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Open Access Highly Accessed Research article

How does lean work in emergency care? A case study of a lean-inspired intervention at the Astrid Lindgren Children's hospital, Stockholm, Sweden

Pamela Mazzocato1*, Richard J Holden2, Mats Brommels1, Håkan Aronsson3, Ulrika Bäckman4, Mattias Elg3 and Johan Thor1

Author Affiliations

1 Medical Management Centre, Karolinska Institutet, Berzelius väg 3, Stockholm, Sweden

2 Department of Medicine and Biomedical Informatics, Vanderbilt University School of Medicine, 733 Medical Arts Building, 1211 21st Avenue S, Nashville, TN, USA

3 Department of Management and Engineering, Linköping University, Linköping, Sweden

4 Astrid Lindgren Children's Hospital/Karolinska University Hospital, Karolinska vägen, Stockholm, Sweden

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BMC Health Services Research 2012, 12:28  doi:10.1186/1472-6963-12-28

Published: 1 February 2012



There is growing interest in applying lean thinking in healthcare, yet, there is still limited knowledge of how and why lean interventions succeed (or fail). To address this gap, this in-depth case study examines a lean-inspired intervention in a Swedish pediatric Accident and Emergency department.


We used a mixed methods explanatory single case study design. Hospital performance data were analyzed using analysis of variance (ANOVA) and statistical process control techniques to assess changes in performance one year before and two years after the intervention. We collected qualitative data through non-participant observations, semi-structured interviews, and internal documents to describe the process and content of the lean intervention. We then analyzed empirical findings using four theoretical lean principles (Spear and Bowen 1999) to understand how and why the intervention worked in its local context as well as to identify its strengths and weaknesses.


Improvements in waiting and lead times (19-24%) were achieved and sustained in the two years following lean-inspired changes to employee roles, staffing and scheduling, communication and coordination, expertise, workspace layout, and problem solving. These changes resulted in improvement because they: (a) standardized work and reduced ambiguity, (b) connected people who were dependent on one another, (c) enhanced seamless, uninterrupted flow through the process, and (d) empowered staff to investigate problems and to develop countermeasures using a "scientific method". Contextual factors that may explain why not even greater improvement was achieved included: a mismatch between job tasks, licensing constraints, and competence; a perception of being monitored, and discomfort with inter-professional collaboration.


Drawing on Spear and Bowen's theoretical propositions, this study explains how a package of lean-like changes translated into better care process management. It adds new knowledge regarding how lean principles can be beneficially applied in healthcare and identifies changes to professional roles as a potential challenge when introducing lean thinking there. This knowledge may enable health care organizations and managers in other settings to configure their own lean program and to better understand the reasons behind lean's success (or failure).