December 11, 2025
Sustainable care quality improvement: a scoping literature review of performance measurement in lean healthcare implementations | BMC Health Services Research
  • World Health Organization, & United Nations Children’s Fund. Operational framework for primary health care: transforming vision into action. 2020.

  • World Health Organization. Long-term care for older people: package for universal health coverage. 2024.

  • World Health Organization. World report on ageing and health. 2015.

  • World Health Organization & United Nations Children’s Fund, 2018. Primary health care measurement framework and indicators: monitoring health systems through a primary health care lens. World Health Organ. 2022.

  • World Health Organization. Continuity and coordination of care: a practice brief to support implementation of the WHO framework on integrated people-centred health services. 2018.

  • World Health Organization. Decade of healthy ageing: plan of action 2021-2030. World Health Organisation. 2020.

  • OECD. Realising the potential of primary health care. OECD; 2020. https://doi.org/10.1787/a92adee4-en.

  • Johnston JL, Bennett D. Lost in translation? Paradigm conflict at the primary-secondary care interface. Med Educ. 2019;53(1). https://doi.org/10.1111/medu.13758.

  • Sampson R, Cooper J, Barbour R, Polson R, Wilson P. Patients’ perspectives on the medical primary-secondary care interface: systematic review and synthesis of qualitative research. BMJ Open. 2015;5(10). https://doi.org/10.1136/bmjopen-2015-008708.

  • Van Hoof SJM, Spreeuwenberg MD, Kroese MEAL, Steevens J, Meerlo RJ, Hanraets MMH, et al. Substitution of outpatient care with primary care: a feasibility study on the experiences among general practitioners, medical specialists and patients. BMC Fam Pract. 2016;17(1). https://doi.org/10.1186/s12875-016-0498-8.

  • World Health Organization. Quality health services: a planning guide. 2020b.

  • Antony J, Sunder M, Sreedharan V, Chakraborty R, A., Gunasekaran A. A systematic review of lean in healthcare: a global prospective. In: Int J Qual Reliab Manag. Vol. 36, (8). Emerald Group Publishing Ltd; 2019. p. 1370–91. https://doi.org/10.1108/IJQRM-12-2018-0346.

  • Chen M, Guan Q, Zhuang J. Patient-centered lean healthcare management from a humanistic perspective. BMC Health Serv Res. 2024;24(1):1261. https://doi.org/10.1186/s12913-024-11755-w.

  • Henrique DB, Godinho Filho M. A systematic literature review of empirical research in lean and six sigma in healthcare. Total Qual Manag Bus. 2020;31, Issues3–4. https://doi.org/10.1080/14783363.2018.1429259.

  • Akmal A, Greatbanks R, Foote J. Lean thinking in healthcare – findings from a systematic literature network and bibliometric analysis. In: Health policy. Vol. 124, (6). Elsevier Ireland Ltd; 2020. p. 615–27. https://doi.org/10.1016/j.healthpol.2020.04.008.

  • Tiso A, Pozzan C, Verbano C. Health lean management implementation in local health networks: a systematic literature review. In: Oper Res Perspect. Vol. 9. Elsevier Ltd; 2022. https://doi.org/10.1016/j.orp.2022.100256.

  • Lennox L, Maher L, Reed J. Navigating the sustainability landscape: a systematic review of sustainability approaches in healthcare. Implementation Sci. 2018;13(1). https://doi.org/10.1186/s13012-017-0707-4.

  • Moore JE, Mascarenhas A, Bain J, Straus SE. Developing a comprehensive definition of sustainability. Implementation Sci. 2017;12(1). https://doi.org/10.1186/s13012-017-0637-1.

  • Womack JP, Jones DT. Lean thinking: banish waste and create wealth in your corporation. 1996. Simon & Schuster, May.

  • Samanta AK, Varaprasad G, Gurumurthy A. Implementing Lean six Sigma in health care: a review of case studies. Int J Multiling Lean Six Sigma. 2023;14(1). https://doi.org/10.1108/IJLSS-08-2021-0133.

  • World Health Organization & United Nations Children’s Fund. A vision for primary health care in the 21st century: towards universal health coverage and the sustainable development goals. World Health Organ. 2018;46(4).

  • World Health Organization and the United Nations Children’s Fund. Global report on assistive technology. Geneva: license CC BY-NC-SA 3.0 IGO. 2022. In Global report on assistive technology summary.

  • de Souza LB. Trends and approaches in lean healthcare. Leadersh Health Serv. 2009;22(2). https://doi.org/10.1108/17511870910953788.

  • Ohno T. Toyota production system beyond large -scale production Taiichi Ohno. Production. 1979.

  • Hines P, Holwe M, Rich N. Learning to evolve: a review of contemporary lean thinking. Int J Oper Prod Manage. 2004;24(10). https://doi.org/10.1108/01443570410558049.

  • Radnor ZJ, Holweg M, Waring J. Lean in healthcare: the unfilled promise? Soc Sciamp; Med. 2012;74(3). https://doi.org/10.1016/j.socscimed.2011.02.011.

  • Mendes L, França G. Lean thinking and risk management in healthcare organizations: a systematic literature review and research agenda. Int J Qual Reliab Manage. 2024. https://doi.org/10.1108/IJQRM-06-2023-0210.

  • Crema M, Verbano C. How to combine lean and safety management in health care processes: a case from Spain. Saf Sci. 2015;79. https://doi.org/10.1016/j.ssci.2015.05.007.

  • Ghebreyesus TA. How could health care be anything other than high quality? The Lancet Global Health. 2018;6(11). https://doi.org/10.1016/S2214-109X(18)30394-2.

  • World Health Organization. Key facts. 2019. Patient safety. https://www.who.int/news-room/fact-sheets/detail/patient-safety.

  • Henrique DB, Filho MG, Marodin G, Jabbour ABLDS, Chiappetta Jabbour CJ. A framework to assess sustaining continuous improvement in lean healthcare. Int J Prod Res. 2021;59(10). https://doi.org/10.1080/00207543.2020.1743892.

  • Schwartz R, Deber R. The performance measurement-management divide in public health. Health Policy (new Y). 2016;120(3). https://doi.org/10.1016/j.healthpol.2016.02.003.

  • Van Panhuis WG, Paul P, Emerson C, Grefenstette J, Wilder R, Herbst AJ, Heymann D, Burke DS. A systematic review of barriers to data sharing in public health. BMC Public Health. 2014;14(1). https://doi.org/10.1186/1471-2458-14-1144.

  • WHO. Framework and standards for country health information Systems. World Health, 2nd Ed(January). 2012. https://doi.org/10.4018/978-1-60566-988-5.

  • dos Santos ACDSG, Reis ADC, Souza CGD, Santos IL, Ferreira LAF, Senna P. Measuring the current state-of-the-art in lean healthcare literature from the lenses of bibliometric indicators. Benchmarking Int J. 2022. https://doi.org/10.1108/BIJ-10-2021-0580.

  • Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6(7). https://doi.org/10.1371/journal.pmed.1000100.

  • S. Sjr -Scimago journal & country Rank [portal]. n.d. Retrieved July 29, 2024, from.

  • Aissaoui NO, Ben Mbarek H, Layeb SB, Hadj-Alouane B, A. A BPMN-VSM based process analysis to improve the efficiency of multidisciplinary outpatient clinics. Production Plann and Control. 2022. https://doi.org/10.1080/09537287.2022.2098199.

  • Al Hroub A, Obaid A, Yaseen R, El-Aqoul A, Zghool N, Abu-Khudair H, et al. Improving the Workflow efficiency of an outpatient Pain clinic at a specialized oncology center by implementing lean principles. Asia Pac J Oncol Nurs. 2019;6(4). https://doi.org/10.4103/apjon.apjon_21_19.

  • Astiena AK, Hadiguna RA, Iswanto AH, Hardisman. Digitalization of outpatient services based on lean management to reduce waiting time in government hospital. Int J Adv Sci Eng Inf Technol. 2022;12(6). https://doi.org/10.18517/ijaseit.12.6.17212.

  • Baril C, Gascon V, Miller J, Côté N. Use of a discrete-event simulation in a Kaizen event: a case study in healthcare. Eur J Oper Res. 2016;249(1). https://doi.org/10.1016/j.ejor.2015.08.036.

  • Cheung YY, Goodman EM, Osunkoya TO. No more waits and delays: streamlining workflow to decrease patient time of stay for image-guided musculoskeletal procedures. RadioGraphics. 2016;36(3):856–71. https://doi.org/10.1148/rg.2016150174.

  • Ciulla TA, Tatikonda MV, Elmaraghi YA, Hussain RM, Hill AL, Clary JM, Hattab E. Lean six sigma techniques to improve ophthalmology clinic efficiency. Retina. 2018;38(9). https://doi.org/10.1097/IAE.0000000000001761.

  • Damle A, Andrew N, Kaur S, Orquiola A, Alavi K, Steele SR, et al. Elimination of waste: creation of a successful Lean colonoscopy program at an academic medical center. Surg Endosc. 2016;30(7). https://doi.org/10.1007/s00464-015-4599-6.

  • Davies C, Lyons C, Whyte R. Optimizing nursing time in a day care unit: quality improvement using lean six sigma methodology. Int J Qual Health Care: J Int Soc For Qual In Health Care. 2019;31(1). https://doi.org/10.1093/intqhc/mzz087.

  • Fields E, Neogi S, Schoettker PJ, Lail J. Using lean methodologies to streamline processing of requests for durable medical equipment and supplies for children with complex conditions. Healthcare. 2018;6(4). https://doi.org/10.1016/j.hjdsi.2017.11.003.

  • Kam AW, Collins S, Park T, Mihail M, Stanaway FF, Lewis NL, et al. Using Lean Six Sigma techniques to improve efficiency in outpatient ophthalmology clinics. BMC Health Serv Res. 2021;21(1). https://doi.org/10.1186/s12913-020-06034-3.

  • Kovach JV, Ingle D. Using Lean six Sigma to reduce patient cycle Time in a nonprofit community clinic. Qual Manag Health Care. 2019;28(3). https://doi.org/10.1097/QMH.0000000000000215.

  • McDermott AM, Kidd P, Gately M, Casey R, Burke H, O’Donnell P, et al. Restructuring of the diabetes day centre: a pilot lean project in a tertiary referral centre in the West of Ireland. BMJ Qual Saf. 2013;22(8):681–88. https://doi.org/10.1136/bmjqs-2012-001676.

  • Naidoo L, Mahomed OH. Impact of lean on patient cycle and waiting times at a rural district hospital in KwaZulu-Natal. Afr J Prim Health Care Fam Med. 2021;8(1). https://doi.org/10.4102/phcfm.v8i1.1084.

  • Salam MA, Khan SA. Value creation through lean management: a case study of healthcare service operations. Int J Soc Res Methodol Serv and Operations Manag. 2016;25(3). https://doi.org/10.1504/IJSOM.2016.10000239.

  • Shaban A, Ayad G, Ahmed NGS. Integration of simulation modelling and lean management to improve patient flow at outpatient clinics. Int J Surg Pathol Of Productivity And Qual Manag. 2022;36(3). https://doi.org/10.1504/IJPQM.2022.124707.

  • Skeldon SC, Simmons A, Hersey K, Finelli A, Jewett MA, Zlotta AR, et al. Lean methodology improves efficiency in outpatient academic uro-oncology clinics. Urology. 2014;83(5). https://doi.org/10.1016/j.urology.2013.11.048.

  • Smith C, Wood S, Beauvais B. Thinking lean: implementing DMAIC methods to improve efficiency within a cystic fibrosis clinic. J Healthc Qual. 2011;33(2). https://doi.org/10.1111/j.1945-1474.2010.00130.x.

  • Sullivan K, Topper L, Rajwani A. Redesigning patient flow in orthopedics and radiology clinics via a three-phase “kaizen” improvement approach and interrupted time series analysis. Int J Qual Health Care. 2022;34(3). https://doi.org/10.1093/intqhc/mzac061.

  • Vidal-Carreras PI, Garcia-Sabater JJ, Marin-Garcia JA. Applying value stream mapping to improve the delivery of patient care in the oncology day hospital. Int J Environ Res Pub Health And Public Health. 2022;19(7). https://doi.org/10.3390/ijerph19074265.

  • Wilson J, Swee M, Mosher H, Scott-Cawiezell J, Levins L, Fort K, Kumar B. Using Lean Six Sigma to improve pneumococcal vaccination rates in a veterans affairs rheumatology clinic. J For Healthcare Qual. 2020;42(3). https://doi.org/10.1097/jhq.0000000000000218.

  • Aleem S. Translating 10 lessons from lean six sigma project in paper-based training site to electronic health record-based primary care practice: challenges and opportunities. Qual Manag Health Care. 2013;22(3). https://doi.org/10.1097/QMH.0b013e31829a6b9a.

  • Al-Zain Y, Al-Fandi L, Arafeh M, Salim S, Al-Quraini S, Al-Yaseen A, Abu Taleb D. Implementing Lean Six Sigma in a Kuwaiti private hospital. Int J Health Care Qual Assur. 2019;32(2). https://doi.org/10.1108/IJHCQA-04-2018-0099.

  • Demirli K, Al Kaf A, Simsekler MCE, Jayaraman R, Khan MJ, Tuzcu EM. Using lean techniques and discrete-event simulation for performance improvement in an outpatient clinic. Int J Multiling Lean Six Sigma. 2021;12(6). https://doi.org/10.1108/IJLSS-09-2020-0138.

  • Duska LR, Mueller J, Lothamer H, Pelkofski EB, Novicoff WM. Lean methodology improves efficiency in outpatient academic gynecologic oncology clinics. Gynecologic Oncol. 2015;138(3). https://doi.org/10.1016/j.ygyno.2015.07.001.

  • Gijo EV, Antony J. Reducing patient waiting time in outpatient department using lean six sigmamethodology. Qual Reliab Eng Int. 2014;30(8). https://doi.org/10.1002/qre.1552.

  • White H, Bowling C, Harris AM. Use of lean methodologies in outpatient urology clinic. Urology Pract. 2021;8(6). https://doi.org/10.1097/UPJ.0000000000000256.

  • Bhat S, Jnanesh NA. Application of Lean Six Sigma methodology to reduce the cycle time of out-patient department service in a rural hospital. Int J Healthc Technol And Manag. 2014;14(3). https://doi.org/10.1504/IJHTM.2014.064257.

  • Igoe A, Teeling SP, McFeely O, McGuirk M, Manning S, Kelly V, Coetzee H, Cunningham Ú, Connolly K, Lenane P. Implementing person-centred Lean six Sigma to transform dermatology waiting lists: a case study from a Major teaching hospital in Dublin, Ireland. Sci. 2024;6(4):72. https://doi.org/10.3390/sci6040072.

  • Kovach JV, Flores MN. Streamlining admissions to outpatient substance use treatment using lean methods. J Subst Use. 2021;26(3). https://doi.org/10.1080/14659891.2020.1821809.

  • Morell-Santandreu O, Santandreu-Mascarell C, Garcia-Sabater JJ. A model for the implementation of lean improvements in healthcare environments as applied in a primary care center. Int J Environ Res Pub Health And Public Health. 2021;18(6). https://doi.org/10.3390/ijerph18062876.

  • Paccagnella A, Mauri A, Spinella N. Quality improvement for integrated management of patients with type 2 diabetes (PRIHTA project stage 1). Qual Manag Health Care. 2012;21(3). https://doi.org/10.1097/QMH.0b013e31824d1917.

  • Schoonhoven M, Kemper BPH, Brilleman MI, Does RJMM. Quality quandaries: streamlining the path to optimal care for cardiovascular patients. Qual Eng. 2011;23(4). https://doi.org/10.1080/08982112.2011.602169.

  • Szekeres D, Lechner M, Moody S, Musso M, Weinberg E, Murray T, Wandtke B. Improving access to outpatient computed tomography. Curr Probl Diagn Radiol. 2025;54(2):233–37. https://doi.org/10.1067/j.cpradiol.2024.10.009.

  • Laganga LR. Lean service operations: reflections and new directions for capacity expansion in outpatient clinics. J Operations Manag. 2011;29(5). https://doi.org/10.1016/j.jom.2010.12.005.

  • Swee ML, Sanders ML, Phisitkul K, Bailey G, Thumann A, Neuzil N, Kumar B, O’Shea AMJ, Dixon BS. Development and implementation of a telenephrology dashboard for active surveillance of kidney disease: a quality improvement project. BMC Nephrol. 2020;21(1). https://doi.org/10.1186/s12882-020-02077-0.

  • van Lent WAM, Goedbloed N, van Harten WH. Improving the efficiency of a chemotherapy day unit: applying a business approach to oncology. Eur J Criminol Cancer. 2009;45(5). https://doi.org/10.1016/j.ejca.2008.11.016.

  • Muharam R, Firman F. Lean management improves the process efficiency of controlled ovarian stimulation monitoring in IVF treatment. J Healthc Eng. 2022, 2022. https://doi.org/10.1155/2022/6229181.

  • Lobo-Prat D, Sainz L, Laiz A, De Dios A, Fontcuberta L, Fernández S, et al. Designing an integrated care pathway for spondyloarthritis: a lean thinking approach. J Evaluation In Clin Pract. 2025;31(2). https://doi.org/10.1111/jep.14132.

  • Bakhai S, Jordan J, Stoll JA. Strategies to improve COVID-19 vaccination in a pregnant, marginalized population: quality improvement project. Am J Public Health. 2024;114(S4):S322–29. https://doi.org/10.2105/AJPH.2024.307665.

  • Bakhai S, Mustafa J, Cloutier M, Islam F, Gudleski GD, Reynolds JL. Lean six Sigma quality improvement approach to implement clinical practice guidelines for prescribing opiates for chronic pain in a primary care setting. BMJ Open Qual. 2024;13(3):e002912. https://doi.org/10.1136/bmjoq-2024-002912.

  • Hung DY, Gray CP, Truong QA, Harrison MI. Sustainment of lean redesigns for primary care teams. Qual Manag Health Care. 2019;28(1). https://doi.org/10.1097/QMH.0000000000000200.

  • Hung DY, Harrison MI, Liang SY, Truong QA. Contextual conditions and performance improvement in primary care. Qual Manag Health Care. 2019;28(2). https://doi.org/10.1097/QMH.0000000000000198.

  • Van Leijen-Zeelenberg JE, Brunings JW, Houkes I, Van Raak AJA, Ruwaard D, Vrijhoef HJM, et al. Using lean thinking at an otorhinolaryngology outpatient clinic to improve quality of care. Laryngoscope. 2016;126(4). https://doi.org/10.1002/lary.25741.

  • Aleem S, Torrey WC, Duncan MS, Hort SJ, Mecchella JN. Depression screening optimization in an academic rural setting. Int J Health Care Qual Assur. 2015;28(7):709–25. https://doi.org/10.1108/IJHCQA-01-2015-0012.

  • Gerard B, Robbins M, Putra J, Ram M, Boukhari M, Mutz J, et al. Applying Lean Six Sigma to improve depression screening and follow-up in oncology clinics. J For Healthcare Qual. 2021;43(3). https://doi.org/10.1097/JHQ.0000000000000294.

  • Kollipara U, Varghese S, Mutz J, Putra J, Bajaj P, Mirfakhraee S, et al. Improving diabetic retinopathy screening among patients with diabetes mellitus using the define, measure, analyze, improve, and control process improvement methodology. J For Healthcare Qual. 2021;43(2). https://doi.org/10.1097/JHQ.0000000000000276.

  • Maitre NL, Burton VJ, Duncan AF, Iyer S, Ostrander B, Winter S, et al. Network implementation of guideline for early detection decreases age at cerebral palsy diagnosis. Pediatrics. 2020;145(5). https://doi.org/10.1542/PEDS.2019-2126.

  • Tlapa D, Zepeda-Lugo CA, Tortorella GL, Baez-Lopez YA, Limon-Romero J, Alvarado-Iniesta A, Rodriguez-Borbon MI. Effects of Lean healthcare on patient flow: a systematic review. Value Health. 2020;23(2). https://doi.org/10.1016/j.jval.2019.11.002.

  • Haakenstad A, Irvine CMS, Knight M, Bintz C, Aravkin AY, Zheng P, et al. Measuring the availability of human resources for health and its relationship to universal health coverage for 204 countries and territories from 1990 to 2019: a systematic analysis for the global burden of disease study 2019. Lancet. 2022;399(10341). https://doi.org/10.1016/S0140-6736(22)00532-3.

  • Narayanamurthy G, Gurumurthy A, Subramanian N, Moser R. Assessing the readiness to implement lean in healthcare institutions – a case study. Int J Prod Econ. 2018;197. https://doi.org/10.1016/j.ijpe.2017.12.028.

  • Rahat N, Sahni S, Nasim S. Mapping sustainability practices in the healthcare sector: a systematic literature review and future research agenda. Int J Consum Stud. 2024;48(1). https://doi.org/10.1111/ijcs.12997.

  • Eijsink JFH, Fabian AM, Vervoort JPM, Al Khayat MNMT, Boersma C, Postma MJ. Value-based health care in Western countries: a scoping review on the implementation of patient-reported-outcomes sets for hospital-based interventions. Expert Rev Pharmacoeconomics Outcomes Res. 2023;23(1):1–13. https://doi.org/10.1080/14737167.2023.2136168.

  • Rathi R, Kaswan MS, Antony J, Cross J, Garza-Reyes JA, Furterer SL. Success factors for the adoption of green Lean Six Sigma in healthcare facility: an ISM-MICMAC study. Int J Multiling Lean Six Sigma. 2023;14(4):864–97. https://doi.org/10.1108/IJLSS-02-2022-0042.

  • Zhu Q, Johnson S, Sarkis J. Lean six sigma and environmental sustainability: a hospital perspective. Supply Chain Forum: An Int J. 2018;19(1):25–41. https://doi.org/10.1080/16258312.2018.1426339.

  • de Menezes LM, Escrig-Tena AB. Performance measurement systems in the health and care sector: are targets and monitoring additional demands or resources for employees? Int J Oper Prod Manage. 2023;43(13). https://doi.org/10.1108/IJOPM-12-2022-0763.

  • Smith M, Bititci US. Interplay between performance measurement and management, employee engagement and performance. Int J Oper Prod Manage. 2017;37(9). https://doi.org/10.1108/IJOPM-06-2015-0313.

  • Talero-Sarmiento LH, Escobar-Rodríguez LY, Gomez-Avila FL, Parra-Sanchez DT. A literature review on Lean healthcare: implementation strategies, challenges, and future research directions. Cogent Eng. 2024;11(1). https://doi.org/10.1080/23311916.2024.2411857.

  • Hallam CRA, Contreras C. Lean healthcare: scale, scope and sustainability. Int J Health Care Qual Assur. 2018;31(7). https://doi.org/10.1108/IJHCQA-02-2017-0023.

  • World Health Organization. Quality of care. 2024b.

  • link

    Leave a Reply

    Your email address will not be published. Required fields are marked *