OPSEARCH (2021) 58:610–635

https://doi.org/10.1007/s12597-020-00490-5

APPLICATION ARTICLE

A lean approach to healthcare management using multi

criteria decision making

Ramkrishna S. Bharsakade1 · Padmanava Acharya1 · L. Ganapathy1 ·

Manoj K. Tiwari1

Accepted: 2 November 2020 / Published online: 1 January 2021

© Operational Research Society of India 2021

Abstract
Recent challenges induced by the global pandemic COVID-19 have highlighted the
critical importance of coping with a sudden surge in demand for front line health-
care services. Motivated by the success of lean implementation in manufacturing
systems, this study attempts to apply the lean principles in healthcare delivery envi-
ronments. The lean approach begins with the identification of seven types of wastes
in any production or service system. This study attempts to identify and prioritize
the present in hospitals. The study contributes to the existing body of knowledge
in two ways. First, we identify the various sources contributing to the seven basic
wastes in healthcare delivery. Second, we prioritize the seven types of wastes and
the dimensions contributing to these wastes using a Multi-Criteria Decision Making
(MCDM). This paper used the fuzzy analytical hierarchy process approach, which is
a well-accepted tool in MCDM. The study was conducted at select hospitals located
in and around Pune city in India. We find that waiting, transportation, motion, and
defects are dominant in adopting lean practices among the seven wastes. The find-
ings of this study may guide hospital management in strategic planning in adopting
a lean healthcare process. To our knowledge, this is one of the first studies to extract,
and prioritise lean wastes within the context of the healthcare sector.

Keywords Lean wastes · MCDM · Fuzzy AHP · Healthcare · Waste prioritization

* L. Ganapathy
[email protected]
Ramkrishna S. Bharsakade
[email protected]
Padmanava Acharya
[email protected]
Manoj K. Tiwari
[email protected]
1
NITIE, Mumbai, India

1Vol:.(1234567890)
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1 Introduction

The recent COVID-19 pandemic has exposed the weaknesses associated with
global healthcare management. In a few months, the unpredictable and uncon-
trolled infection spread severely, impacting several sectors worldwide [66]. Sev-
eral countries’ governments were unable to stop or control the spread of COVID-
19 infection despite several measures. Dela in developing the vaccines worsened
the spread day by day, resulting in an unprecedented surge in healthcare demand
due to which the entire healthcare supply chain got distressed, testing its resil-
ience [19, 28]. The pandemic outbreak was a significant source that initiated
several political and economic disruptions [58]. In this turbulent environment,
healthcare needs to be more resilient.
Many countries are putting earnest research efforts in developing the vaccine
for COVID-19 to control the pandemic effectively. Currently, many vaccines are
undergoing a phase of human trials with successful results. In the coming times,
the COVID-19 vaccine may be available. The substantial degree of fear and anxi-
ety induced by the pandemic may result in a striking outburst in demand for the
vaccine requiring the vaccine’s mass production in a shorter time. However, it is
highly challenging to rapidly distribute a vaccine’s mass production in a global
setup. This requires a disruptive supply chain resilience with adequate planning,
adaptability of the disruptions, and proper coordination. A lean thinking approach
can play a crucial role in improving healthcare service quality and operational
efficiency in such circumstances.
The lean manufacturing concept became a global phenomenon in the 1990s
after the hugely popular book by Womack, describing its lineage to the Japa-
nese automotive manufacturer Toyota [29, 77]. In manufacturing operations, it
is well known that a lean system is capable of handling considerable fluctuations
in customer demand. Toyota Motor Company had successfully introduced lean
tools and techniques in its plants and documented its efforts. Since then, these
have been widely accepted and implemented in manufacturing and services [69].
Within the service sector, healthcare is a significant contributor to the economy of
several countries. Healthcare delivery systems consist of several processes neces-
sary to maintain or improve humans’ physical or mental conditions, compromised
due to illness or injury. The processes are termed as curative, aimed to treat the
patients, prevent disease, and rehabilitate for post-treatment care [38]. Healthcare
services vary significantly in terms of quality and accessibility according to pop-
ulation, income, and location [20]. The increased demand for healthcare services
makes it essential to review healthcare processes to improve its performance [5].
Lean philosophy mainly focuses on adding value to the customer by identi-
fying and eliminating various types of waste present in the system [73]. In the
healthcare setting, the ultimate customer is the patient seeking healthcare. In
contrast, other customers include the patient’s relatives, friends, insurance com-
panies, non-government social organizations, among internal customers include
doctors, nurses, and employees. Different customers have different expecta-
tions, requirements, and perceptions of quality [64]. Lean healthcare begins with

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identifying various sources of wastes and their dimensions; however, healthcare

operations are unique in terms of the degree of urgency, degree of complexity,
and the customer’s role in making it arduous task [48]. The next steps prioritize
this waste to eliminate it and achieve a value-added healthcare delivery process.
Prioritization of the wastes leads to determine the relative importance of vari-
ous wastes, which can help filter out the actions to minimize or eliminate these
wastes. Lean healthcare implementation can help to develop efficient, competi-
tive, and patient-centric processes [13].
The term leanness is associated with quantifying the overall development and
influence of lean initiatives in the organization [61]. In the healthcare context, lean-
ness can be defined as improving overall healthcare system performance in terms
of budget and service time. Healthcare systems need to improve their performance
in terms of healthcare costs, utilization of healthcare resources, quality of care, the
efficiency of diagnostic methods, time to treat an increasing number of patients, and
arrangement of healthcare facilities [6]. Leanness can be improved by eliminating
lean wastes present in the system. It is useful to prioritize the improvement oppor-
tunities and enhance the healthcare systems’ leanness to bring about speedy and
noticeable performance improvements [4]. Therefore it is needed to have a struc-
tured framework including all stakeholders to rank different improvement opportu-
nities. As a well-accepted MCDM tool, the fuzzy AHP approach presented in this
paper can be useful in developing such a framework. The primary objectives of this
study are:

1. To recognize various dimensions of seven basic types of waste in the healthcare

processes.
2. To prioritize the identified wastes and their dimensions.
3. To develop a framework of leanness assessment and validate for the healthcare
system.

This paper is organized as follows: Sect. 2 discusses lean implementation in

healthcare. In Sect. 3, we discuss various wastes and their dimensions present in
the healthcare process. Section 4 discusses a fuzzy AHP methodology to prioritize
lean wastes. Section 5 presents the results and discussion, and Sect. 6 presents the
conclusions.

2 Lean implementation in healthcare

The earliest efforts to adopt lean thinking in healthcare were made in the UK in
2001 and the USA in 2002 [50]. Over the last two decades, lean implementation in
healthcare has rapidly increased, particularly in developing countries [13]. Imple-
mentation of Lean in healthcare results in reported tangible benefits like reduction in
procedural errors, waiting time, and cost, as well as intangible benefits like increased
patient satisfaction, improved healthcare delivery quality, and increased patient
motivation [17, 49, 62]. Lean helps to improve efficiency and the effectiveness of the

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healthcare delivery process [50]. Lean implementation in a healthcare organization

can be achieved through continuous improvement, which will help healthcare organ-
izations to improve their quality [21]. Lean implementation in healthcare allows
health organizations to improve their flow efficiency, cost reduction, and quality [14,
30, 31].
The first step to achieving lean implementation is identifying and eliminating
waste to add value to the customers or patients using several lean tools and tech-
niques [73]. Several success stories of lean healthcare applications are available in
the literature [13]. Patient cure or pain relief is the utmost goal of the healthcare
system [75]. All the healthcare processes are directed to achieve this final goal.
Healthcare resources like drugs, pharmaceuticals, medical devices, etc. were used
to accomplish this ultimate goal. Healthcare delivery time and the patients’ comfort
are the critical performance measures of lean implementation in the healthcare sys-
tem [2]. A multi-skilled workforce is needed in healthcare settings to handle various
healthcare processes with the patient’s active involvement in the process. The qual-
ity improvement in healthcare mostly depends on the frontline staff, which needs to
change [46]. and need to increase work satisfaction by providing immediate feed-
back on efforts. The lean implementation focuses on improving operational effec-
tiveness through reduction of steps in the process [30, 31, 41, 70], reduction in staff
walking distance [12], reduced time to resolve error alerts, etc.

3 Waste in lean healthcare

The seven wastes that are identified by Taichi Ohno for the manufacturing domain
are transportation, inventory, motion, waiting, over-processing, overproduction,
and defect. In healthcare, the patient’s care problems and exasperations are termed
as waste [18]. NHS III initially described the significant waste in line with manu-
facturing waste present in healthcare in 2007, adopted for further study by several
researchers [50, 52].
Almost every healthcare process consists of wastes like wasteful motions, pro-
cedural errors, communication errors, etc. It is critical to identify the presence of
these wastes in day to day healthcare delivery [33]. The presence of waste creates
inconsistency in care, unreliable delivery, and interruptions in the healthcare deliv-
ery system, which results in high cost, errors, and lack of motivation in the workers
[30, 31]. Any waste, by definition, is a non-value adding activity, the customer iden-
tifies value as per their desired performance from the product or the service [29, 77].
In this study, we have identified various types of waste for the healthcare process as
follows.

3.1 Waste of transportation

In manufacturing transportation, waste refers to the unnecessary or excessive move-

ment of the product’s delivery process. In several situations, a certain amount of
transport is essential to add value to the product or the service. In hospital setup,

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several patient movements occur from arrival in the hospital to discharge from the
hospital (Eg. movement from department to department, a movement for the lab
test, medication, etc.). In many hospitals, the specific equipment types are located
at designated places, resulting in unnecessary patient movements. In the healthcare
system, unnecessary movements of patients, test samples, medication, and supplies
represent the transportation type of waste [22, 24, 37]. Hospital layout can play a
vital role in reducing these unnecessary movements as many hospital layouts follow
the process type of layout approach.

3.2 Waste of inventory

Any supply in excess than required or unavailable when needed is termed inven-
tory waste. Several material supplies, consumables, equipment, and medicine are
necessary to perform intended work in a hospital. When these materials are kept
in excess, lead to more inventory, high inventories often lead to cash tied up, some
stock may expire, including the supplies and medicines [18]. Holding patients for
a more extended period than required making the facility unavailable for a further
patient can also be termed as an inventory type of waste in the healthcare process
[68]. Healthcare inventory management is vital in managing system quality and
measuring the delivery process’s performance. [32, 67].
As a lean initiative, keeping low inventory levels impaired many manufacturing
organizations [18]. Lean philosophy mainly focuses on the patient’s needs by con-
tinuing the most economical inventory levels. Hospitals need to think of holding a
proper inventory of emergency medicines. Maintaining too much inventory may uti-
lize excess funds, but running out of stock may lead to high expenditure for unnec-
essary movements, ineffective operational procedures, or even harm to the patient
[57]. Improved inventory management can help hospitals to reduce other types of
wastes also.
One of the forms of inventory waste can be in terms of an excessive storage of
patient information. In the present era of information technology, extra information
waste may lead to several consequences like efficiency lost, delays in treatment, or
complexity in healthcare. Whereas insufficient information leads to complexity in
the healthcare process, excessive information waste requires more effort to capture,
store, search, and manage it. Relevant details of data need to be achieved with inves-
tigations in the proper time, to be retrieved when required.

3.3 Waste of motion

While transportation waste focuses on the patients’ unnecessary movements (ana-

logical to products), waste of motion refers to unnecessary movements of the
employees (analogical to workers) in the healthcare system [37]. It is necessary to
make the healthcare process smooth to avoid motion waste [25]. Walking of employ-
ees in the hospital to treat the patients can be seen as the most common example
of motion waste. Although technicians, nurses, and physicians cannot be stationary
in a hospital, one must focus on eliminating unnecessary movements. Movements

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of employees often occur due to improper layout of the hospital. The locations for
various employees are mostly stationary, so to provide services to the patient, they
have to move from their designated areas to the patient locations. Unavailability
of equipment needed at the required place may result in the excess movement of
employees. Motion waste can also lead to a delay in providing service to the patient.
An improved layout can help to reduce motion waste. Since unnecessary movement
does not add any value, it is essential to eliminate motion waste in any healthcare
setup.

3.4 Waste of waiting

Waiting is simply defined as time lapsed by the patient without any activity. Patients
wait in the process due to a delay for the next action to happen. In some cases,
employees need to wait in the process due to an unbalanced workload. In the health-
care system, patients typically wait for a doctor’s diagnosis, admission to hospital or
in-patient ward, or even wait for discharge from the hospital [27]. In many health-
care activities, patient queues are formed due to improper scheduling. Waiting for
the pathological or radiological test is very common in hospitals as most of the diag-
nosis depends on these tests. Long setup time required for some of the healthcare
activities also leads to waiting. Waiting by the patients at the healthcare facility for
medical examinations leads to low utilization of the available resources leading to
an inefficient process [11].

3.5 Waste of overproduction

In a manufacturing system, overproduction refers to producing more products than

is required by the next process, producing earlier than is needed for the following
process, or producing faster than expected [77]. In a healthcare context, it is quite
tough to spot overproduction may occur by requesting unnecessary procedures that
are not adding value, or ordering more medicines than required, just in case [24,
48]. Studies indicate that in many cases, unnecessary pathological tests or radiologi-
cal tests were suggested for investigations [50]. In many cases, unnecessary sched-
uled follow-up was recommended, which can be termed as overproduction waste. In
some cases, some unwanted treatments were suggested, which leads to excess efforts
by patients as well as employees. Overproduction leads to hiding other wastes, as
in the case of a pharmacist requiring more time to process the returned medicines.
Increased frequency of tests can also increase patient transportation within the hos-
pital and increase employee movements in the process.

3.6 Waste of overprocessing

The over-processing form of waste refers to the misuse of processing itself. Over-
processing mainly occurs when doctors want to do something at a higher level of
quality than required by the patient. One example is in terms of requiring duplication
of pathological tests [7]. In many cases, more than one blood test is suggested than

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needed. One of the forms of over-processing is about patient information. It may

occur in the way of taking unnecessary patient history every time. In some cases,
healthcare professionals may repeat the same procedures to show they are taking
more care of the patient, which may not always be required. Often, over-processing
may result from miscommunication within the staff.

3.7 Waste of defects

Defects referred to any activity that was not done as per the required standard. In
healthcare, defects or errors are more severe as it can lead to the injury or even death
of the patients. Defects in healthcare are usually caused due to procedural mistakes,
miscommunications, or wrong diagnoses. In surgical operation, miscommunication
may lead to wrong-side surgery, or negligence may occur as some foreign material
may remain inside the patient body. Healthcare equipment needs to be appropriately
calibrated; otherwise, it may provide wrong results, resulting in the wrong diagnosis.
However, a defect does not always cause harm, and procedural irregularities may
lead to rework [18]. In some cases, the wrong diagnosis may lead to re-admission.
Several errors occur in healthcare due to incorrect procedures, which may delay the
patients’ curing. Defect leads to wastage of time as well as resources, which also
leads to patient dissatisfaction.
Based on the above discussion, the different types of waste identified in health-
care dimensions are summarized in (Table 1).

4 Overview of analytical hierarchy process and fuzzy analytical

hierarchy process

Analytical Hierarchy Process (AHP) is one of the most popular techniques used to
solve complex multi-criteria decision-making problems to provide an efficient solu-
tion involving several criteria for making the decision [60]. Saaty initially proposed
AHP [55, 56]. AHP considers a hierarchical system of objectives, attributes, and
alternatives to solve decision-making problems. AHP is based on pairwise com-
parisons among the various attributes based on the expert’s judgment to prioritize
these attributes. In this process, the pairwise comparison is based on an understand-
ing representing one factor’s dominance over the other. AHP is suitable to handle
several decision situations, including idiosyncratic judgments by multiple decision-
makers. AHP also measures consistency in decision making (R. K. [63, 71]. In this
process, experts’ opinions are used to decompose a problem into a hierarchy [16,
65]. AHP is a beneficial technique to evaluate the influence of the criteria on the
objective or the goal of the system under consideration [26].
In the present study, the goal is to identify and prioritize the healthcare sys-
tem’s waste to evaluate its leanness. The approach in the present study is to pro-
vide a more responsive and patient-centric healthcare delivery process. While
Analytical Hierarchy Process (AHP) method has been extensively used to solve
decision-making problems, the conventional AHP method is not precise and is

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 Table 1  Lean waste with healthcare dimensions
Waste Waste dimensions Description

Transportation Patient movement Unnecessary movement of patient, material, and specimens through the system
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Movement for equipment

Improper Layout
Inventory Excessive material stock Improper inventory management systems non-availability of material when needed while outdated stocks
Excessive data storage are present
Emergency medicine unavailability
Motion Staff Movement Unnecessary staff movement for providing services, equipment or due to improper location in the system
Equipment unavailability
Staff Location
Waiting Diagnosis The patient may have to wait for diagnosis due to delay in test reports, to get admitted as well as to
Admission discharge
Discharge
Overproduction Lab Tests Doing more than what is needed to cure the patient in terms of pathological, radiological tests, follow-
Scheduled Follow-up ups, or unnecessary treatment
Unwanted Treatment
Over-processing Patients information Performing nonvalue added work not aligned with the patient’s need like taking unnecessary patient his-
Test Duplication tory, duplication of the pathological or radiological test, duplication of processes.
Process duplication
Defects Re-admission Any errors occur, resulting in unnecessary delay in curing the patient or re-admission due to wrong side
Equipment errors surgery; foreign material remains in the body. Improper diagnosis due to equipment errors. Following
Procedural errors the incorrect procedure for the diagnosis
617

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not capable of handling the uncertainty and vagueness involved in linguistic judg-
ments [9, 40, 51]. The fuzzy AHP approach is based on expressing an expert’s
subjective judgments using fuzzy triangular numbers [10]. Fuzzy AHP can trans-
form qualitative judgments with vagueness into quantitative data using a system-
atic decision-making approach [34, 54, 74].
The fuzzy AHP methodology is widely acceptable by the researchers, particu-
larly in the prioritization issues. In recent times, [36] use this methodology to
prioritize the Halal food supply chain’s risk elements. In this study, the authors
identified the risk elements associated with Halal supply chains using system-
atic literature methodology. Authors then use expert professionals to consolidate
risk elements and prioritize them using the fuzzy AHP approach. Furthermore,
they emphasized a holistic approach that will help to integrate internal processes
and outsourcing activities to overcome the risk associated with Halal food SC.
[74] identified Indian pharmaceutical supply chain (PSC) barriers by reviewing
the literature and expert’s opinions. In this paper, the authors used a fuzzy AHP
approach to overcome the expert’s decision-making process’s uncertainty. In this
study, the authors scanned 26 barriers in six significant criteria and found that
market-related barriers are significant in Indian PSC. This study can help the drug
industry by mitigating the obstacles to sustainability and improved quality manu-
facturing. [3] uses a fuzzy AHP approach for the measurement of property level
flood resilience. In this work, the significant flood resilient attributes and their
sub-attributes were identified by reviewing the literature.The authors then use
FAHP methodology to develop a new model ‘Composite Flood Resilient Index’
based on the weightage associated with attributes and the sub-attributes. This
study developed a quantitative measurement approach for clear and unambiguous
flood resilience measurement using an evidence-based method in individual prop-
erty. [23] discussed the technique for ‘Product Service System (PSSs)’ by analyz-
ing customer needs for value offerings enhancement. The authors initially devel-
oped the ‘Quality Function Deployment’ model for PSSs using the Kano model
to screen customers’ requirements and transform into ‘Receiver State Parameters
(RSPs).’ Further, the fuzzy AHP methodology is used to assess these parameters
and their intrinsic uncertainty. Finally, they have validated the proposed proce-
dure by implementing it in medical device sector in product oriented regulated
market.
The wastes present in the healthcare delivery process are often intangible. Most
of the healthcare wastes lead to uncertain perceptions among the patients. The cus-
tomer involved in the health care process may be different at different stages, like a
patient’s family waiting outside the operation theatre, wanting to know only about
the patient situation. These different customers might define a waste differently,
leading to ambiguity and diversity in the meaning of waste. The description of the
value of the healthcare process is almost always linguistic and vague. The assess-
ment of the attribute associated with waste present in the system is still subjective
and imprecise. This leads to making healthcare management more complex, multi-
faceted with the involvement of several stakeholders [42]. Therefore, conventional
AHP is not adequate to prioritize the waste explicitly.

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The ambiguity associated with human thought can be tackled using the fuzzy set
theory, initially proposed by Zadeh [78]. Fuzzy set theory can effectively deal with
imprecise linguistics terms used in human subjective judgment and effectively deal
with conflicting criteria [9, 43]. The fuzzy AHP approach uses fuzzy sets for pair-
wise comparison, which may be more suitable to model the vagueness in human
preference [47]; Kwong and Bai [40].
The fuzzy AHP approach typically uses the triangular number technique to rep-
resent the vagueness associates with linguistic terms [45]. The fuzzy set theory uses
a fuzzy membership function that assigns membership grade to each object in the
range between 0 and 1. In literature, one finds several ways of constructing the fuzzy
membership functions. In the present study, we have used a triangular membership
function as it is widely acceptable and easy to apply [59]. This set used general
terms like large, medium, and small to capture the numerical value. A triangular
fuzzy number can be expressed as T̃ = (l, m, u) where l is a lower limit, u is an upper
limit of the T̃ support, and m is the mid-value [15, 43]. The membership function is
defined as shown in Eq. (1).

(1)

4.1 Computations for fuzzy AHP process

The fuzzy AHP approach uses the following steps in the computational proce-
dure for calculating the priority of various waste present in the healthcare delivery
process.

Step 1 Development of problem hierarchy

Step 2 Construction of Fuzzy comparison matrix
Step 3 Determining the weights for the criteria involved
Step 4 Calculation of consistency of the judgments
Step 5 Development of final priority framework

4.1.1 Development of problem hierarchy

This step aims to identify and prioritize healthcare wastes to assess the healthcare
delivery process’s leanness, as shown in (Fig. 1). The highest level of this hierarchy
in fuzzy AHP represents the goal. The goal of the present study is to assess leanness
in the healthcare delivery system kept at Level 1. The seven wastes present in the
healthcare system are considered the criteria representing a level 2 in the hierar-
chy. Each waste is then subdivided as per its dimensions representing sub-criteria at
Level 3.

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Fig. 1  Hierarchy for fuzzy AHP

4.1.2 Construction of fuzzy comparison matrix

A questionnaire was designed to develop a pairwise comparison matrix. The ques-

tionnaire is in the form of a conventional AHP approach consisting of a nine-point
rating suggested by [55, 56]. The experts were asked to rank the relative importance
of each criterion as well as sub-criteria. After collecting the data, crisp numbers
are transformed into fuzzy numbers [44]. The linguistic terms associated with the
respective fuzzy number are as shown in (Table 2).
The fuzzy pairwise comparison matrix is as shown in (Table 3).

4.1.3 Determination the weights for the criteria involved

In this study, we have used a geometric mean method to compute each criterion’s
weight, as suggested by [53, 72].
� We calculate
� the fuzzy geometric mean ( gi) for all
1∕n
∏
n
the criteria using formula gi = Aij and the fuzzy weights (wi) for each crite-
j=1
rion and sub-criterion using equation were calculated wi= ∑ngi gi . Where gi represents
i=1
the geometric mean for i­th criterion., Aij is the pairwise comparison value of crite-
rion i to criterion j. wi is the weight for ith criterion. The fuzzy weights are then de-
fuzzified to get the normalized weights. Several methods are available for

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Table 2  Linguistic terms used for pairwise comparison

Crisp scale Linguistic variables Triangular fuzzy Triangular
scale fuzzy reciprocal
scale

9 Extremely strong important (8,9,9) (1/9,1/9,1/8)

8 Intermediate (7,8,9) (1/9,1/8,1/7)
7 Very strong important (6,7,8) (1/8,1/7,1/6)
6 Intermediate (5,6,7) (1/7,1/6,1/5)
5 Strong important (4,5,6) (1/6,1/5,1/4)
4 Intermediate (3,4,5) (1/5,1/4,1/3)
3 Moderately important (2,3,4) (1/4,1/3,1/2)
2 Intermediate (1,2,3) (1/3,1/2,1/1)
1 Equally important (1,1,1) (1/1,1/1,1/1)

Table 3  Fuzzy pairwise comparison matrix for the main criteria

C1 C2 C3 C4 C5 C6 C7

C1 (1,1,1) (2,3,4) (1,2,3) (1/4,1/3,1/2) (3,4,5) (2,3,4) (2,3,4)

C2 (1/4,1/3,1/2) (1,1,1) (1/4,1/3,1/2) (1/5,1/4,1/3) (1,2,3) (1/3,1/2,1/1) (1/4,1/3,1/2)
C3 (1/3,1/2,1/1) (2,3,4) (1,1,1) (1/4,1/3,1/2) (2,3,4) (2,3,4) (1,2,3)
C4 (2,3,4) (3,4,5) (2,3,4) (1,1,1) (4,5,6) (3,4,5) (2,3,4)
C5 (1/5,1/4,1/3) (1/3,1/2,1/1) (1/4,1/3,1/2) (1/6,1/5,1/4) (1,1,1) (1/3,1/2,1/1) (1/4,1/3,1/2)
C6 (1/4,1/3,1/2) (1,2,3) (1/4,1/3,1/2) (1/5,1/4,1/3) (1,2,3) (1,1,1) (1/3,1/2,1/1)
C7 (1/4,1/3,1/2) (2,3,4) (1/3,1/2,1/1) (1/4,1/3,1/2) (2,3,4) (1,2,3) (1,1,1)

defuzzification. In the present study, we have used the center of area method for
defuzzification of the fuzzy weights due to its easiness and efficiency [47]. The non-
fuzzy crisp weight ­(Wi) can be calculated by taking the average of lwi, mwi and uwi
[8]. Further, ­Wi represents the non-fuzzy number; it needs to be normalized to get
normalized weight (Ni) by dividing each weight by the sum of total non-fuzzy
weights [64]. The fuzzy and the normalized weights for each main criterion are
shown in (Tables 4, 5, 6, 7, 8, 9, 10 and 11).

4.1.4 Calculation of Consistency of the Judgments

Once the pairwise comparison is complete, it is essential to check the consistency of

these comparisons. The consistency of fuzzy judgment matrices is tested by defuzzi-
fication of the fuzzy pairwise comparison matrix number of consistency models are
available in the literature [76]. In the present study, we used a graded mean integra-
tion approach to construct a de-fuzzified matrix. Defuzzification of each TFN of the
matrix is carried out using the Eq. (6) [39].

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Table 4  Weights calculations Criteria Fuzzy weight Non-fuzzy

for the main criteria concerning weights
the overall goal
L m u Wi NI

Transportation (C1) 0.1104 0.2100 0.3711 0.2305 0.2037

Inventory (C2) 0.0320 0.0584 0.1179 0.0694 0.0614
Motion (C3) 0.0806 0.1561 0.3045 0.1804 0.1594
Waiting (C4) 0.1919 0.3415 0.5878 0.3737 0.3302
Overproduction (C5) 0.0248 0.0445 0.0967 0.0553 0.0489
Over processing (C6) 0.0391 0.0755 0.1522 0.0889 0.0786
Defects (C7) 0.0599 0.1140 0.2262 0.1334 0.1179

Dfi = ((li + 6mi + ui)∕6) (2)

The consistency index (CI) for the de-fuzzified matrix of all criteria, as well as the
sub-criterion, is calculated using Eq. (7) developed by Saaty (CI = 𝜆max−n n−1
) [55, 56].
Where λmax is the highest eigenvalue of the pairwise comparison matrix, and n repre-
sents the pairwise comparison matrix’s order.
The consistency ratio is then calculated using the formula CR = CI/RI, Where RI
represents the random index. The average RI values are generated for the matrix of
order ten and a sample size of 500 by Saaty, as shown in (Table 12). If the CR is less
than 0.10, then it is believed that the derived judgments are consistent, and the weights
assigned to the criteria are considered to be reliable.
The defuzzification of the fuzzy pairwise comparison matrix for the main criterion
and sub-criterion is shown below (Table 13).
To calculate the Consistency index and consistency ration, we use the following
method

(1) Calculate the relative normalized de-fuzzified weight (wj) of each criterion

a. by calculating the geometric mean of the i-th row, and

b. normalizing the geometric means of rows in the comparison matrix.

(2) Calculate matrices A3 and A4 such that A3 = A1 * A2 and A4 = A3/A2, where

A2 = [w1, w2, ….., ­wj]T. A3 and A4 matrix are shown below,

⎡ 1.57729 ⎤ ⎡ 7.57019 ⎤
⎢ 0.44586 ⎥ ⎢ 7.48588 ⎥
⎢ 1.16609 ⎥ ⎢ 7.42103 ⎥
⎢ ⎥ ⎢ ⎥
A3 = ⎢ 2.554 ⎥ A4 = ⎢ 7.57762 ⎥
⎢ 0.33719 ⎥ ⎢ 7.3328 ⎥
⎢ 0.56371 ⎥ ⎢ 7.36333 ⎥
⎢ ⎥ ⎢ ⎥
⎣ 0.86048 ⎦ ⎣ 7.45869 ⎦

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Table 5  Fuzzy pairwise comparison matrix and weights for transportation

Patient movement Movement for equipment Improper layout Fuzzy Weights Non-fuzzy weights
l m u Wi Ni

Patient movement (1,1,1) (2,3,4) (2,3,4) 0.3561 0.5937 0.9499 0.6332 0.5799
Movement for equipment (1/4,1/3,1/2) (1,1,1) (1,2,3) 0.1413 0.2493 0.4315 0.2740 0.2510
Improper layout (1/4,1/3,1/2) (1/3,1/2,1/1) (1,1,1) 0.0976 0.1570 0.2992 0.1846 0.1691
623

13
 624

13
Table 6  Fuzzy pairwise comparison matrix and weights for inventory
Excessive material stock Excessive data Emergency medicine Fuzzy weights Non-fuzzy weights
storage unavailability
l m u Wi Ni

Excessive material stock (1,1,1) (2,3,4) (1/4,1/3,1/2) 0.1754 0.2683 0.4229 0.2889 0.2728
Excessive data storage (1/4,1/3,1/2) (1,1,1) (1/5,1/4,1/3) 0.0814 0.1172 0.1847 0.1278 0.1207
Emergency medicine unavailability (2,3,4) (3,4,5) (1,1,1) 0.4016 0.6145 0.9111 0.6424 0.6066
OPSEARCH (2021) 58:610–635
 OPSEARCH (2021) 58:610–635

Table 7  Fuzzy pairwise comparison matrix and weights for motion

Staff movement Equipment unavailability Staff location Fuzzy weights Non- fuzzy weights
l m u Wi Ni

Staff movement (1,1,1) (1/4,1/3,1/2) (3,4,5) 0.1942 0.2796 0.4201 0.2980 0.2848
Equipment unavailability (2,3,4) (1,1,1) (4,5,6) 0.4275 0.6268 0.8929 0.6491 0.6204
Staff location (1/5,1/4,1/3) (1/6,1/5/1/4) (1,1,1) 0.0688 0.0936 0.1352 0.0992 0.0948
625

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626 OPSEARCH (2021) 58:610–635

Table 8  Fuzzy pairwise comparison matrix and weights for waiting

Diagnosis Admission Discharge Fuzzy weights Non-fuzzy
weights
l m u Wi Ni

Diagnosis (1,1,1) (2,3,4) (3,4,5) 0.4016 0.6144 0.9111 0.6424 0.6066

Admission (1/4,1/3,1/2) (1,1,1) (2,3,4) 0.1754 0.2684 0.4229 0.2889 0.2728
Discharge (1/5,1/4,1/3) (1/4,1/3,1/2) (1,1,1) 0.0814 0.1172 0.1847 0.1278 0.1207

Table 9  Fuzzy pairwise comparison matrix and weights for overproduction

Lab tests Scheduled Unwanted Fuzzy weights Non-fuzzy
follow-up treatment weights
l m u Wi Ni

Lab tests (1,1,1) (2,3,4) (2,3,4) 0.3561 0.5937 0.9499 0.6332 0.5799
Scheduled (1/4,1/3,1/2) (1,1,1) (1,2,3) 0.1413 0.2493 0.4315 0.2740 0.2510
follow-up
Unwanted treat- (1/4,1/3,1/2) (1/3,1/2,1/1) (1,1,1) 0.0976 0.1570 0.2992 0.1846 0.1691
ment

Table 10  Fuzzy pairwise comparison matrix and weights for over-processing

Patients Test duplica- Process dupli- Fuzzy weights Non-fuzzy
informa- tion cation weights
tion
l m u Wi Ni

Patients infor- (1,1,1) (1/6,1/5,1/4) (1/5,1/4,1/3) 0.0688 0.0936 0.1352 0.0992 0.0948
mation
Test duplica- (4,5,6) (1,1,1) (2,3,4) 0.4275 0.6267 0.8929 0.6490 0.6203
tion
Process dupli- (3,4,5) (1/4,1/3,1/2) (1,1,1) 0.1942 0.2797 0.4201 0.2980 0.2848
cation

Calculate (λmax) maximum eigenvalue. The λmax is the average of the A4 matrix.

𝜆max = 7.4585
(3) Calculate the consistency using the formula CI = [(λ max-n)/n-1], where n is the
order of the matrix. The consistency index for the present problem is as follows,
Consistency Index = 0.07641

(4) Calculate consistency ratio using the formula CR = (CI/RI). The consistency
ratio for the present problem is as follows,

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Table 11  Fuzzy pairwise comparison matrix and weights for defects

Patients information Test duplication Process duplication Fuzzy weights Non-fuzzy weights
l m u Wi Ni

Patients information (1,1,1) (3,4,5) ((3,4,5) 0.4505 0.6608 0.9523 0.6879 0.6512
Test duplication (1/5,1/4,1/3) (1,1,1) (1,2,3) 0.1267 0.2081 0.3257 0.2202 0.2084
Process duplication (1/5,1/4,1/3) (1,2,3) (1,1,1) 0.0878 0.1311 0.2258 0.1482 0.1404
627

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628 OPSEARCH (2021) 58:610–635

Table 12  Random index (RI) N 1 2 3 4 5 6 7 8 9 10

based on matrix size [56]
RI 0 0 0.52 0.89 1.11 1.25 1.35 1.40 1.45 1.49

Table 13  Defuzzification of fuzzy AHP matrix

C-1 C-2 C-3 C-4 C-5 C-6 C-7 Geometric mean Defuzzied weights

C-1 1 3 2 0.345 4 3 3 1.85126 0.20836

C-2 0.345 1 0.345 0.255 2 0.555 0.345 0.52920 0.05956
C-3 0.555 3 1 0.345 3 3 2 1.39614 0.15713
C-4 3 4 3 1 5 4 3 2.99468 0.33704
C-5 0.255 0.555 0.345 0.2033 1 0.555 0.345 0.40857 0.04598
C-6 0.345 2 0.345 0.255 2 1 0.555 0.68022 0.07656
C-7 0.345 3 0.555 0.345 3 2 1 1.02505 0.11537

Table 14  Consistency index Waste category Consistency index Consistency ratio

and consistency ratio for each
sub-criterion Transportation 0.05305 0.09147
Inventory 0.04996 0.08613
Motion 0.05336 0.09201
Waiting 0.04996 0.08613
Overproduction 0.05305 0.09147
Over-processing 0.05336 0.09201
Defects 0.04803 0.08281

Consistency Ratio = 0.0579

The consistency index and consistency ratio for the sub-criterion are also calculated,
which is also less than 0.10. This indicates that the subjective judgments made in the
study are consistent. The consistency index and consistency ratio for each sub-criterion
are shown in (Table 14).

4.1.5 Development of final priority framework

The final priority framework for leanness in healthcare by prioritizing various waste
present in the healthcare delivery process is developed, as shown in (Fig. 2).

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OPSEARCH (2021) 58:610–635 629

Fig. 2  Leanness priority framework

5 Results and discussion

The main focus of lean implementation in healthcare is on waste minimization pre-

sent in the healthcare delivery process. In the present study, we have identified the
seven wastes (criteria) of lean thinking in the healthcare process and the healthcare
dimensions (sub-criteria) for each waste. Fuzzy Analytical Hierarchical Process
(FAHP) methodology provides the ranking of 7 major healthcare wastes and 21 dif-
ferent healthcare wastes dimensions, which help us to assess the healthcare process’s
leanness. The output obtained by the fuzzy AHP approach is used to rank various
dimensions of healthcare waste, as shown in (Table 15) and (Table 16)

Table 15  Priority of waste Priority Waste Weight

for leanness in the healthcare
delivery system 1 Waiting 0.3302
2 Transportation 0.2037
3 Motion 0.1594
4 Defects 0.1179
5 Over-processing 0.0786
6 Inventory 0.0614
7 Overproduction 0.0489

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Table 16  Priority of sub-criteria for leanness in the healthcare delivery system

Rank Waste dimensions Weight Waste category

1 Waiting for diagnosis 0.2003 Waiting

2 Patient movement 0.1181 Transportation
3 Equipment unavailability 0.0989 Motion
4 Waiting for admission 0.0901 Waiting
5 Re-admission 0.0768 Defects
6 Movement for equipment 0.0511 Transportation
7 Test duplication 0.0487 Overprocessing
8 Staff movement 0.0454 Motion
9 Waiting for discharge 0.0398 Waiting
10 Emergency medicine unavailability 0.0372 Inventory
11 Improper layout 0.0344 Transportation
12 Lab tests 0.0284 Overproduction
13 Equipment errors 0.0246 Defects
14 Process duplication 0.0224 Over-processing
15 Excessive material stock 0.0167 Inventory
16 Procedural errors 0.0165 Defects
17 Staff location 0.0151 Motion
18 Scheduled follow-up 0.0123 Overproduction
19 Unwanted treatment 0.0083 Overproduction
20 Patients information 0.0075 Over-processing
21 Excessive data storage 0.0074 Inventory

The four significant criteria are waiting, transportation, motion, and defects
receiving high importance in the present study. These are mainly related to the
operational aspects of the healthcare process. This means that hospitals need to
emphasize the highest priority waste, that is, waste due to waiting. Waiting by
patients at various stages is a major concern for leanness as it directly impacts
patient satisfaction and is most frequently occurring in the hospitals. [1, 67]. Fur-
ther, waiting for the resources in the healthcare systems plays a vital role as it
may reduce service quality and system efficiency [35].
Transportation waste has been given second priority. The unnecessary move-
ment of the patient within the hospital to get treated is disconsolate the patients
[37]. Most of the supporting facilities like pathology lab, radiology equipment,
pharmacy are located at the designated places resulting in more patient move-
ment. A centralized store location also creates unnecessary waste due to the una-
vailability of equipment when needed.
The wastes due to motion and defects are given the third and the fourth ranks,
respectively. Unnecessary staff movement in search of the equipment or from
department to department may, or the procedural errors, delay the patient treat-
ment resulting in reduced system efficiency [37, 48]. Minimization of these
types of waste mainly concerns quality practices. Hospitals also need to focus on
unnecessary movements of their staff. Additionally, this can also help properly

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utilize the human resource in the hospitals, which is also termed the eighth waste
in lean thinking.
The over-processing, inventory and overproduction types of wastes are given the
least importance. This shows that these criteria are not so significant in develop-
ing patient-centric lean healthcare as these factors do not directly affect the health-
care delivery process’s quality. However, some of the dimensions from these fac-
tors influence the overall leanness of the healthcare system. For example, the factors
like test duplication and unavailability of emergency medicines impact the leanness
significantly.

6 Conclusions

The healthcare sector has shown exceptional growth in the last three decades, with
increasing per capita healthcare expenditure. Recent pandemic has demonstrated
that healthcare facilities throughout the world can be overwhelmed by a sudden
upsurge in demand for healthcare. Healthcare organizations need to adopt a lean
philosophy to seek high quality and cost-effective treatments to achieve operational
excellence and competitive advantage.
We have proposed the prioritization of 7 major healthcare wastes and 21 different
dimensions of healthcare wastes to assess the healthcare process’s leanness. This can
be useful to initiate a structured approach for lean healthcare implementation. Our
study shows that four of the seven wastes, namely, waiting, transportation, motion,
and defects, play a more dominant role in evaluating healthcare systems’ leanness.
These four wastes contribute almost 80% to the leanness of the system. Among the
seven wastes, waiting is found to be the most prevalent; waiting for a diagnosis is
more critical in the healthcare system. The remaining three wastes, over-processing,
inventory, and overproduction, receive the least importance in assessing the lean-
ness. This indicates that the healthcare people are more conscious for the healthcare
quality. Some of the sub-criteria, like test duplication and emergency medicine una-
vailability, play an essential role in assessing leanness. These wastes from the over-
processing and inventory category receive high importance in the overall ranking,
which is more important from the quality perspective in delivering patient-centric
healthcare. The study offers some managerial implications that may assist healthcare
professionals in hospitals to initiate measures to improve their healthcare delivery
system’s leanness. This can help monitor and regulate the lean healthcare imple-
mentation process to improve the delivery to patients.
For completeness, we now point out some of the limitations of this study. This
study has focused on waste prioritization considering complete hospitals as units.
However, the different departments within the hospital may give different results.
Further, this study is carried out only in Indian hospitals, located at and near Pune.
A comparison of the leanness of Indian hospitals with those in other countries may
provide interesting results. The comparison of observed improvements with the pri-
oritization provided by the fuzzy AHP framework presented in this study can be
exciting for future research.

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632 OPSEARCH (2021) 58:610–635

Authors contribution The major work of field study, including data collection and analysis, was carried
out by the research student, Mr. Ramkrishna S. Bharsakade. As faculty guides, the overall direction at
different stages of research, including data collection and analysis as well as in writing the document, was
provided by the faculty guides, Prof. L. Ganapathy and Prof. Padmanava Acharya, and Director, Prof.
Manoj K. Tiwari. All authors have read and approved the final manuscript.

Funding All expenses for the research were borne by the research scholar. There was no funding source
for the research in the design of the study and collection, analysis, and interpretation of data and in writ-
ing the manuscript.

Availability of data and material Data sharing not applicable to this article as no datasets were generated
or analyzed during the current study.

Compliance with ethical standards

Conflict of interest The authors declare that they have no competing interests.

Consent to participate No animals or human tissue or other data used in the study

Consent for publication The author’s consent to publish will be provided upon acceptance. Third-party
consent is Not Applicable. No images or personal data is reported in the study.

Ethics approval Not Applicable.

Informed consent No animals or human tissue or other data used in the study.

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