beds. A total
to a total of EUR 5,334,031 (PLN 24,472,532.00), while costs amounted to EUR 6,182,530
of 6162 patients were admitted to the departments in 2019. The revenues of the
(PLN 28,365,447.00), which means the loss of EUR 848,499 (PLN 3,892,913.00) in a year. In
departments
2017 and 2018, amounted to a total toofEUR
the loss amounted EUR841,982
5,334,031
(PLN(PLN 24,472,532.00),
3,863,015.00) and EUR while costs
829,905
amounted to EUR 6,182,530 (PLN 28,365,447.00), which means the loss of
(PLN 3,807,604.00), respectively. The systematically deteriorating financial situation of the EUR 848,499
(PLN and
units 3,892,913.00) in a year.toInincrease
growing pressure 2017 and the2018, the loss amounted
effectiveness to EURwere
of the treatment 841,982 (PLN
the direct
3,863,015.00) and EUR 829,905 (PLN 3,807,604.00), respectively. The
reasons why the management of the hospital took steps to make changes in the organization systematically
deteriorating
of financial itsituation
the work. However, was not onlyof thetheunits andsituation
financial growingthat pressure
convinced to increase
the hospitalthe
effectiveness of the treatment were the direct reasons why the management
management that organization of the work of the departments required improvement. of the hospital
took steps to make changes in the organization of the work. However, it was not only the
financial situation that convinced the hospital management that organization of the work
of the departments required improvement.
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(1)The aim of the project:

to identify waste and analyse
its impact on the process of
service provision

(2) Establishment of the team

(identification of the area,
allocation of budget, creation
of problem solving groups)

(3) Direct observations

(3b) Creation of solving groups

(3a) Interviews with persons
and observation of individual
responsible for project
elements of the process and
implementation
search for solutions

(4) Preparation of proposals

for solutions

(5) Implementation of
selected solutions

(6a) Verification of
attitudes, expectations (6b) Observation and analysis
and concerns in of initial results
interviews

Figure
Figure 3. Scheme
3. Scheme of theofresearch
the research project
project implementation
implementation process.
process. Source:
Source: OwnOwn study.
study.

In the
In the subsequentstages,
subsequent stages, direct
direct observations
observationswere
weremade (3), interviews
made with managers
(3), interviews with
responsible for project implementation were conducted (3a), and working groups (named
managers responsible for project implementation were conducted (3a), and working
groups solving) were formed. To this groups were appointed employees from the units
groups (named groups solving) were formed. To this groups were appointed employees
where the project was implemented, and they, through their involvement in its implemen-
from the units where the project was implemented, and they, through their involvement
in its implementation, became leaders of particular stages (3b). This was followed by
Int. J. Environ. Res. Public Health 2022, 19, 800 6 of 23

tation, became leaders of particular stages (3b). This was followed by meetings in working
groups. Their task was to identify the most important areas for improvement, which were
then passed on to members of the core team. Their task was then to verify the problems
reported within the solving groups and the proposed solutions (4).
The next step was a formal implementation of solutions—changing the internal docu-
mentation, changing the organizational structure, including funds in the budget for the
implementation of new ideas, and making changes in the purchase or investment plans (5).
The final stage was to verify the attitudes of managers responsible for the project—the
extent to which their expectations and concerns were met (6a)—and to observe and analyze
the initial results of the implemented solutions (6b).
The budget of the project was EUR 50,130 (PLN 230,00.00). As part of the project
budget, the hospital financed the work of consultants from an external company and the
work of hospital employees.

2.2. Characteristics of the LM Tools Used in the Project

The principles of Lean Management involve five main areas, and the project uses four
of them directly related to the process:
1. Identifying the value generated by each process for the customer (external or internal).
From the patient’s perspective, this is related to the process of admission and entire
treatment. Lean refers to the need to design the diagram in a way that optimizes and
eliminates unnecessary movements and activities.
2. Mapping the value stream of each service, which allows one to capture places that do
not bring value and generate waste.
3. Improving the flow, where it is necessary to remove any barriers that hinder or delay
the process.
4. Striving for perfection (Japanese kaizen) [15].
The fifth area—the pull system—refers to the time of delivery of the service product to
the customer [27]. Delivery should take place when there is a need for a given product or
service [28]. This area was not covered as the project did not include inventory management
or verification of the timing of service delivery in line with patient needs [29]. However,
the principles of the pull system relating to replenishment of resources after their use have
been used in the implementation of electronic documentation.
In accordance with the principles of Lean Management, the work on the project took
place in a place where the value was created (Japanese: gemba walk). The observations
began in the place where the patient had direct contact with the hospital, i.e., in the admis-
sion room. The literature encounters the view that entering gemba and direct observation
of the process allow for the best analysis of the value stream flow [12]. According to J.
Womack [27], this brings measurable benefits. Working in the place where the service
is produced enables managers to change the perspective and view the process exactly
where it occurs. It improves the efficiency of the process and coaching of line managers.
Communication, which is one of the basic elements of the effective implementation of
Lean Management tools, is an important determinant of the project effectiveness [18]. The
first part of the project involved a detailed analysis of the process of admitting a patient
to hospital, which is a very important activities and one of the main processes in the unit.
For this purpose, the trainers spent 14 days in all organizational units responsible for
its implementation, i.e., admission room and departments, they participated in meetings
of teams working in the departments, observed the preparation of documentation and
ordering examinations, and analyzed the methods of in-hospital communication. Their
main task was to prepare a map of the entire process, along with a report on identified
problems/waste. Thanks to the use of the 5Why method (repeating the questions starting
with the word “why” until the root cause of the problem was discovered) [9], in the first
stage of the project, they not only made observations of the activities performed by the
staff, but also asked questions in order to specify the elements of the process, understand
their significance, or, at an early stage, identify problems and threats.
Int. J. Environ. Res. Public Health 2022, 19, 800 7 of 23

Subsequently, in the departments, the activities performed at individual positions

were verified through the process of direct observations. The information was gathered
from the people directly involved in particular tasks in individual positions. Free interviews
focused on the possibilities of improving work. The trainers worked directly with the staff
in the appropriate departments and recorded the activities performed by doctors, nurses,
and administrative staff. The elements of a given process were noted in the cycle time
measurement card, and then the notes were used to describe the entire process along with
the characteristics of identified or reported problems and deficits.
The joint work resulted in the creation of a value stream map—a diagram of the process
of patient admission and treatment. Mapping is a tool that allows for the recognition and
visual presentation of individual elements of the process in order to optimize it, improve
efficiency, eliminate problems, and improve the flow of value [30]. Therefore, the project
inventoried the basic activities performed by medical and administrative staff in the process
of admitting a patient to the hospital and transferring him/her to a department. Next, the
stages of the process were carefully monitored in order to identify waste.
In the process of waste identification, working solving groups used A3 reports
(Supplementary File S1). They consisted of the following elements:
1. Problem definition;
2. Determining the current state (along with a description of the most important prob-
lems and their dimensioning);
3. Defining the goal (and the main indicators of its implementation);
4. Analysis of the causes and steps necessary to achieve the target state;
5. Defining remedial measures, enabling the implementation of the next stages of the
project;
6. Creating the work plan—persons responsible, tasks, schedule.

2.3. Main Findings of the Working Groups in the Project

2.3.1. Patient Flow Analysis, Scope, and Method of Data Collection and Processing
The first problem identified in the admission room was excessive patient and emer-
gency room staff traffic. Therefore, the processes related to the admission of a patient to
the admission room, transfer to the ward, and discharge were analyzed and mapped. The
resultant value stream map is shown in Figure 4.
The unit does not have a Hospital Emergency Department (HED); there are admission
rooms treating patients depending on the type of disease. There are six structurally sepa-
rated rooms: internal medicine, gastroenterological, surgical, neurological, and infectious
admission room, as well as an admission room for children. There are five admission rooms
in the building for adult patients, four of them in the same location, i.e., building A/A1.
Within each of the admission rooms, there is a separate room that registers patients for
elective procedures. Before the start of the project, elective patients were registered on
strictly defined days and hours. The remaining patients, who came with a referral and
were brought by ambulance, or those whose health condition required immediate medical
assistance, were directed by an employee of the information point to the appropriate room
where medical assistance was provided. If the patient had a referral, he/she was referred
to the appropriate admission room based on the diagnosis. In a situation where the patient
did not have an appropriate document, he/she was referred by a service worker to an
internal medicine admission room, or other—if the patient wanted to be seen by a doctor
of a specific specialty. Often, while waiting in the corridor for the doctor’s arrival, the
patient, initially asked about the ailments by the nurse, was redirected to another area
in the admission room. There, he/she was still waiting for a doctor who, after taking
medical history and initial examination, could decide to transfer the patient to a doctor of
another specialty (based on the initial diagnosis). There were situations when the patient
walked/was transported within the admission room from one area to another; each sub-
sequent doctor re-examined the patient and made an independent decision as to further
treatment. This caused significant chaos and unnecessarily prolonged the patient’s stay
Int. J. Environ. Res. Public Health 2022, 19, 800 8 of 23

in the admission room. Such a situation was favored by the layout of the rooms, which,
in the medical staff, strengthened the feeling of working for the admission room of the
department and not the idea of comprehensive patient care. The patient, on the other
hand,
Int. J. Environ. Res. Public Health 2022, 18, x FOR was forced to visit subsequent rooms, and even wait in several different
PEER REVIEW 8 of 24 queues to be
admitted by the appropriate doctor, and then to the hospital. The diagram of the rooms is
shown in Figure 5.

Figure 4. Diagram showing the process of admitting and treating a patient before the introduction of
LM. Source: Own study.
 and made an independent decision as to further treatment. This caused significant chaos
and unnecessarily prolonged the patient’s stay in the admission room. Such a situation
was favored by the layout of the rooms, which, in the medical staff, strengthened the
feeling of working for the admission room of the department and not the idea of
comprehensive patient care. The patient, on the other hand, was forced to visit subsequent
Int. J. Environ. Res. Public Health 2022, 19, 800 9 of 23
rooms, and even wait in several different queues to be admitted by the appropriate doctor,
and then to the hospital. The diagram of the rooms is shown in Figure 5.

Figure
Figure 5. 5.
TheThe diagram
diagram showing
showing theplaces
the placesininthe
theadmission
admissionroom
roombefore
beforethe
thechanges
changes were
were made.
made. Source:
Source: ownown study.
study.

After admitting the patient to the appropriate admission room, the nurse entered
all the necessary data into the IT system and registered him/her in the admission book
(made a manual entry) and called the doctor on duty, who, after examining the patient,
made a decision on the necessary tests. The examinations in the system were ordered by a
nurse who also collected material for tests. The patient waited for the results, which were
sent via pneumatic mail from the hospital laboratory. After receiving the test results, the
doctor examined the patient once again and made a decision on whether or not to admit
the patient to the ward. Any patient who was referred to the hospital ward was transported
to the appropriate room under the care of a paramedic. In the department, registration
in the system was made again by a nurse. The basic data of the patient, entered into the
system in the admission room, also appeared in the ward. However, it was necessary
to again complete the paper documentation. Further tests were ordered. Each of the
departments and the admission room used different order card templates, which resulted
in frequent mistakes when completing them and the need to complete them once again.
Very often, it was only at the ward that it was discovered that the documentation collected
at the admission room lacked key information—e.g., telephone number of the next of kin
and telephone number of the patient. Keeping the patient’s medical records was also
significantly difficult because most of the documentation was kept in a paper version. The
hospital already had an IT system for the introduction of electronic documentation, but the
appropriate forms were not entered into the program, and the medical staff did not have
sufficient knowledge regarding the operation of the system.
After treatment, the patient was discharged home by the attending physician. At the
ward, he/she waited for the arrival of his/her family, left the hospital on his/her own, or
waited for the arrival of the transport ordered by the hospital.

2.3.2. Findings Made during Interviews

As part of the project, standardized interviews were conducted with selected people
from the hospital management board and middle-level managers working in the depart-
ments participating in the project. The following persons were interviewed: Deputy
Director for Treatment, Head of the Department of Internal Medicine, Ward matron of the
Department of Gastroenterology, and Deputy Director for Finance. The interviewees were
Int. J. Environ. Res. Public Health 2022, 19, 800 10 of 23

purposefully selected. They were directly responsible for carrying out the project in the hos-
pital: medical issues—Deputy Director for Treatment, costs—Deputy Director for Finance,
medical staff—Head of VI Internal Medicine Department, and nursing staff—Ward matron
of the VII Department of Gastroenterology. The respondents belonged to the management
staff of the Hospital. This is a group of persons with extensive experience in the health-
care sector (from 15 years, in the case of the Deputy Financial Director, to over 20 years
of managerial experience, in the case of the remaining respondents). They belonged to
the age groups: 45–50 years—two persons—and 55–60 years—two persons. Three of the
respondents had a medical degree, while the Deputy Director of Finance had an MBA.
At the same time, these were people who had not worked with Lean Management tools
before, with the exception of the Deputy Director of Finance, who had been exposed to this
management concept in previous jobs.
The director of the hospital and the respondents, who gave their informed consent
to participate in the study, consented to the interviews. A qualitative questionnaire was
prepared for this purpose. The interview was conducted in the first weeks of the project
implementation and after its completion.
The first sheet (Supplementary File S2) contained the following questions:
1. What areas within the Internal Medicine Department, Department of Gastroenterology,
and the Admission Room for Adults need improvement?
2. What tasks performed by medical personnel engage them to the greatest extent and
are not directly understood as providing health services?
3. What are your expectations towards the implementation of the Lean Management
project?
4. Do you have any concerns about the project? What are they regarding?
The next sheet (Supplementary File S3) was part of the interviews conducted after the
end of the project; it contained two questions:
1. What problems were solved during the project implementation?
2. Have the concerns you had before starting the project been confirmed? If so, which
ones? If not, what had a direct impact on the elimination (reduction) of the concerns?

3. Results
3.1. Identified Waste
Wastes identified at particular stages of patient admission and treatment were ranked
in nine main groups:
1. searching and explaining;
2. waste of overprocessing;
3. waste of defects;
4. waste of overproduction;
5. waste of waiting;
6. waste of motion;
7. waste of human potential;
8. waste of inventory;
9. blame.
Two groups have been added, wasted human potential and blame, which reflect a
huge problem in the hospital affecting the effectiveness of the unit and organizational
culture.
The ranked wastes are presented in Supplementary File S4.
A percentage distribution of the most common wastes in the unit, broken down into
groups, is presented in Figure 6.
 8. waste of inventory;
9. blame.
Two groups have been added, wasted human potential and blame, which reflect a
huge problem in the hospital affecting the effectiveness of the unit and organizational
culture.
The ranked wastes are presented in Supplementary File S4.
Int. J. Environ. Res. Public Health 2022, 19, 800 11 of 23
A percentage distribution of the most common wastes in the unit, broken down into
groups, is presented in Figure 6.

Figure 6.
Figure 6. Identified
Identifiedwastes.
wastes.Source: ownown
Source: study basedbased
study on theon
hospital materials.
the hospital materials.

The
The analysis
analysisidentified a total
identified of 137
a total different
of 137 problems.
different Their distribution
problems. into nineinto nine
Their distribution
groups and a proposal of possible solutions is presented in Table 1.
groups and a proposal of possible solutions is presented in Table 1.

Table 1. A distribution of wastes and proposed solutions by groups.

Number of Proposed
Type of Waste Number of Identified Wastes
Solutions
searching and explaining 31 21
waste of waiting 30 22
waste of overproduction 25 19
waste of defects 18 17
waste of overprocessing 12 11
waste of human, material,
10 6
service potential
waste of motion 8 7
blame 2 0
waste of inventory 1 1
Total 137 104

The most common waste in the unit are activities devoted to searching for information,
both information regarding the patient and the information needed to conduct the process
of treatment (e.g., telephone numbers at which patient transport can be ordered, key
information regarding changes in the principles of operation of laboratories or the method
of patient appointments, the lack of guidelines for patient management after diagnostic
tests). In addition, the results of observations made in the admission room showed that the
medical staff spent a lot of time explaining/informing the patient on issues not related to the
process of treatment—for example, about what to take to the hospital, things he/she cannot
have during the examination, where to go to collect personal belongings, etc. Additionally,
the patients in the room were looking for someone to help them, and they were sent from
one room to another. Subsequent doctors performed tests and sent the patient further
away. The patient was then awaiting further examination or admission and examination
by medical staff.

3.2. Changing the Schedule of Admitting a Patient

After identifying numerous problems in the admission room, the Board of the Hospital
decided to rebuild it. Designers, in cooperation with lean experts and with the participation
Int. J. Environ. Res. Public Health 2022, 19, 800 12 of 23

ofxthe
Int. J. Environ. Res. Public Health 2022, 18, FORemployees,
PEER REVIEW redesigned
the rooms so that they allowed for the optimal
13 ofpatient
24 flow.
The new diagram of places in the admission room is shown in Figure 7.

Figure
Figure7. 7.
TheThe scheme
scheme of rooms
of the the rooms
in thein the admission
admission room
room after theafter the had
changes changes had been
been made. made. Source:
Source:
own
ownstudy.
study.

Architectural
Architecturalchangeschanges allowed
allowed the the hospital
hospitalto to provide
provide the patient
the patient with
with comprehensive
comprehensive care from the moment of entering the admission
care from the moment of entering the admission room. The change in room layout room. The change in resulted
room layout resulted in improved patient flow and direct patient identification and
in improved patient flow and direct patient identification and registration. At the same
registration. At the same time, it provided greater supervision of patients, improved the
time, it provided greater supervision of patients, improved the efficiency of staff work,
efficiency of staff work, and ensured better patient waiting comfort. Now, immediately
and entering
after ensuredthe better patient
hospital, thewaiting
patient comfort.
is directed Now,
to the immediately after entering
centrally located the hospital,
registration.
There, his/her data is entered into the system (which relieves the nursing staff fromis entered
the patient is directed to the centrally located registration. There, his/her data
into the system
unnecessary (which
activities, who,relieves
before thethechanges,
nursinghad staffto from unnecessary
register the patient),activities,
and then thewho, before
the changes,
patient is directedhadtototheregister
admission the box.
patient), and then
Depending the patient
on whether is directed
the patient has a to the admission
referral
orbox. Depending
presents with urgenton whether
ailments, the patient
he/she is seenhasby a specialist
referral or presents
based on thewith urgent
diagnosis or ailments,
by an internist.
he/she is seen Inby
theasecond case,based
specialist after taking
on themedical
diagnosishistoryor and
by anexamining
internist.theInpatient,
the second case,
the physician
after taking decides
medicalwhether
historytoand callexamining
a specialist intheanother
patient, field
thefor consultation,
physician admit
decides whether to
the patient to the ward, or refuse admission if there are no indications
call a specialist in another field for consultation, admit the patient to the ward, or refusefor hospitalization.
The patient
admission no longer
if there are nohas to move from
indications one room to another. He/she is fully cared
for hospitalization.
for in the admission box and then transferred to a given admission room in order to be
The patient no longer has to move from one room to another. He/she is fully cared
admitted to the ward. In addition, the new construction solutions provide patients with
for in the admission box and then transferred to a given admission room in order to be
great comfort, even when waiting for admission. Before the renovation, the patients
admitted to the ward. In addition, the new construction solutions provide patients with
waited for admission in the corridor. There was no place to ensure privacy and the
great comfort,
possibility even waiting
of peaceful when waiting for admission.
for the examination. ThereBefore
were the
onlyrenovation,
a few chairsthe patients waited
prepared
for admission in the corridor. There was no place to ensure
for these patients in the corridor. Currently, the admission room has a separate waiting privacy and the possibility
of peaceful
room waiting
with several for the
separate examination.
rooms open to theThere were
corridor. only
This a few chairs
arrangement prepared
of the rooms for these
patients
allows forin thecomfort
the corridor.andCurrently,
intimacy of thepatients
admission while room has a separate
maintaining safety. waiting
Universalroom with
several separate
admission boxes allow rooms open to
the patient theexamined
to be corridor.byThis arrangement
a doctor of thewho
of any specialty, roomsthenallows for
decides on the and
the comfort further diagnostic
intimacy path. Thewhile
of patients patient is the center safety.
maintaining of attention of the hospital
Universal admission boxes
staff,
allow who thecan optimally
patient to becare for him/her
examined byand provideofnecessary
a doctor assistance.
any specialty, who Changing the
then decides on the
further diagnostic path. The patient is the center of attention of the hospital staff, who can
Int. J. Environ. Res. Public Health 2022, 18, x FOR PEER REVIEW 14 of 24

Int. J. Environ. Res. Public Health 2022, 19, 800 13 of 23

layout of the rooms forced a change in the way of admitting the patient, which is
presented in care
optimally Figure
for8.him/her and provide necessary assistance. Changing the layout of the
rooms forced a change in the way of admitting the patient, which is presented in Figure 8.

Figure 8. The scheme of admitting the patient after the changes have been made. Source: own study.
Figure 8. The scheme of admitting the patient after the changes have been made. Source: own study.
Int. J. Environ. Res. Public Health 2022, 18, x FOR PEER REVIEW 15 of 24

Int. J. Environ. Res. Public Health 2022, 19, 800 14 of 23

Another solution for improving the patient’s admission to hospital, proposed in the
fieldAnother
of Visual Management,
solution was the
for improving theintroduction of simple
patient’s admission to and clearproposed
hospital, instructions for
in the
patients to prepare for a hospital stay. The solution allowed the hospital
field of Visual Management, was the introduction of simple and clear instructions for to not only use
the medical
patients staff’sfor
to prepare working timestay.
a hospital moreTheefficiently, but alsothe
solution allowed tohospital
reduce the patient’s
to not only usestress
the
prior to arrival at the hospital. The information—also in an electronic version—was
medical staff’s working time more efficiently, but also to reduce the patient’s stress prior toplaced
on the at
arrival hospital website.
the hospital. The information—also in an electronic version—was placed on the
hospital website.
3.3. Solutions for Collection, Processing, and Transmission of Information
3.3. Solutions
Next infororder
Collection,
of theProcessing,
numberand of Transmission of Information
identified wastes were problems related to
overproduction,
Next in ordercorrection of deficiencies
of the number and wastes
of identified errors, andwereoverprocessing.
problems related to overpro-
Onecorrection
duction, of the key activities that
of deficiencies andtemporarily
errors, and involve medical personnel and do not
overprocessing.
belong
Onetoofstrictly
the keymedical activities
activities is completing
that temporarily medical
involve medical documentation.
personnel andItdo is not
an activity
belong
that
to must medical
strictly be performed by both
activities doctors andmedical
is completing nurses; documentation.
it is one of their basic
It is duties, but often
an activity that
must be performed by both doctors and nurses; it is one of their basic
takes a significant amount of time. During the project, the time needed to complete the duties, but often
takes a significant
patient’s medical amount of time. and
documentation During the documents
other project, the time needed
prepared in to
thecomplete
wards was the
patient’s
measured. medical documentation
The employees of the and other documents
departments filled in prepared in the wards
the documentation in was mea-
the paper
sured.
version.TheMeasurements
employees of the departments
were made on filled in the documentation
the wards in the paperand
using direct observation version.
time
Measurements
measurementswere made on the wards
on stopwatches. using directresults
The individual observation and time
of each measurements
measurement were
on stopwatches.
recorded The individual
on observation results
sheets andofthen
each transferred
measurementtowere an recorded on observation
Excel spreadsheet. The
sheets and then transferred to an Excel spreadsheet. The experiment
experiment with the use of standard forms filled in manually by a doctor and with the use of stan-
a nurse
dard
versusforms filled in manually
the preparation of the by a doctor
same and a nurse
documents versus theversion
in an electronic preparation of the
clearly same
indicated
documents
the waste ofintimean electronic versionthe
when choosing clearly
paperindicated the wasteresults
version. Detailed of timeofwhen choosing the
the experiment are
paper version.
presented Detailed
in Figures results of the experiment are presented in Figures 9–11.
9–11.

Figure9.9.Time
Figure Timeto
tocomplete
completethe
thenursing
nursingdocumentation
documentationof
ofaanewly
newlyadmitted
admittedpatient.
patient.Source:
Source:Own
Own
study based on the hospital materials.
study based on the hospital materials.

The results of the project clearly show that filling in paper documentation, both for a
newly admitted patient and for a patient staying in the ward, is much more time-consuming
than filling in the same documentation in an electronic version. The time-savings were,
respectively, 63 min for a patient admitted to the hospital and 38 min for an already
hospitalized patient. The results may differ depending on the capabilities and competences
of the person completing the documentation, which was also confirmed by the experiment,
which covered both young people working perfectly in modern IT systems, as well as
the elderly. In each case, the electronic version turned out to be faster than the paper
version. This was mainly related to the elimination of unnecessary activities, such as
entering headings, completing the patient’s data again and again (in subsequent columns),
and the need to rewrite the basic results or information regarding the tests ordered. At the
same time, the results of the observations revealed that other documents were also kept in
paper versions, the filling of which required a significant involvement of medical personnel.
Int. J. Environ. Res. Public Health 2022, 19, 800 15 of 23

Int. J. Environ. Res. Public Health 2022,These

18, x FOR PEER
were REVIEW
various types 16 of 24
of registers: scheduled admissions, ordered transports, queues
Int. J. Environ. Res. Public Health 2022, 18, x FOR PEER REVIEW 16 of 24
for treatments, and imaging examinations.

Figure10.
Figure 10.Time
Timetotocomplete
completethe
thepatient’s
patient’snursing
nursingdocumentation
documentation in
inthe
theward.
ward.Source:
Source: Own
Own study
study
Figure
basedon 10.the
on Time to complete
hospital the patient’s nursing documentation in the ward. Source: Own study
materials.
based the hospital materials.
based on the hospital materials.

Figure 11. Time to complete the medical documentation. Source: Own study based on the hospital
Figure 11. Time
materials.
Figure 11. Timeto
tocomplete
completethe
themedical
medicaldocumentation.
documentation. Source:
Source: Own
Own study
study based
based on
onthe
thehospital
hospital
materials.
materials.
The results of the project clearly show that filling in paper documentation, both for a
The analysis
The results ofof thewaste
project clearly show
identified that filling
as excessive in paper documentation, both for
hasa
newly admitted patient and for a patient stayingprocessing
in the ward,of paper
is muchdocuments
more time-
newly
shown admitted patient
that transferring and
documentsfor a patient staying in the ward, is much more time-
consuming than filling in the samefrom paper to electronic
documentation version brings
in an electronic version.measurable
The time-
consuming
benefits, such than
as filling
time in thefor
savings same documentation
medical staff. With in
anan electronic
average number version.
of newThe time-
savings were, respectively, 63 min for a patient admitted to the hospital and 38 minadmis-
for an
savings
sions to were,
the respectively,
ward of 350 63 minper
patients formonth,
a patient admitted
the time to thefor
savings hospital
nursing andstaff
38 min for an
are 368 h
already hospitalized patient. The results may differ depending on the capabilities and
already
(2.3 hospitalized
FTEs) andof 175 patient.
h (1.09 FTEs) The results
for medical may differ depending on the capabilities and
competences the person completing the staff. The value ofwhich
documentation, the staff
was working time saved
also confirmed by
competences
was EUR of the person
3089/month completing
(14,173.00 the documentation,
PLN/month) for nurses which
and was2855/month
EUR also confirmed(PLNby
the experiment, which covered both young people working perfectly in modern IT
the experiment,
13,100.00/month) which
forthe covered
specialist both young people working perfectly in modern IT
systems, as well as elderly.doctors.
In each This
case,isthe
oneelectronic
of the keyversion
reasonsturned
to modify
out the current
to be faster
systems,
ways as well as In the
the elderly. In each case, the electronic version turned out tosector,
be faster
than of
theworking.
paper version. faceThis
of large
wasshortages of medical
mainly related to personnel in the health
the elimination of unnecessary all
than the that
solutions paper version.
allow for moreThis was mainly
effective relatedoftohuman
management the elimination
capital in of organization
the unnecessary
activities, such as entering headings, completing the patient’s data again and again (in
activities,
are such as entering headings, completing the patient’s data again and again (in
necessary.
subsequent columns), and the need to rewrite the basic results or information regarding
subsequent columns), and the need to rewrite the basic results or information regarding
the tests ordered. At the same time, the results of the observations revealed that other
the tests ordered. At the same time, the results of the observations revealed that other
documents were also kept in paper versions, the filling of which required a significant
documents were also kept in paper versions, the filling of which required a significant
involvement of medical personnel. These were various types of registers: scheduled
involvement of medical personnel. These were various types of registers: scheduled
admissions, ordered transports, queues for treatments, and imaging examinations.
admissions, ordered transports, queues for treatments, and imaging examinations.
 admissions to the ward of 350 patients per month, the time savings for nursing staff are
368 h (2.3 FTEs) and 175 h (1.09 FTEs) for medical staff. The value of the staff working
time saved was EUR 3089/month (14,173.00 PLN/month) for nurses and EUR 2855/month
(PLN 13,100.00/month) for specialist doctors. This is one of the key reasons to modify the
current ways of working. In the face of large shortages of medical personnel in the health
Int. J. Environ. Res. Public Health 2022, sector,
19, 800 all solutions that allow for more effective management of human capital16inofthe23

organization are necessary.

3.4.The
3.4. TheWaiting
WaitingTime
Timeofofthe
thePatient
Patientfor
forTransport
TransportHome
Home
Asaaresult
As resultof ofthe
theproject,
project,waste
wasterelated
relatedtotothethepatient’s
patient’swaiting
waitingfor fortransport
transporthomehome
wasidentified.
was identified.TheThepatient
patientwaswasdischarged
dischargedfrom fromthe theward,
ward,awaiting
awaitingthe thearrival
arrivalofofhis/her
his/her
family,
family,ororleft
leftthe
thehospital
hospitalon onhis/her
his/her own.
own. In In the
the case
case of
of472
472patients
patientsdischarged
dischargedin inthe
the
period
periodfrom
from1 July 2019
1 July to 31
2019 toDecember
31 December 2019, 2019,
it wasitnecessary to transport
was necessary them by external
to transport them by
hospital
externaltransport, which repeatedly
hospital transport, picked them
which repeatedly up with
picked a significant
them up with adelay. This limited
significant delay.
the possibility of admitting a new patient to the ward. The analysis of patient
This limited the possibility of admitting a new patient to the ward. The analysis of patient transports
home ordered
transports homeby ordered
the hospitalby theshowed
hospitalthatshowed
over 10% thatofover
the transports
10% of thetook place after
transports took
8place
p.m. after
and almost 6% after
8 p.m. and almost106%p.m. Pursuant
after 10 p.m.to the Act to
Pursuant onthe
healthcare services financed
Act on healthcare services
from public
financed funds
from [31],funds
public a patient
[31],with a motor
a patient withorgan dysfunction,
a motor which prevents
organ dysfunction, whichhim/her
prevents
from using
him/her public
from transport,
using public istransport,
entitled toissanitary
entitledtransport provided
to sanitary by a provided
transport medical entity
by a
free of charge on the basis of a doctor’s order. If the patient can walk,
medical entity free of charge on the basis of a doctor’s order. If the patient can walk, sanitary transport
issanitary
available for a fee
transport or a partial
is available forpayment. The analysis
a fee or a partial payment.of the
Thetransports
analysis ofcarried out in
the transports
the second half of 2019 revealed that patient transports home constituted
carried out in the second half of 2019 revealed that patient transports home constituted 25% of all the
transports.
25% of all the transports. A distribution of types of transports ordered by the hospitalinis
A distribution of types of transports ordered by the hospital is presented
Figure 12. in Figure 12.
presented

Figure12.
Figure 12.The
Thenumber
numberof oftransports
transportsordered
orderedby
bythe
thehospital
hospitalininthe
thesecond
secondhalf
halfofof2019.
2019.Source:
Source:own
own
study based on hospital data.
study based on hospital data.

Ofall
Of allpatient
patienttransports
transportshome,
home,more
morethan
than4% 4%were
wereordered
orderedforforwalking
walkingpatients
patientsfor
for
whom,in
whom, inaccordance
accordancewith withthe
theprovisions
provisionsof ofthe
theabove-mentioned
above-mentionedAct, Act,the
thehospital
hospitalisisnot
not
obligedtoto
obliged provide
provide transport
transport or in
or may, may, in demand
return, return, demand reimbursement
reimbursement of funds.
of funds. According
According to the information obtained from the Finance and Accounting
to the information obtained from the Finance and Accounting Department, the hospital did Department, the
hospital
not invoicedid not invoice
patients’ homepatients’ home
transports. transports.
Each Each of
time the costs time
thethe costs ofwere
transport the borne
transport
by
were
the borne The
hospital. by the hospital.
transport The transport
of walking patients ofhomewalking patients
was most often home
orderedwasby most often
the staff of
ordered
the by the Admission
Neurological staff of theRoom.
Neurological
The directAdmission Room.
observations The that
revealed direct
thisobservations
was due to
the staff’s that
revealed fear this
of the
waslegal
dueconsequences
to the staff’s of a possible
fear event
of the legal on the patient’s
consequences of a way home.
possible event
Moreover,
on the patient’sthewayanalysis
home. showed that 60% of the transports were ordered between
3 p.m. and 4 p.m. This could be the reason for waiting so long for an ambulance. In 3% of
cases, the ambulance came to pick up the patient more than 10 h after the transport order
(these were usually night hours, e.g., 1:00 a.m., 2:30 a.m.). This resulted in the necessity to
extend the stay of the patient already discharged from the hospital in the ward. In several
situations, the doctor decided not to transport the patient home at night for the good of the
patient.
Another large group of orders were transports of patients for consultations to another
hospital—23%, or transfers of patients to other entities—31%. At the same time, 14% of
transports were transports of medical documentation for the purpose of external consulta-
tions. This transport could be replaced by introducing teleinformatic consultations. The
hospital has a sufficient technical infrastructure. It would only be necessary to conclude
Int. J. Environ. Res. Public Health 2022, 19, 800 17 of 23

agreements with appropriate units and agree on the means of communication through
which the patient’s documents would be safely accessible.

3.5. Analysis of Prolonged Stays in Wards

Prolonged stays are another waste identified in the project. One of the reasons for
them was the inability to take the patient home (no immediate family to take care of the
patient—so-called stays for social reasons). Direct observations showed that this situation
usually concerned the elderly, sick, and those requiring constant care. These patients
remained in the hospital ward until someone from their family came for them, or a hospital
social worker found a place for such a person in a care and treatment facility. Waiting
for the end of hospitalization also concerned situations in which the patient could not be
discharged because the necessary tests or consultations had not been performed, or their
results were not yet available. This is a big challenge, not only in terms of organization;
prolonged stays of patients in hospital wards increase the risk of nosocomial infections.
They are also a general measure of hospital efficiency and are directly related to cost
reduction [32].
The aforementioned waste requires a broader analysis of the causes and the application
of organizational, legal, and financial solutions to shorten the patient’s stay in the hospital
and, subsequently, reduce the risk of recurrent nosocomial infections.

3.6. Discussion of Interview Results

Some very important elements considered before the implementation of the project
were communication problems reported by the staff (the lack of communication or in-
adequate communication within the organization), errors in the medical documentation,
and the lack of time to correct the mistakes along with the need to complete the current
documentation, as well as problems reported by patients, such as the lack of necessary
information, long waits to be admitted to hospital, and no precise instructions. The attitude
of the medical staff towards new challenges was another major challenge. Despite the
problems reported by the staff, there was resistance and reluctance to change habits. This
was often accompanied by the fear of the unknown and of using new technologies at work
(especially in the case of older doctors). In the first phase of the project, the Deputy Medical
Director especially expressed his distrustful attitude; his doubts were consistent with those
expressed by the medical and nursing staff.
Interviews with persons responsible for the implementation of the project highlighted
the concerns of individual groups of staff related to the implementation of new solutions
in the healthcare unit. There were doubts as to the possibility of observing the effects in
a short period of time. This fear led to discouragement and distrust of the project. In the
opinion of the interview participants, it could also lead to the lack of involvement of line
employees and middle-level managers in the departments. Moreover, fears related to the
improvement of individual processes and activities of organizational units were expressed.
Improving the work of one of the departments could, in the opinion of the staff, lead to a
deterioration in functioning of another. The interviews revealed organizational problems
with ordering examinations, carrying out transports, transferring patients to other units,
and performing consultations, as well as with completing paper documentation. There
were also problems with cooperation and communication between organizational units.
The interviews confirmed the silo approach of the departments and the fact that
they worked exclusively for their own good without taking into account the hospital as a
whole. The expectations regarding the implementation of the project concerned primarily
the improvement of the organization of work inside the hospital and easier completion
of documentation, as well as the improvement of the IT system, but also changes in
the organizational culture—focusing on the patient as a customer of services. Moreover,
the need to introduce changes in personnel management was formulated. In terms of
rationalization of employment in individual departments, the following were taken into
account: the current needs of the hospital, the epidemiological situation, and occupancy of
Int. J. Environ. Res. Public Health 2022, 19, 800 18 of 23

the department, as well as building commitment to work for the benefit of the patient and
the hospital and improving work efficiency by linking the effects with measurable financial
effects for the employee.
The interviews conducted after the implementation of Lean Management tools showed
that the project did not meet all expectations. The respondents indicated a noticeable
improvement in filling in medical documentation, which allowed for the acceptance of new
solutions by all medical workers in the departments covered by the project. The employees
positively responded to the effects of the improvements; however, some of them expected
spectacular changes in a short period of time. The high complexity and fragmentation of
the organization made the operation of the hospital inflexible, and this was noticed by the
interviewees. Moreover, they drew attention to the significant influence of the external
factors (regulators—the Ministry of Health, the National Health Fund and supervisory
bodies), which prevent the implementation of dynamic changes. Top-down regulations
hinder the introduction of an incentive system for hospital employees, e.g., regulations
changing the rules of remunerating employees without taking into account the specificity of
units or their financial resources for pay raises, no possibility of remuneration for the effect
of treatment due to the method of valuation of services, or limited supply for the medical
worker market, resulting in the need to maintain employment regardless of the results of
work—especially in relation to nursing staff for whom statutory employment standards
apply [33]. However, the interviews revealed that the introduction of Lean Management
tools resulted in the involvement of staff in the implementation of individual solutions; at
the same time, noticeable effects and proposed organizational solutions aroused an interest
in continuing the implementation of the project in other areas of hospital operations.
Moreover, it transpired that the Lean Management training, precisely defined goals, and
detailed division of work in groups were of great importance for the positive reception of
the project.

4. Discussion
The existing implementations of Lean Management in healthcare units around the
world show many benefits related to the elimination of waste, such as reduced patient
waiting time, reduced number of patient visits, fewer errors, and improved patient and staff
satisfaction, as well as increased work efficiency [16,21,34–38]. In the hospital in Huston, the
implementation of lean tools in HEDs significantly reduced the patient’s waiting time for
assistance, and thus shortened the ED stay [39]. Another study shows a correlation between
the overcrowding of emergency medical units and the number of errors made by medical
and nursing staff [40]. The implementation of lean tools at Odense University Hospital
confirmed the benefits and improvements throughout the organization, in particular in
terms of logistics and distribution [2,41]. Additionally, in many places, an improvement
in the organization of work and an increase in efficiency of particular organizations were
directly observed [25,42].
The most important waste identified after the implementation of LM tools related
to the collection, processing, and transfer of information. The introduction of electronic
medical documentation in the hospital allowed a shortening of the time of completing it
by doctors by 67% and by nurses by 76% for a newly admitted patient, and by 69% for
a patient staying in the ward. This is a very important result as it justifies the efforts to
broadly computerize the healthcare sector. Starting from 2021, keeping electronic medical
records is an obligation imposed by the Regulation of the Minister of Health of 6 April
2020 on types, scope, and templates of medical documentation [43]. The results of the
research carried out in the hospital in Wroclaw confirm that computerization of hospitals
and electronic medical documentation are the right course of action. However, not all
hospitals in Poland are prepared to implement the above obligation [44]. The Minister
of Health envisaged solutions enabling adaptation to the new requirements, at the same
time, constant digitization of healthcare in Poland is to be implemented [45]. From the very
Int. J. Environ. Res. Public Health 2022, 19, 800 19 of 23

beginning, the process has raised concerns in the medical community, which was confirmed
by a survey conducted by the Supreme Medical Chamber and the resultant statement [46].
The project confirmed the claim in the literature that the implementation of Lean
Management can improve the functioning of healthcare units by identifying wastes in
processes [47]. The use of value-stream mapping allowed for the transformation of the
process of admitting the patient to the hospital and treatment, as well as for the identification
of defective points. At the same time, the study showed that the attitudes of employees
are of great importance when implementing Lean Management. The first fear, reluctance
to apply new solutions, may be a factor that will significantly affect the possibility of
implementation. However, as the interviews revealed, after the completion of the project
and the first positive results, reluctance may turn into openness and interest in new areas
and opportunities for improvement. It is important to combine the implementation of Lean
Management tools with the elements of work psychology in order to stimulate motivation
among employees [48]. An indispensable element of lean implementation is the training
and involvement of all hospital workers in improving the inner processes in conjunction
with the active support of leaders (through supporting delegation of tasks, joint decision-
making, and joint management) [49]. Identifying the waste of processing too much data
in the paper version and the involvement of staff in the implementation of electronic
documentation meant that positive results were obtained, along with a change in the
attitudes of employees as they became more open to IT systems. In the Netherlands, the
systems for exchanging data between healthcare facilities via secure e-mails, a regional IT
structure, and a national service point, where professionals can share medical information,
are increasingly used. After the patient gives his/her consent, the physician has access to
his/her data provided at the point by another unit [49].
Research indicates that the problems with the implementation of LM tools include the
complexity of processes in hospitals, difficulties in involving medical personnel, and the
need to adapt the tools to the specificity of the unit and supplement them with additional
methods and instruments available in other management systems [2,41]. According to
the study conducted in the Wroclaw hospital, the resistance of employees and the fear
of having to learn about the new electronic system may be another problem with the
implementation of LM tools. Observations and conversations with employees in the wards
confirmed that many of them do not know the system or all of its functions and potential
possibilities. The solution was proposed to record tutorials showing how to work in the
system and to familiarize employees with new technologies in a way that reduces tension
through systematic training, face-to-face meetings, and supporting mutual aid initiatives.
Moreover, such IT projects should be planned in great detail, taking into account both the
necessary implementation time and the involvement of individual units. In subsequent
stages, it will be necessary to monitor the effects to ensure staff involvement and effective
implementation [50].
In addition, other wastes were identified during the project that make the work of
medical staff significantly more difficult. The analysis revealed potential causes of some
difficulties; as a result, possible solutions were presented. The analysis of individual areas
of the hospital operation has shown that many of them require further detailed research and
improvement. The use of Lean Management tools can be a solution to improve the work
and treatment of the patient. At the same time, it is necessary to pay attention to the analysis
of the patient’s and family’s satisfaction at each stage of making improvements [51]. This
element was not included in the project; therefore, the unit could not evaluate the activities
undertaken in this area. Moreover, Lean Management tools were implemented in only three
departments. The remaining departments were not covered by the project, which makes
it impossible to assess the impact of the implementation on the entire unit. The duration
of the project was also a significant limitation, which was strictly defined (1 July 2019–31
December 2019). The hospital management decided to continue, in 2020, cooperation
with external experts and thus expand the area of implementing LM tools throughout the
hospital. Unfortunately, the outbreak of the SARS-CoV-2 pandemic made it impossible to
Int. J. Environ. Res. Public Health 2022, 19, 800 20 of 23

implement the project in its original form. The hospital was entirely dedicated to providing
services to patients infected with the virus, therefore the participation of experts and the
implementation of the project were focused on preparing the hospital to fight the pandemic.

5. Conclusions
The use of Lean Management tools in the hospital allowed for identification of the
waste in the process of admitting and treating a patient. Defining the problems and
implementing improvements allowed for the development of new work standards that
significantly shortened the time for staff to perform activities not directly related to the
treatment of the patient. Working in teams resulted in the involvement of not only managers,
but also the staff working directly with the patient. It was one of the key elements of the
project’s success that allowed for the reduction of resistance to new solutions.
The project confirmed the possibility of implementing the principles of Lean Manage-
ment in the healthcare sector in Poland. The situation of Polish hospitals is currently very
difficult. They are struggling with financial problems resulting from the under-financing
of the healthcare sector in Poland and the shortage of human resources among medical
personnel. In 2019, Poland spent 6.5% of its GDP on healthcare expenditure, which places it
in 26th place out of 31 EU countries [52]. In addition, in 2018, in the Euro Health Consumer
Index report, Poland was ranked 32nd out of 35 countries in Europe, achieving one of the
worst results in all areas, especially in terms of patient rights, information, availability, and
range and scope of operation [23].
The use of Lean Management in the hospital presented in this article allowed for
a significant improvement in the efficiency of the work of medical personnel and for
significant savings in working time that could be spent on patient care. The implemented
solution resulted in a better use of the human capital resources available in the unit, which
is one of the key challenges faced by healthcare sector units in Poland. The deteriorating
staff situation, visible in Figures 1 and 2, necessitates the use of solutions that will eliminate
unnecessary activities performed by medical personnel, so that a limited number of people
can efficiently perform basic tasks related to the provision of health services.
The experiences of other countries show that the use of Lean Management in healthcare
has positive effects, and it is a desired direction of hospital development. The method taken
from the manufacturing sector brings real benefits, for instance, increased efficiency and
savings [53]. Under the conditions of the large financial and staffing problems of hospitals,
the use of Lean Management in Poland seems to be a necessity, while the number of LM
implementations both in the Polish healthcare sector and in units in the eastern part of
Europe is still small [22,30]. Thanks to the research and the results presented in the article,
all organizations interested in Lean Management will be able to follow the example of the
Wroclaw hospital, and thus they will implement Lean Management tools much faster.
The study and the results presented in the article indicate that, even in a large multi-
specialty hospital, where the staff had no knowledge or skills regarding how to use new
methods of management, and also in the conditions of dynamic changes in the environment
caused by the SARS-CoV-2 virus pandemic, it is possible to implement LM solutions. The
study, in the form of a case study, also showed that the use of LM tools results, not only
in the implementation of many improvements that facilitate the work of medical staff
and streamlined the process of providing health services, but also in the improvement of
economic efficiency and productivity. This is an important aspect in terms of science, as it
points to possible practical solutions to organizational and cost-effectiveness problems that
arise in hospitals. The example of this study should help increase interest in the concept of
Lean Management in healthcare system. The operationalization of particular elements of
LM concept implementation and the effectiveness of introduced changes, presented in the
article, can be an inspiration and also a model for carrying out a similar process in other
units.
Int. J. Environ. Res. Public Health 2022, 19, 800 21 of 23

Supplementary Materials: The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/ijerph19020800/s1, File S1. The A3 report. File S2. Pre-project
interview sheet. File S3. Post-project interview sheet. File S4. Waste identified in the project.
Author Contributions: Conceptualization, R.K. and A.Z.-M.; methodology, R.K., A.R.-S. and A.Z.-M.;
software, A.Z.-M.; validation, R.K. and A.R.-S.; formal analysis, R.K. and A.R.-S.; investigation, R.K.,
A.R.-S. and A.Z.-M.; resources, A.Z.-M. and A.R.-S.; data curation, A.Z.-M.; writing—original draft
preparation, A.Z.-M., A.R.-S. and R.K.; writing—review and editing, R.K., A.R.-S., T.C. and M.M.;
visualization, A.Z.-M.; supervision, R.K., T.C. and M.M.; project administration, A.Z.-M.; funding
acquisition, A.Z.-M. and R.K. All authors have read and agreed to the published version of the
manuscript.
Funding: This research was financed by the EU-financed project InterDoktorMen (POWR.03.02.00–
00-1027/16).
Institutional Review Board Statement: The study was conducted according to the guidelines of
the Declaration of Helsinki, and approved by general director of hospital where the research was
conducted.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the
study.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author.
Acknowledgments: Thank you very much to J. Gromkowski Regional Specialist Hospital in Wroclaw,
Poland for allowing us to conduct the survey and the structured interviews to researchers. We would
also like to thank you for the opportunity to participate in the lean project and use in the article the
data collected during the project. Thank you very much to Lean in Healthcare for allowing us use of
the data collected during the project.
Conflicts of Interest: The authors have no relevant affiliations or financial involvement with any
organization or entity with a financial interest in or financial conflict with the subject matter or
materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock
ownership or options, expert testimony, grants or patents received or pending, or royalties.

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