The term “lean” has a meaning of “thin” bearing positive connotation. The thinness, in this case, is achieved by removing unnecessary complexity – in other words, “extra weight.” Similar principles can be observed in philosophies of artists and scholars throughout history and are best illustrated by the maxim usually attributed to Einstein “Everything should be made as simple as possible, but not simpler than that.”
The principle becomes gradually more important in the field of healthcare, with oncology being among the brightest examples of its relevance. Healthcare, along with several other areas, is constantly driven by ceaseless demand as its availability is ingrained in the equity principles of the modern society. At the same time, constant improvement in the technological and scientific background of healthcare leads to an increasing degree of complexity of procedures (Mazzocato, Savage, Brommels, Aronsson, & Thor, 2010). The phenomenon of an ageing population, which is fundamentally caused by the improvement in health services, paradoxically introduces new challenges to the field (Montesarchio et al., 2012). Finally, while some of the previously unbearable health issues have been resolved in the recent years, the expansion of health providers’ area of responsibilities compensates for the somewhat shrunken burden of operations. Preventive care and patient education are two most recognised examples: both aim at relieving clinicians and nurses from additional load but require allocation of resources and budgeting (Young & McClean, 2008). All of the mentioned factors create a setting where the cost of the services inevitably increases, which visibly conflicts with the goal of improved accessibility mentioned above. This, in turn, contributes to the cost explosion phenomenon where the price growth is exponential and its dynamics are almost self-sustained (Toussaint & Berry, 2013). A growing concern with the gap in health care access is among the most recognised consequences of such uncontrolled growth rates.
Overview of Lean in Cancer Care
Oncology is among the most visible branches impacted by the described effect. Cancer has been associated with poor patient outcomes despite the best efforts of the medical professionals for a long time and remains a priority in medical research throughout the world (Belter et al., 2012). Thus, the attention of stakeholders, most prominently, patients and donors, was focused on the efficiency of treatment and the new, as well as potential, ways of addressing the disease. Understandably, the emergence of the modern anti-cancer medications was met with optimism and promoted by media. The high cost of this type of treatment is briefly acknowledged at best or, more often, omitted entirely from the reviews and, as a result, from public perception until faced in the oncology department. A similar situation is observed in professional medical sources. The majority of literature on the topic is focused on the efficiency of treatment and the patient outcomes while its budgeting issues, cost efficiency, and organisational issues are rarely scrutinised and evaluated. Meanwhile, at least one paper indicates the discrepancies in cancer care practices in Oman grounded in structural and organisational issues pertinent to the field (Al-Moundhri, 2013). In essence, oncology is susceptible to the introduction of accessibility gaps and the emergence of conditions leading to the inequity among patients from different social and economic strata. At the same time, certain social and structural particularities prevent these issues from surfacing and being recognised by the stakeholders. In addition, the question of appropriate budgeting remains open, especially considering the individual cases of the patients with multiple diseases and the compatibility of ethical choices.
As can already be seen, medical practices often function in separation from an economic perspective. While effectiveness and efficiency of healthcare procedures are often stated as a priority, the former is commonly measured by the rate of positive patient outcomes and the latter is considered fulfilled if its principles are maintained. The economic considerations are not apparent in any of the above and are rarely considered as a factor in a decision-making process. Importantly, while economic sustainability can be achieved through enhancement of the operations, it is also achievable by eliminating unnecessary steps and elements from the structure. Such approach is notably consistent with the principles of lean management outlined above. Specifically, the unnecessary elements, known as waste in lean management literature, are widely present in the field of oncology, which is already diverse and multi-faceted enough to create problems in management. They are usually categorised as organisational, procedural, and pharmacological. The pharmacological category includes unnecessary pre-medications leading to adverse effects, wrongly administered costly drugs, and, in some cases, prescription of knowingly ineffective chemotherapy for the sake of calming down the patients who otherwise feel as being mistreated or neglected. The organisational category usually includes unnecessary travel among departments (this includes both patients and clinicians during the patient visit), excessively long waits in queues, and uneven load (certain specialists are less in demand than others). Finally, the structural waste mostly consists of unnecessary or redundant PET and inappropriate issuing of antiemetic therapy. Thus, as is already apparent, the oncology already suffers from overabundance and, by extension, misuse of the available means and is in need of lean approach. In accordance with the “achieving more with less” principle, it is possible to create a more consistent, time- and cost-efficient process which will fundamentally reassess priorities, allocate the excessive resources to the areas with the most demand, and ultimately create a more economising environment without sacrificing any of the necessary components. The overall simplification made possible by the Lean oncology will result in the elimination of unnecessary therapies, combining the required ones into more time-efficient bulks, a more streamlined procedure flow thanks to automatisation, improved efficiency of admissions and medication prescriptions, appropriate use of Target Therapy, and utilisation of health technology assessment and integration.
Currently, the healthcare provider’s standpoint does not account for all of the aspects mentioned above. Thus, to make sure that interests of all stakeholders are maintained and that the economic integrity is not compromised in the process, it is necessary to implement lean philosophy in cancer care services in Oman.
State of Cancer Care in Oman
The annual reports by the National Oncology Center illustrate a steady rise in cancer incidence in Oman for the last decade. The latest data shows an increase of 25% compared to the previous year (Khan, 2016). According to the representative of Sultan Qaboos University Hospital, about one-third of the cases could be prevented by lifestyle changes, two other reasons are responsible for the increase. First, efforts of cancer care institutions to raise public awareness of the problem are yielding results, including better understanding and higher report rates, which improves chances of timely interventions but leads to increase in a number of patients. More importantly, recent overall improvements in health care have led to an increase in life expectancy beyond the age of 70 (Khan, 2016). Because the chances of getting cancer increase sufficiently with age, it is logical to expect additional load on cancer care institutions. Besides, both factors are likely to persist, which leads some experts to believe that the number of cases could double by 2030 (Bhattacharjee, 2014). Naturally, such setting necessitates the implementation of lean philosophy in cancer care in Oman to manage the rising demand without compromising efficiency.
Implementing Lean Philosophy in Cancer Care Services in Oman
Lean philosophy was introduced in the second half of the twentieth century in the business segment. It was originally applied in automotive industry, but thanks to its flexibility and diversity was soon utilised in other fields, including healthcare. Currently, it is being adopted in various healthcare establishments throughout the world, and its results are widely reported as overwhelmingly positive (Duska, Mueller, Lothamer, Pelkofski, & Novicoff, 2015; Kim, Hayman, Billi, Lash, & Lawrence, 2007; Holden, 2011). At this point it is important to note that while the approach originates from Japan, the majority of case studies and theoretical support for its use in healthcare come from the US, Great Britain, and Australia (Campbell, 2009). Nevertheless, the reported difficulties coincide across studies and commonly include extremely long patient admittance and waiting time, transportation issues in reaching the cancer care facility, the lack of coordination in required screening and diagnostic procedures which collectively increase the delay, and the lack of synchronisation between various clinicians and departments (Joosten, Bongers, & Janssen, 2009). While no hard data exists to confirm the coincidence of issues and thus suggest the applicability of the previous experience to Omani cancer care establishments, it is possible to assume that at least some of the issues are inherent in the oncology practice internationally – particularly, the structure of the organisation demands the presence of multiple entities and equipment which inevitably leads to confusion without specific effort directed at its coordination. Besides, at least some healthcare establishments already reported on similar complaints (Al-Moundhri, 2013), which suggests the need for similar interventions and improvements.
Types of Waste
Such uniformity allows us to conceive a preliminary list of waste types characteristic for cancer care in Oman.
A range of errors which are avoidable, preventable, and require non-value-added re-work (e.g. a mislabelled medication or wrongly admitted patient)
On some occasions, walking distances between two consecutive steps are unnecessarily long but avoidable (e.g. sample collection location and test lab)
Both clinicians and nurses often need to search for missing or erroneous supplies, documents, and data.
An opposite of a bottleneck, a setting where capabilities of a certain department exceed the need and lead to cluttering on subsequent stages (e.g. fast delivery of samples to lab combined with slow processing time).
A step which is unnecessarily complex or productive for the expected outcome (e.g. an MRI where a simpler X-ray would suffice)
Poor inventory management
The lack of coordination leads to an expiration of medications and lack of access to certain equipment and, by extension, unnecessary expenses.
Waste of human potential
The lack of opportunities for appropriate utilisation and application of skills, competencies, and initiative of staff members.
The list above is incomplete and may be expanded or altered upon further inquiry. However, it can be utilised in its present state to a broader implementation of lean philosophy because of the flexibility and ubiquitous nature of the approach described above. If the goal is to establish lean culture on an institutional level and address general and commonly present issues, an overview of the state of industry will sufficient. If, on the other hand, a more focused approach is required to implement lean as a solution to a certain problem, additional analysis of the situation is recommended.
Tools for Implementation of Lean
Different versions of lean theory suggest a wide array of tools and methods for assessment and analysis, with the following being predominant:
Value stream mapping (VSM)
The procedure consists of a discussion followed by visual mapping of discovered issues, waste types, and the desired outcomes in accordance with the chosen concept of vision. The produced visual map is used to monitor the progression and evaluate the success of the intervention. VSM is often implemented using PDCA principle in the following succession: value stream identification (current state), problem analysis and value proposition (future state), action plan (value delivery), and sustainability (value maintenance).
A straightforward and transparent method of assigning weight to identified problems which may be necessary when some of the identified problems are potentially more resource-demanding or time-consuming than the others. It allows approximating the priority of each problem and the urgency of a solution.
A tool used to track the actual physical flow of materials. It is especially important for the cancer care establishments because the majority of oncology centres suffer from inadequate flow of patients, supplies, and documents. The existing experience of the Lean implementation also indicates that in the majority of instances, the actual setup is complex enough to actually necessitate the use of spaghetti diagrams for the lean team to be able to produce a solution.
On most occasions, lean management makes use of the experience and competence of the practitioners directly involved in the process and encourages their participation. Thus, discussion techniques such as brainstorming are favoured over formal reporting. Affinity diagrams are useful to systematise the obtained ideas and suggestions.
Five Whys approach
One of the methods devised by Sakichi Toyoda, one of the founders of the Lean philosophy, the “five whys” method can be used to quickly determine the root cause of the problem to be able to address the cause rather than the effect. This technique is often accompanied by the use of cause and effect diagrams to visualise the findings and improve understanding.
Aside from the more obvious aspect of physical organisation of the workplace, this approach is applicable to a broader range of meanings, including the layout of equipment and location of different activities. Usually, the cancer care facilities are conceived by “bootstrapping” new services without applying 5S, which understandably leads to setbacks in efficiency (Deschenes, 2012).
It is worth mentioning that while the described methods are recommended to streamline the process, they are not necessarily required for a transition to lean practices. Besides, most of these tools are recommended for a more in-depth inquiry and monitoring of the progression while the transformation of the institutional scale requires their application on a selective basis. Basically, all of the techniques produce the best results when used to address a specific issue. For instance, patient admittance is a common problem in the cancer care centres. The first point in solving the problem would be locating the so-called “bottle neck” a place or procedure associated with excessive load or presenting a significant barrier to the patient flow. The arrival and registration area is commonly associated with both effects. Usually, it employs several attendants who engage in receiving the arriving patients, appointing medical and nurse visits, scheduling and review of chemotherapies, refills of prescriptions, approvals of treatment, and a variety of other activities depending on the particularities of the establishment. In many instances both the patients and the staff of the facility report inappropriate waiting times, erratic document completion, delays, lack of coordination, data loss, and uneven distribution of tasks. The situation is aggravated by the fact that the majority of cancer care facilities deal with patients who travel great distances and often arrive earlier than required and still face queues. It can be argued that the majority of issues can be defined as waste and are thus susceptible to eradication by applying lean philosophy, as was done in the Medical Oncology Unit of Regional Hospital from Vale do Paraiba, Brazil. The lean team was assembled, and a series of training sessions and workshops on lean were conducted. In addition, weekly meetings were scheduled aimed at evaluating quality improvements. Notably, no thorough evaluation or prior research was done to confirm the suggested reason behind the delays and inefficiency – instead, an approximation of Takt time was done to determine the direction of actions. A simple calculation and a spaghetti diagram allowed the team to envision the inconsistencies in workload and locate the most stressful points in the process. In addition, most of the patient routes turned out to be extremely confusing. Finally, the Takt time analysis revealed that of 112 minutes allocated for each patient admission, only 37 were of value-added time while 75 were of non-value-added time. After this, the team developed a series of suggested improvements and, importantly, a set of quantitative and qualitative measures to evaluate the results of switching to lean. The improvements included logistical restructuring, preparations of certain documents based on the expected future activities, redistribution of several tasks to and from the area in question, and, most importantly, signalling for patients who were previously waiting for approval of certain procedures or discharge (kanban). Particularly, the patients who had previous appointment could now skip a step and be pulled to chemotherapy directly (Pinto, 2016). Finally, the new scheme of operations was evaluated using the same method. The results obtained by observation were recorded and compared to the projected outcomes to reveal acceptable discrepancy and displayed significant improvement over an initial situation. Importantly, according to the team, no extra resources were required for the duration of the lean transformation except for the time used to make necessary calculations, conceive a plan of improvements, and move the furniture on certain occasions (Pinto, 2016). While this example is not immediately applicable to the Oman Cancer Care facilities until necessary inquiries are made in each particular case, it provides several necessary insights. First, it illustrates the impressive cost-efficiency of the suggested approach – in reality, no expense was associated with the entire experience. Second, while the majority of steps taken was fairly standard and did not require modification, the chosen strategy still resulted in significant improvement. Third, the implementation, in this case, did not rely on costly and lengthy assessment – a fairly inaccurate evaluation was enough.
A similar framework can be applied to other areas of cancer care in Oman. For instance, patient intake process, new patient slot availability, systematic and coordinated scheduling, transfer and handling of medical records, scheduling lab functioning according to unavoidable limitations and alternating the duration of infusions share the same structure and display a comparatively similar range of problems. Thus, the exemplified framework can be used in Omani cancer care centres with only minor alterations. On the other hand, the reduction of the required number of steps, reorganisation of physician orders, changes in over time of certain departments and rooms, and adjustments of the staff shifts are only partially consistent with the suggested model and will require a somewhat different angle and the introduction of additional benchmarking techniques, including questionnaires, surveys, and computerised logging methods integrated into patient-centred software (Murphree, Vath, & Daigle, 2011).
A more comprehensive switch to lean was demonstrated by Aptium Cancer Care, a subsidiary of the US-based Aptium Oncology (Aherne & Whelton, 2016). Instead of targeting a specific issue and devising an action map with concrete steps, they conceived three encompassing categories. First, instead of a concept of an employee, they introduced a culture which prioritised certain traits and mind-sets over others and allowed the HR department to locate people with an open mind who are not afraid of change. This effect was enhanced with interviews performed at the initial stage and training sessions immediately after the appointment and later in the course of work. The job descriptions and performance reviews were also redesigned with lean principles in mind and both pointed to and encouraged the use of them in everyday activities. Importantly, such design also acknowledged and addressed individuals who were reluctant to enter the culture by providing incentives and encouraging discussion of the conflicting points. Second, an end-to-end process was developed to ensure the exposure of all involved stakeholders in as many aspects of healthcare as possible, including economic and administrative ones. The process involved developing a specific plan where each process was deconstructed to illustrate the objectives of the patients and staff members, the “quick wins”, and the long-term benefits of achieving the outlined goal. The plan also predicted main elements of the process, assessed possible issues, and suggested ways of overcoming them. Finally, alternative routes were mapped to account for possible deviations. The developed plan was then used to determine the reasons for discrepancies in the process and find ways of avoiding them in the future. Importantly, the accountability was shared based on the principles of no-blame culture which further decreased reluctance to participate and take responsibility. Third, the process was constantly reviewed and compared to the planned outcomes. Except for the adjustments of the procedures, such monitoring was also accounted in the ongoing training sessions of the personnel and was used to improve motivation of the staff members.
As can be seen from the example above, the implementation of lean philosophy does not need to be focused on a specific issue – instead, it can be extended to the scope as broad as functioning of the entire complex. In addition, while some unmentioned issues certainly triggered the introduction of the lean implementation, the described method provides overall improvement. Again, at certain points developing a scheme such as the one highlighted in a previous example may be necessary, but in the long term, the lean culture will decrease the need for such interventions as the staff will generally be predisposed to the constant improvement and readjustment.
Key Performance Indicators (KPIs)
As was illustrated above, the application of lean philosophy requires regular benchmarking and surveillance of specific key performance indicators regardless of the scope and time frame. For cancer care in Oman, the following KPIs can be suggested:
- Waiting time for new non-urgent patients, measured from the time of request;
- Waiting time for a review, measured from arrival;
- Compliance with the pre-specified time period of all of the appointed consultations of oncology department as well as related departments;
- Discussion of newly diagnosed cancer cases by a dedicated multidisciplinary team;
- Completion of the appointed tests and required diagnostics within the pre-defined time frame;
- Continuous monitoring and addressing of the unplanned admissions and re-admissions following a planned discharge;
- Comprehensive and relevant description of the case in surgical pathology reports to exclude unnecessary inquiries;
- Appropriate and justified appointment of advanced diagnostic procedures, such as PET and CT scans;
- Availability and justification of the breast conservation procedure;
- Possibility of non-operative histological diagnosis by core needle biopsy;
- Coordination and systematisation of radiologic investigations;
- Availability and accessibility of neoadjuvant and post-operative therapy for patients with high-risk breast cancer;
- Appropriate radiotherapy for patients with breast cancer who underwent local excision;
- Appropriate evaluation for locally advanced, nodal or bony metastatic disease for patients with high-risk prostate cancer.
It should be specified that points 1 through 8 of the list present the direct outcomes of lean philosophy and are universally applicable to cancer care and, with minor adjustments, to other fields of health care, while points 9 through 14 are indirect consequences of the suggested transformation and will likely be observed in the long run rather than on the initial stage. Thus, the former can be described as organisational KPIs while the latter display operational improvements and should be viewed as ultimate positive outcomes rather than direct monitoring tools.
Outcomes of Lean Implementation
As Lean is already a recognised and thoroughly studied practice in American and European corporate culture, it would be wise to assess possible benefits of its implementation to get an overall image of the outcomes in Oman. One of the most recognised benefits in light of the steadily rising cost of cancer care services is the economising effect observed after a shift to Lean. American hospitals, for example, report the decrease in expenses associated with Lean (Graban, 2011). One reason for such rise in cost efficiency is an elimination of preventable errors, which gradually become recognised by payers and impact the budgeting of hospitals. Another improvement comes from 60% reduction of turnaround time for clinical laboratory results which is achieved without additional staffing or purchase of new equipment. Graban (2011) also cites the improved effectiveness of services as a reason behind higher revenues: the length of hospital stay was reduced by 29%, the time required for equipment preparation was decreased by 70%, and the waiting time was substantially cut. The former contributed to the capabilities of the establishment to accommodate more patients while the latter improved customer satisfaction. The reported 95% decrease in septicemia-associated deaths also contributed to higher excellence of patient care, improved consistency of care, warranted patient safety, and strengthened self-esteem and morale of employees and customers.
A 17 percent increase in patient flow coupled with a four percent cost reduction was also reported by McKesson Oncology Network USA (Fryefield et al., 2012). Importantly, the center also observed a 6% increase in new patient volume resulting from reduced wait times, increased patient satisfaction, and increased referrals. The staff also displayed higher satisfaction with improved workplace conditions resulting from better workload balance, optimised staff capacity, and reduced re-work incidence (Fryefield et al., 2012).
The implementation of Lean in uro-oncology showed similar results. In 60 days from the commence of lean initiative, the median cycle time was from 46 minutes to 35 minutes, the average length of an assessment by a physician increased from 7.5 to 10.6 minutes at baseline (Skeldon et al., 2014). Overall, both the time of initial assessment and the patient cycle time were improved, with an average proportion of value-added time increase from 30.6% to 66.3% (Skeldon et al., 2014). Such efficiency is the reason of wide application of lean philosophy in NHS hospitals in the United Kingdom (Yousri, Khan, Chakrabarti, Fernandes, & Wahab, 2011).
A pilot lean project in lean management undertaken by the staff of Hospital Regional do Vale do Paraiba, Brazil yielded similar results. The average waiting time from registration to surgery dropped by 61% (90 to 35 days) while the average time from registration to the first chemotherapy saw a 50% improvement (114 to 56 days) (Marotta, Rais, & Coelho, 2015). The removal of waste also resulted in the decrease of a number of necessary visits from seven to two. While no cut in expenses was reported, we can assume that the improved efficiency contributed to it in a similar manner to the examples described above.
On the whole, the intermediate outcomes of lean implementation are mostly observable among the employees (better waste recognition, readiness to change, satisfaction, and Lean routinisation) while ultimate outcomes include all stakeholders (increase in efficiency, e.g. shorter wait times, customer satisfaction, economic sustainability resulting from reduced expenses, and overall improvement of care quality) (Carman et al., 2014).
Currently, Lean implementation is a necessary transformation in light of the factors mentioned above. The growing cost of cancer treatment coupled with the recent events demonstrating the instability of global economic environment require improvements of cost efficiency in cancer care. The widening gap between customer financial capacity and demand for oncology services further aggravate the problem and necessitate swift and effective intervention. At the same time, the current rate of cancer incidence in Oman and the projected rise of patients with cancer suggest the need for improved performance of existing care centres.
The reviewed results show tremendous improvements in efficiency and financial performance of organisations without significant resource allocation. However, it should be acknowledged that Lean implementation is only possible when the staff is dedicated and persistent enough and at the same time displays good understanding of goals, benefits, and barriers on the way to achieving lean culture. Thus, while it is tempting to perceive Lean as a quick and easy solution for the majority of organisational, operational, and financial issues, it would be more accurate to consider it a long-term investment which is not restrictive financially or academically.
To conclude, the current state of Omani oncology requires change, and Lean philosophy is a perfect candidate considering its accessibility, sustainability, universality, and diversity of applications. Simply put, we are both prepared and capable of implementing it in cancer care in Oman.
Aherne, J., & Whelton, J. (2016). Applying lean in healthcare: A collection of international case studies. Boca Raton, FL: CRC Press.
Al-Moundhri, M. (2013). The need for holistic cancer care framework: breast cancer care as an example. Oman Medical Journal, 28(5), 300-302.
Belter, D., Halsey, J., Severtson, H., Fix, A., Michelfelder, L., Michalak, K.,…De Ianni, A. (2012). Evaluation of outpatient oncology services using lean methodology. Oncology Nursing Forum, 39(2), 136-140.
Bhattacharjee, M. (2014). Cancer rate in region could double by 2030: WHO. Web.
Campbell, R. J. (2009). Thinking lean in healthcare. Journal of AHIMA, 80(6), 40-43.
Carman, K. L., Paez, K., Stephens, J., Smeeding, J., Garfinkel, S., & Blough, C. (2014). Improving care delivery through lean: implementation case studies. Web.
Deschenes, S. (2012). 7 ways lean healthcare management reduces cost. Web.
Duska, L. R., Mueller, J., Lothamer, H., Pelkofski, E. B., & Novicoff, W. M. (2015). Lean methodology improves efficiency in outpatient academic Gynecologic Oncology clinics. Gynecologic oncology, 138(3), 707-711.
Fryefield, D. C., Kafora, R., Bradshaw-Hucko, L., Tribble, C., Jensen, T., Chentnik, T., & Beveridge, R. (2012). Community oncology care delivery staffing model. ASCO Annual Meeting Proceedings, 30(34), 87-95.
Graban, M. (2011). Lean hospital: Improving quality, patient safety, and employee satisfaction. Boca Raton, FL: CRC Press.
Holden, R. J. (2011). Lean thinking in emergency departments: a critical review. Annals of emergency medicine, 57(3), 265-278.
Joosten, T., Bongers, I., & Janssen, R. (2009). Application of lean thinking to health care: issues and observations. International Journal for Quality in Health Care, 21(5), 341-347.
Khan, M. (2016). MoH report says 25% rise in cancer cases in Oman. Web.
Kim, C. S., Hayman, J. A., Billi, J. E., Lash, K., & Lawrence, T. S. (2007). The application of lean thinking to the care of patients with bone and brain metastasis with radiation therapy. Journal of Oncology Practice, 3(4), 189-193.
Marotta, E., Rais, S. V., & Coelho, S. M. (2015). A fast track to cancer treatment. Web.
Mazzocato, P., Savage, C., Brommels, M., Aronsson, H., & Thor, J. (2010). Lean thinking in healthcare: a realist review of the literature. Quality and Safety in Health Care, 19(5), 376-382.
Montesarchio, V., Grimaldi, A. M., Fox, B. A., Rea, A., Marincola, F. M., & Ascierto, P. A. (2012). Lean oncology: a new model for oncologists. Journal of translational medicine, 10(1), 74-76.
Murphree, P., Vath, R. R., & Daigle, L. (2011). Sustaining Lean Six Sigma projects in health care. physician Exec, 37(1), 44-48.
Pinto, C. F. (2016). Improving wait times at a medical oncology unit. Web.
Skeldon, S. C., Simmons, A., Hersey, K., Finelli, A., Jewett, M. A., Zlotta, A. R., & Fleshner, N. E. (2014). Lean methodology improves efficiency in outpatient academic uro-oncology clinics. Urology, 83(5), 992-998.
Toussaint, J. S., & Berry, L. L. (2013). The promise of Lean in health care. Mayo Clinic Proceedings, 88(1), 74-82.
Young, T. P., & McClean, S. I. (2008). A critical look at Lean Thinking in healthcare. Quality and Safety in Health care, 17(5), 382-386.
Yousri, T. A., Khan, Z., Chakrabarti, D., Fernandes, R., & Wahab, K. (2011). Lean thinking: can it improve the outcome of fracture neck of femur patients in a district general hospital?. Injury, 42(11), 1234-1237.