Nursing
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Item The contribution of a person-centred model of Lean Six Sigma to the development of a healthful culture of health systems improvement(Frontiers Media, 2025-08-18) Teeling, Sean Paul; Baldie, Deborah; Daly, Ailish; Keown, Anne Marie; Igoe, Aileen; Dowling, Ciara; McNamara, MartinBackground: A failure to distinguish between person-centredness, person-centred care, and person-centred cultures can result in improvement initiatives focusing solely on improvement initiative metrics and outcomes, excluding the authentic experiences of patients and staff. Building on the foundational work of Dewing and McCormack, we have designed, piloted, and implemented the Person-centred Lean Six Sigma (PCLSS) model in public and private acute and community healthcare settings across Ireland. This model uses Lean Six Sigma, a widely adopted improvement methodology, through a person-centred lens with which improvement practitioners and healthcare staff can inspect their Lean Six Sigma practice and critically evaluate whether, to what extent, and how it is synergistic with person-centred approaches. Aim: This paper explores the deployment of the PCLSS model across four clinical study sites and examines its alignment with McCance and McCormack's conceptual work on healthful cultures, evaluating its contribution to creating cultures that support sustainable improvement, compassion, and respect. Methods: The PCLSS model was embedded within a university-accredited education programme for healthcare staff. The model was applied across four distinct healthcare settings in Ireland: a public acute teaching hospital, a private full-service acute hospital, an integrated ophthalmology service bridging hospital and community care, and a public rehabilitation hospital. A case study methodology was used to examine implementation and impact. Results: Across all four sites, the PCLSS model facilitated improvements in operational efficiency, staff and patient engagement, interprofessional collaboration, and reflective practice. The model supported leadership at all levels, fostered sustainable change, and successfully mapped onto key domains associated with healthful cultures, as articulated in the work of McCance and McCormack. Conclusion: The PCLSS model represents a sustainable, values-based approach to improvement that aligns operational excellence with person-centred principles. Its application contributes meaningfully to the development of healthful cultures in healthcare organisations.Item The contribution of leaders' and managers' attributes, values, principles, and behaviours to the sustainable implementation of Lean in healthcare: A realist review protocol(Health Research Board, 2024-08-13) Keown, Anne Marie; Teeling, Seán Paul; McNamara, MartinBackground Global healthcare faces challenges such as rising costs, budget constraints, aging populations, chronic diseases, and increasing patient expectations. Healthcare organisations are deploying continuous improvement methodologies to address these challenges. Lean, derived from the Toyota Production System, focuses on eliminating non-value-adding activity and enhancing efficiency, making it a prominent quality improvement approach in healthcare. Effective implementation of Lean requires robust leadership to sustain improvements and foster a culture of continuous improvement. However, the attributes, values, principles, and behaviours of effective Lean leaders in healthcare remain underexplored. Methods This realist review protocol details methods to research how leaders' and managers' attributes, values, principles, and behaviours contribute to the sustainable implementation of Lean in healthcare. Following the RAMESES guidelines, a five-stage structured methodology will be used: defining the scope of the review and developing initial theories, developing the search strategy, reviewing primary studies and extracting data, synthesising evidence and developing conclusions, refining theory iteratively, and disseminating findings. An Expert Panel and reference groups of healthcare managers and leaders will refine candidate programme theories (CPTs) into initial programme theories (IPTs), guiding detailed evidence searches and data extraction. Conclusion This realist review will deepen our understanding of the specific mechanisms by which leadership impacts Lean implementation outcomes in the context of acute hospitals. By exploring how leadership attributes, values, principles and behaviours shape outcomes for diverse stakeholders, the review aims to provide critical insights into the dynamics driving the success of Lean in healthcare. The findings will inform policy and practice, enhancing leadership strategies to improve patient and staff experiences, patient outcomes, and organizational performance.Item A Realist Review Protocol into the Contexts and Mechanisms That Enable the Inclusion of Environmental Sustainability Outcomes in the Design of Lean Healthcare Improvement Interventions(MDPI AG, 2024-07-02) Mead, Elaine Shelford; Teeling, Sean Paul; McNamara, MartinHealthcare makes a significant contribution to the social, economic and environmental benefits of communities. It is correspondingly a significant employer and consumer of both energy and consumables, often at high costs. Lean, a quality improvement methodology focuses on the elimination of non-value add (NVA) activities (steps that do not add value from the perspective of the customer) to improve the flow of people, information or goods. Increasingly, Lean thinking is evolving from its initial focus on eliminating NVA to a more holistic approach that encompasses sustainability. However, little work has been undertaken intentionally, including environmental sustainability outcomes in Lean healthcare interventions. Realist review methodology facilitates an understanding of the extent to which an intervention works, for whom, in what context, why and how, and has proven useful in research relating to Lean interventions in healthcare settings. This protocol provides details for a realist review that will enable an understanding of the specific contexts in which certain mechanisms are activated that enable the inclusion of environmental sustainability outcomes in the design of Lean healthcare improvement interventions.Item Using Lean Six Sigma in a Private Hospital Setting to Reduce Trauma Orthopedic Patient Waiting Times and Associated Administrative and Consultant Caseload(MDPI AG, 2023-09-26) Pierce, Anthony; Teeling, Sean Paul; McNamara, Martin; O’Daly, Brendan; Daly, AilishIn Ireland, the extent of outpatient orthopedic waiting lists results in long waiting times for patients, delays in processing referrals, and variation in the consultant caseload. At the study site, the Define, Measure, Analyze, Improve, and Control (DMAIC) Lean Six Sigma framework was applied to evaluate sources of Non-Value-Added (NVA) activity in the process of registering and triaging patients referred to the trauma orthopedic service from the Emergency Department. A pre- (October–December 2021)/post- (April–August 2022) intervention design was employed, utilizing Gemba, Process Mapping, and the TIMWOODS tool. Embracing a person-centered approach, stakeholder Voice of Customer feedback was sought at each stage of the improvement process. Following data collection and analysis, a co-designed pilot intervention (March 2022) was implemented, consisting of a new triage template, dedicated trauma clinic slots, a consultant triage roster, and a new option to refer directly to physiotherapy services. This resulted in the total wait time of patients for review being reduced by 34%, a 51% reduction in the process steps required for registering, and an increase in orthopedic consultant clinic capacity of 22%. The reduction in NVA activities in the process and the increase in management options for triaging consultants have delivered a more efficient trauma and orthopedic pathway.Item The Utilization of Lean Six Sigma Methodologies in Enhancing Surgical Pathways and Surgical Rehabilitation(MDPI AG, 2023-06-08) Teeling, Sean Paul; McGuirk, Michelle; McNamara, Martin; McGroarty, Marie; Igoe, AileenThe authors offer their perspective on the application of Lean Six Sigma methodology to surgical pathways, from referral to post-operative rehabilitation, and how it has resulted in sustainable improvements in patient outcomes, and patient and staff satisfaction. The origin of Lean Six Sigma is described before considering its application to improving scheduled surgical care. The concept of ‘flow’, and its relevance to pre-, intra-, and post-operative care, is discussed as well as the role of Lean Six Sigma in supporting innovation and in promoting an organizational culture that promotes openness to new ideas. The elements of the methodology that render it especially suitable for the redesign of surgical pathways include eliciting the customer voice, co-design, enabling system awareness and inculcating a continuous improvement mindset. The necessary conditions for the successful implementation of Lean Six Sigma initiatives include managerial support, high-quality education and training, and alignment with organizational strategy. Future directions for practice and research are discussed before presenting a key finding from the literature and from the authors’ collective experience: Lean Six Sigma initiatives will not lead to sustainable improvements where the key elements of the methodology are not recognized and enacted, and where the necessary conditions are absent.Item Making a Sustainable Difference to People, Processes and Systems: Whole-Systems Approaches to Process Improvement in Health Systems(MDPI AG, 2023-03-23) McNamara, Martin; Ward, Marie; Teeling, Sean PaulThe eighteen papers in this Special Issue, ‘Whole-Systems Approaches to Process Improvement in Health Systems’, address an enduring challenge in healthcare: to improve efficiency with existing or reduced resources, while maintaining safe and effective care [...]Item Using a combined Lean and person-centred approach to support the resumption of routine hospital activity following the first wave of COVID-19(MDPI, 2022-02-27) Daly, Ailish; Teeling, Sean Paul; Garvey, Suzanne; Ward, Marie; McNamara, MartinThe unexpected advent of the COVID-19 pandemic led to a sudden disruption of routine medical care, with a subsequent reorganization of hospital structures and of care. Case studies are becoming available in the literature referring to the logistical difficulties involved in a hospital resuming normal activity following the first COVID-19 lockdown period. This paper details the experience of a study site, a private hospital in Dublin, Ireland, in the redesign of service delivery in compliance with new COVID-19 prevention regulations to facilitate the resumption of routine hospital activity following the first wave of COVID-19. The aim was to resume routine activity and optimize patient activity, whilst remaining compliant with COVID-19 guidelines. We employed a pre-/post-intervention design using Lean methodology and utilised a rapid improvement event (RIE) approach underpinned by person-centred principles. This was a system-wide improvement including all hospital staff, facilitated by a specific project team including the chief operation officer, allied therapy manager (encompassing health and social care professionals), infection prevention and control team, head of surgical services, clinical nurse managers, patient services manager and the head of procurement. Following our intervention, hospital services resumed successfully, with the initial service resumption meeting the organizational target of a 75% bed occupancy rate, while the number of resumed surgeries exceeded the target by 13%. Our outpatient visits recovered to exceed the attendance numbers pre-COVID-19 in 2019 by 10%. In addition, patient satisfaction improved from 93% to 95%, and importantly, we had no in-hospital patient COVID-19 transmission in the study period of July to December 2020.Item The use of Lean Six Sigma methodology in the reduction of patient length of stay following anterior cruciate ligament reconstruction surgery(MDPI, 2022-01-30) Moffatt, Sinead; Garry, Catherine; McCann, Hannah; Teeling, Sean Paul; Ward, Marie; McNamara, MartinBackground: The purpose of this study was to reduce the length of stay of anterior cruciate ligament reconstruction patients within a private hospital in Ireland, reducing any non-value-added activity in the patient pathway, with the goal of increasing patient flow, bed capacity, and revenue generation within the hospital system, while maintaining patient satisfaction. Methods: We used a pre-/post-intervention design and Lean Six Sigma methods and tools to assess and improve the current process. Results: A reduction in inpatient length of stay by 57%, and a reduction in identified non-value-added activity by 88%, resulted in a new day-case surgery pathway for anterior cruciate ligament reconstruction patients. The pathway evidenced no re-admissions and demonstrated patient satisfaction. Conclusion: Six months post-project commencement, we had successfully achieved our goals of reducing our anterior cruciate ligament reconstruction patient’s length of stay. This study contributes to the growing body of published evidence which shows that adopting a Lean Six Sigma approach can be successfully employed to optimise care and surgical pathways in healthcare.Item A case study of a whole system approach to improvement in an acute hospital setting(MDPI, 2022-01-22) Ward, Marie E.; Daly, Ailish; McNamara, Martin; Garvey, Suzanne; Teeling, Sean PaulChanges in healthcare tend to be project-based with whole system change, which acknowledges the interconnectedness of socio-technical factors, not the norm. This paper attempts to address the question of whole system change posed by the special issue and brings together other research presented in this special issue. A case study approach was adopted to understand the deployment of a whole system change in the acute hospital setting along four dimensions of a socio-technical systems framework: culture, system functioning, action, and sense-making. The case study demonstrates evidence of whole system improvement. The approach to change was co-designed by staff and management, projects involving staff from all specialities and levels of seniority were linked to each other and to the strategic objectives of the organisation, and learnings from first-generation projects have been passed to second and third-generation process improvements. The socio-technical systems framework was used retrospectively to assess the system change but could also be used prospectively to help healthcare organisations develop approaches to whole system improvement.Item Redesigning the process for scheduling elective orthopaedic surgery: A combined Lean Six Sigma and person-centred approach(MDPI, 2021-11-13) Daly, Ailish; Wolfe, Nicola; Teeling, Sean Paul; Ward, Marie; McNamara, MartinThe Health Service Executive Ireland model of care for elective surgery supports the delivery of elective surgical care in achieving both process and clinical outcomes. This project was conducted in the Orthopaedic Department. Following an outpatient consultation with an orthopaedic surgeon, patients who required surgical intervention were scheduled for their intervention by the administrative team. Prior to commencing this project, the average time from patient consultation to being scheduled for surgery on the hospital system was 62 h/2.58 days. A pre- and post-team-based intervention design employing Lean Six Sigma methodology was applied to redesign the process for scheduling elective orthopaedic surgery. The project was informed by collaborative, inclusive, and participatory stakeholder engagement. The goal was to streamline the scheduling process for elective orthopaedic surgery, with a target that 90% of surgeries are scheduled “right first time” within 48 h/two working days of the outpatient consultant appointment. The main outcome measures showed that 100% of orthopaedic surgeries were scheduled successfully within 2 days of outpatient appointment. Duplication in work between patient services and scheduling teams was eliminated and facilitated a reduction in unnecessary staff workload. This project highlights the importance of collaborative interdisciplinary stakeholder engagement in the redesigning of processes to achieve sustainable outcomes, and the findings have informed further improvements across the hospital’s surgical scheduling system.