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Table 1 Document characteristics

From: The sustainability of Lean in pediatric healthcare: a realist review

Author, year, country

Design

Theoretical framework

QI method and QI purpose

Study purpose

Implementation leaders

Setting and system level

Primary research studies (n = 6)

Tekes, 2015, USA [42]

Pre-post survey

No mention at all

Lean, Six Sigma, clinical

Determine if multi-disciplinary LSS could reduce reliance on head CT in pediatric hydrocephalus population by 50% within 6 months, 24/7.

Multi-disciplinary team, project leader (neuroradiologist), and a physician champion.

Division of pediatric radiology and neuro radiology (meso)

Czulada, 2015, USA [43]

Multi-methods

No mention at all

Lean, Six Sigma, process

Describes the inclusion of a family advisor on an improvement project team to increase communication opportunities.

Multi-disciplinary team, medical director, nurse manager, family advisor.

Pediatric intensive care unit (meso)

Harrison, 2016, USA [45]

Mixed-methods

Explicit statement of theoretical framework and/or constructs applied to the research.

Lean, process and system

Examine how internal organizational context affected the implementation and outcomes of organization-wide Lean initiatives and cycle Lean process redesign projects, were embedded within the “initiatives.”

Senior leadership support, middle management, multi-disciplinary teams, internal or external Lean experts, organizations (added Lean to existing QI practices).

Five organizations, one was a pediatric care continuity (meso).

Northway, 2015, Canada [47]

Multi-methods

No mention at all

Lean and other QI “classic” methods, process and system

Report the long-term sustainability of a transfer protocol.

Multi-disciplinary team, physician and clinical leaders, external Lean experts.

Pediatric intensive care unit (meso).

Mazzacato, 2014, Sweden [48]

Mixed-methods

Explicit statement of theoretical framework and/or constructs applied to the research

Lean, process

Explain how different emergency services adopt and adapt the same hospital-wide Lean-inspired intervention and how this is reflected in hospital process performance data.

Hospital management strategic-hospital-wide Lean-inspired program. Multi-disciplinary improvement teams, internal improvement coaches, physician leaders.

Seven emergency service departments (2 pediatric) (meso)

Mazzacato, 2012, Sweden [49]

Mixed-methods

No mention at all

Lean, process and system

To unpack how and why such a lean application may work.

Multi-disciplinary team, physician lead, internal process improvement coaches, hospital management.

Pediatric emergency unit (meso).

Quality improvement reports (n = 5)

Wong, 2016, Canada [44]

Commentary/descriptive

No mention at all

Lean, process and system

Illustrate how an implicit mental model pervades in the healthcare system based on deeply held but unexamined assumptions that arise from heuristics and biases, that can be examined by objective data and how we can build a new mental model.

Multi-disciplinary team, process improvement team and senior hospital management support.

Pediatric eye clinic (micro).

Luton, 2015, [46]

Commentary/descriptive

No mention at all

Lean, Six Sigma, IHI Model for Improvement, clinical and process

To describe how a program to prevent feeding errors was developed, implemented, and evaluated.

Multi-disciplinary team, QI project manager, executive task force support (leaders).

Newborn center (three discrete NICUs, milk bank, and formula room) (meso)

Carman, AHRQ, 2014, USA [50]

Commentary/descriptive

No mention at all

Lean, process and system

To examine the ways in which each organization has implemented Lean and identify the factors that influenced progress within individual Lean projects and on the ultimate outcomes.

Executive managers, CEO, clinical managers, external Lean consultants, management engineers, and multi-disciplinary front-line teams.

Five case studies of organizations that implemented Lean-blended adult and pediatrics. Case 1, four hospitals, 3 are pediatrics (macro)

Hung, AHRQ, 2016, USA [51]

Multi-methods

Explicit statement of theoretical framework and/or constructs applied to the research.

Lean, process and system

Study the scaling and sustainability of Lean redesigns as an organization wide initiative, with a particular focus on analyzing contextual factors affecting the success of implementation efforts.

Ambulatory care system-wide Lean initiative, executive leadership, external Lean consultants, clinical leaders, physicians and multi-disciplinary front-line staff.

Ambulatory care system with primary care departments (includes pediatrics) across Palo Alta Medical Foundation (macro)

Rotter, 2014, Canada [52]

Multi-methods

Explicit statement of theoretical framework and/or constructs applied to the research.

Lean, process and system

Evaluate the early stages of the implementation of Lean (Saskatchewan’s Lean Management System) in the provincial health system.

Ministry strategy policy makers, executive management support, external Lean consultants, clinical leaders, Kaizen promotion office, multi-disciplinary teams.

Saskatchewan Healthcare System (twelve regions)–focus on four regions for realist evaluation (pediatric data) (macro)

  1. Legend of the information extracted, four levels of change in health system: the individual (micro level), the group or team, the organization (meso level), and the larger system or environment (macro level) in which individual organizations are embedded [70, 71]. Clinical: (a) involving direct observation of the patients’ clinical diagnosis, (b) based on or characterized by observable and diagnosable symptoms clinical treatment [73]. Process: A series of actions or steps (procedures) taken in order to achieve a particular end (outcome) [74]. System: (a) a set of detailed methods, procedures, and routines created to carry out a specific activity, perform a duty, or solve a problem (b) an organized, purposeful structure that consists of interrelated and interdependent elements (components, entities, factors, members, parts, etc.)
  2. These elements continually influence one another (directly or indirectly) to maintain their activity and the existence of the system, in order to achieve the goal of the system [74]. Theoretical framework: no mention at all, reference to broad theoretical basis, reference to specific theoretical basis, explicit statement of theoretical framework and/or constructs applied to the research [34]