The research provides a literature overview from a timespan of more than 60 years with articles historically and thematically organized about the application of “Lean thinking” (LT) concept and the main research findings through different industries. Lean thinking is an important but yet still under researched aspect of strategic management. By collecting research records from ISI web of knowledge naming directly the lean thinking issue; 34 Web of science records, 10 Medline records and 2 Chinese citation database records were found. Results show that the main focus areas on lean thinking researches are mainly applied in health care industry (with the 48% of the collected records) followed by manufacturing industry (17%), construction (10%), product development (7%), training and education (7%) and supply chain (2%). Other industries (9%) are also starting to apply lean thinking philosophy according to the particularities of their domain. We find research gaps and provide directions for further investigation.

1. WORLD ACADEMIC JOURNAL OF BUSINESS & APPLIED SCIENCES-MARCH-SEPTEMBER 2013 EDITION
International Journal of Business & Management
June 2013 VOL.1, No,4
Lean Thinking Literature Review and Suggestions for
Future Research
Haritz Gorostidi Martinez (Corresponding author)
Glorious Sun School of Business and Management, Donghua University West Yan An Road 1882
Wang Xue Lu
Shanghai First Maternity and Infant Hospital, 536 Changle Road Jing’an, Shanghai 200040, China
Accepted 25 June 2013
Abstract
The research provides a literature overview from a timespan of more than 60 years with articles
historically and thematically organized about the application of “Lean thinking” (LT) concept and the
main research findings through different industries. Lean thinking is an important but yet still under
researched aspect of strategic management. By collecting research records from ISI web of knowledge
naming directly the lean thinking issue; 34 Web of science records, 10 Medline records and 2 Chinese
citation database records were found. Results show that the main focus areas on lean thinking researches
are mainly applied in health care industry (with the 48% of the collected records) followed by
manufacturing industry (17%), construction (10%), product development (7%), training and education
(7%) and supply chain (2%). Other industries (9%) are also starting to apply lean thinking philosophy
according to the particularities of their domain. We find research gaps and provide directions for further
investigation.
Key words: Lean thinking, strategic management, health care
1. Introduction
The application of lean thinking has made a significant impact both in academic and industrial
circles over the last decade, at the same time, fostered by a rapid spread into many other industry sectors
beyond the automotive industry, there has been a significant development and "localization" of the lean
concept (P. Hines, Holwe, & Rich, 2004). Lean is a revolution, not just about the using of tools, or
changing few steps in manufacturing processes, it's about the complete change of the businesses; how
the supply chain operates, how the directors direct, how the managers manage, how employees or
people go about their daily work, in short words, every aspect of the business (Czabke, Hansen, &
Doolen, 2008; Melton, 2005).
The background of lean thinking is based in the history of Japanese manufacturing techniques
which have now been applied world-wide within many types of industry (Melton, 2005). As prescribed
by Womack and Jones, LT principles have been successfully applied to manufacturing and operations
environments. Case studies as well as research literatures have been published extensively (Haque &
James-Moore, 2004). Its advantages and advancements have turned into a new generation guidance
thinking of management revolution since the 21st century (Wang, Qi, & Ieee, 2008). Even though
initially lean thinking was mainly applied within the manufacturing industry (Czabke, et al., 2008;
Davies & Greenough, 2001; Fearne & Fowler, 2006; Haque & James-Moore, 2004; P. Hines, et al.,
2004; Melton, 2005). Lean thinking has also been introduced in the health care service industry helping
to get rid of wasteful steps and fasten up patient flow problems (Ben-Tovim et al., 2008; Ben-Tovim et
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al., 2007; Holden, 2011; Joosten, Bongers, & Janssen, 2009; King, Ben-Tovim, & Bassham, 2006;
Mazzocato, Savage, Brommels, Aronsson, & Thor, 2010; Young & McClean, 2008).
2. Literature review
2.1. Manufacturing lean thinking
Maintenance practices within manufacturing industry can cost companies between 30-50% of their
production, to avoid that burden, an investigation on the level of presence of LT within the maintenance
domain was done, resulting in a summary of maintenance techniques (Davies & Greenough, 2001).
Despite successful "lean" applications in a range of settings, lean approach has also been criticized on
many levels such as the lack of human integration or its limited applicability outside highly repetitive
manufacturing environments. The resulting lack of definition has also led to a confusion and fuzzy
boundaries with other management concepts (P. Hines, et al., 2004). Lean thinking philosophy can
enable any enterprise including a power plant to run at maximum efficiency or constructing a lean
production information system, and produce top-quality products at the lowest cost (Meng, Liu, & Fan,
2007; Motley, 2004). LT can also help secondary wood product manufacturers become more profitable,
improving the marketing process, customer services, new product development process and customer
satisfaction. There are challenges however related to communication. Its critical to communicate the
vision and values of lean thinking to all the employees, making them understand and accept the LT
benefits (Czabke, et al., 2008). Traditional applications of lean thinking are also believed to be limited
in production, manufacturing, and just in time projects. These traditional lean thinking have some
limitations and that is why a “Total Life cycle Lean Thinking” should be promoted through the total life
cycle of the product (Wang, et al., 2008).
Using lean manufacturing methodology in a remanufacturing industry, a disassembly and
reassembly product scheme with nine scenarios of material and information flows processes were
offered for future managerial advice (Kanikula & Koch, 2010). A boat factory that would put the lean
thinking into practice, proposing the most appropriate concepts was also shown, taking from case study
of Finish LT pioneer boat factories (Ehrs, Rymaszewska, & Pekkala, 2012).
2.2. Product Development lean thinking
Womack and Jones’ principles of lean thinking were applied to the New Product Introduction (NPI).
In particular, the five lean principles; specify value, identify the value stream and eliminate waste, make
the value flow, let the customer pull the process and pursue perfection in 40 aerospace companies.
Finalizing with a summary of the key methods and tools that enable LT in NPI (Haque & James-Moore,
2004).
A study in product development in a traditional sector such as the furniture industry two case
studies were analyzed focusing on the organization to balance functional expertise, establish customer
defined value, front load the product development process and standardization tools. The results in new
product development in furniture study revealed an inefficient flow of information in all phases of the
product development leading to numerous sources of waste (Medeiros, Seibel, Jorge, Fernandes, &
Asme, 2010). One of the latest studies addresses sustainability and environmental issues from the
product development design state through its product life cycle, identifying a baseline on developing
tools for future research (Sorli, Sopelana, Salgado, Pelaez, & Ares, 2012).
2.3. Construction lean thinking
To use lean thinking discretely and indiscriminately in an environmental project with high levels of
complexity and uncertainty can produce a potential danger. Some attempts as removing capacity in
transportation, stockholding and on-site labor can be logical and cost-saving but others can result in
reduced levels of responsiveness and flexibility. Common thinking to the application of lean principles
to the construction industry is challenged and called for awareness of the project-centric nature of the
construction industry and the application of LT on it (Fearne & Fowler, 2006).
The aim of presenting a study discussing the role of rapid prototyping in a seamless lean process
from the concept design (3D CAD models) to the construction of a building was also proposed in the
fields of rapid manufacturing and automated construction techniques (Celani, Granja, & Pinheiro,
2008).
To increase productivity in installation of water and sewer services in metropolitan construction
projects, avoiding delays workflow must be improved (Kung, Alex, Al-Hussein, & Fernando, 2008).
The recognition of the importance of sustainable construction by the government gives impulse to the
investigation of a sustainable construction model based on LT. This made construction schemes more
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sustainable, acceptable, saving resources and costs of the projects, benefiting society, environment, as
well as cutting the construction cycle and enhancing the building quality (Yan, Wang, Zhang, & Zou,
2008).
2.4. Supply chain lean thinking
Food value chain analysis (FVCA) based on lean paradigm has been applied to eight different
value chains in the UK. System theory was used to evaluate FVCA, based on four sub-system goals and
values; logistics, human resources and management structure, resulting in a positive potential logistics
benefits along the chain. The two most important implementation issues proved to be the intercompany
alignment of other sub-systems and chain organizational stability through time (Simons & Taylor,
2007).
2.5. Health care service lean thinking
2.5.1. Helping to eliminate wasteful activities
Adopting the “Lean” management technique can help hospital staff to eliminate wasteful activities
(Castle, 2007). Bone and brain metastases treatment for example should begin as soon as possible and
the operational improvement method based on lean thinking could help. LT’s main principles improved
the processes, cutting the number of individual steps to begin treatment. The patients receiving
consultation, simulation and treatment on a day, rose form 43% to 95%, improving the overall delivery
of clinical care to bone or brain metastases patients (Kim, Hayman, Billi, Lash, & Lawrence, 2007). In
health care, lean thinking has emerged as a comprehensive approach towards improving processes in the
diagnostic, treatment and care activities with cost containment results, however it can be used also as an
approach to effective organizational change (Tsasis & Bruce-Barrett, 2008). One of the concepts used
for redesign health care delivery is lean thinking; however lean often leads to resistance due to its lack
of high quality evidence supporting lean premises. The need to use the original lean tools may be
limited because health care may have different instruments and tools already in use that are in line with
lean thinking principles. LT has the potential to improve health care delivery but there are some
methodological and practical considerations that need to be taken into account otherwise lean
implementation will be superficial and fail, adding the existing resistance and making it difficult to
improve health care for the long term (Joosten, et al., 2009). Lean thinking encourages service providers
to focus on value as defined by the customer and the elimination of waste that impedes the flow of value.
The following factors are key for Lean project success: expert guidance for initial efforts, leadership in
the form of clinical champions, senior management support of the improvement work, frontline worker
engagement in mapping out "current state" processes, identifying waste and designing an improved
"future state," using metrics to develop and track interventions, and defining a realistic project scope
(Kim, Spahlinger, Kin, Coffey, & Billi, 2009).
Disruption affecting surgical process can be identified and reduced addressing firstly these
questions; (1) what elements of information flow govern the implementation of an existing activity
within surgical process? (2) What information is needed from other activities before starting and
completing the existing activity? (3) How can the interdependencies between disruption events be
identified? (Al-Hakim & Su, 2010). Lean thinking has been applied successfully in a wide variety of
healthcare settings. But while lean theory emphasizes a holistic view, most cases report narrower
technical applications with limited organizational reach. To better realize the potential benefits,
healthcare organizations need to directly involve senior management, pursue value creation for patients
and other customers, and nurture a long-term view of continual improvement (Mazzocato, et al., 2010).
Actor network theory (ANT) is useful for explicitly tracking how organizational players shift their
positions and network allegiances over time, and for identifying objects and actions that are effective in
engaging individuals in networks which enable transition to a Lean process (Papadopoulos, Radnor, &
Merali, 2011).
In a study of process design comparison in lean thinking framework, exploring efficiency in terms
of lead times, visits and costs, the environmental context and operational focus primarily influenced the
process design of cataract pathways. Hospitals can use these systematic benchmarking data to decrease
the frequency of hospital visits, lead times and costs (Van Vliet et al., 2011).
There is experience in hip fracture patients after applying LT value-stream approach. Using
available resources in an efficient manner, there is a significant reduction of 5%-9.3% in the 30 day
and overall mortality after its implementation (Yousri, Khan, Chakrabarti, Fernandes, & Wahab, 2011).
The new approach of identifying areas for change in an ongoing nurse-led liaison service for older
adults resulted in improving access to mental health services for elderly medically ill inpatients and
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improved quality of their overall care (Atkinson & Mukaetova-Ladinska, 2012). Redesigning the
pathway for un-sedated patients, using lean thinking transformation to focus on patient-derived
value-adding steps, wastes was removed and creating a more efficient process. In the primary unit the
patient pathway reduced from 19 to 11 steps with a reduction in the maximum lead time from 375 to 80
min following the pretended lean thinking transformation (Hydes, Hansi, & Trebble, 2012). Lean
thinking principles were also utilized to set up “One-stop cholecystectomy clinics” at which patients
underwent the surgical and the preoperative assessment during the same visit. This resulted on a
significant reduction in the number of patient visits as well as the waiting time to surgery. It can be
highlighted too, that patient care can be improved by good team working (Siddique, Elsayed, Cheema,
Mirza, & Basu, 2012).
A pilot study in a hospital showed that many unnecessary diagnostic tests were performed routinely.
To reduce costs of unnecessary diagnostic tests, with the introduction of few simple measures to
improve awareness among the physicians, LT led to a significant reduction in the diagnostic costs in the
department of internal medicine (Vegting et al., 2012).
In a cardiology department’s investigation to adopt and adapt lean, its adoption varied with the
degree to which the staff saw a need for change. Work redesign and teamwork were also found helpful
to improve patient care (Ulhassan et al., 2013).
2.5.2. Lean thinking to help patient flow
The flow of patients into groups of patients cared for by a specific team of doctors and nurses, and
the minimizing of complex queues in emergency department by altering the practices in relation to the
function of the Australasian Triage Scale method improved patient flow, decreasing chances for
overcrowding (King, et al., 2006).
Redesigning care has not been aimed at changing the specifics of clinical practice but rather has
been concerned with improving the flow of patients through clinical and other systems (Ben-Tovim, et
al., 2007). The Flinders medical center program was on improving the flow of patients through the
emergency department, but the program quickly spread to involve the redesign of managing medical
and surgical patients throughout the hospital, and improving major support services. The program had
three main phases: "getting the knowledge"; "establishing high-volume flows"; and "standardizing and
sustaining". Results showed that the redesigning care program enabled the hospital to provide safer and
more accessible care during a period of growth in demand (Ben-Tovim, et al., 2008). In the 7th people’s
hospital of Shanghai, the business process of an outpatient appointment and queuing system was
improved with a system of operation efficiency and patients waiting time, on the basis of lean thinking
(Xiangpeng, Rui, & Zhibin, 2008).
There is still scope for methodological development by defining three themes associated with the
operational, the clinical and the experiential value (Young & McClean, 2008). Emergency departments
(EDs) face problems with crowding, delays, cost containment, and patient safety. After the
implementation of lean in a study, patient care improved, decreasing the length of stay, waiting times etc.
There were some indications of positive effects on employees and organizational culture too as
employee involvement, management support, and preparedness for change (Holden, 2011). Bottlenecks
in patients journeys trough an emergency department were evaluated with reference to a lean thinking
value-stream map (Ryan et al., 2013).
2.6. Training and education lean thinking
A lean course arrangement model of a university under the guidance of lean production thinking
was proposed. The aim was to solve the time conflict in the election courses proposing a “same group
different time, same class different heads” course arrangement model. The basic idea was not arranging
schedule ranked by the same group courses at the same time, but ranked by different group of courses
(Li & Liu, 2008).
A rational for the design and development of a video simulation used to teach lean thinking and
workflow analysis was judged effective because it allowed students to visualize a real-world process,
contemplate the scenes depicted in the video along with the concepts presented in class in a risk-free
environment, developing hypotheses about why problems occurred in the workflow process and
therefore develop solutions to redesign a process (Campbell, Gantt, & Congdon, 2009).
A case study described one residency program's educational curriculum to provide foundational
knowledge in quality improvement QI and patient’s safety PS to all its trainees. The aim was to
highlight a resident team based project that apply principles of LT to evaluate the process responding to
an in-hospital cardiopulmonary arrest providing residents with a practical experience but also presenting
an opportunity for trainees to align with the health system's approach to improving quality and safety
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(Kim et al., 2010).
2.7. Other Industry LT
A tentative legal supply chain model was explored in how lean thinking can be successfully
extended into the legal sector, looking where and how the implementation of LT could start, and the
modifications required to its success (Peter Hines, Martins, & Beale, 2008).
Lean government is part of a growing trend of management tools designed to lower costs and
improve efficiency of government operations. However, the transference of lean techniques from the
private sector to the public sector requires a careful balancing of administrative law and management
labor relations (Scorsone, 2008).
Lean methods are difficult to implement in companies from the distribution sector due to the
volatility of customer demand, the high degree of human participation and the demanding mechanical
and repetitive activities in retail and storage activities. A methodology for change management to adopt
lean practices in distribution centers was presented proving it suitable for establishing a lean culture in
these type of companies and resulting in good outcomes in terms of productivity, employee attitudes and
participation (Jaca, Santos, Errasti, & Viles, 2012).
Waste management using a sample of small and medium sized hotels in 19 European countries was
researched naming the LT seven value mapping streams: Process activity mapping, supply chain
response matrix, production variety channel, quality filter mapping, demand amplification mapping,
decision point analysis and physical structure with particular reference guest reservation and reception.
It was found that hotels do apply value mapping techniques, and similarities were found in hotel
operations regardless of location. It is suggested that every value stream mapping technique (except
production variety funnel and supply chain response matrix), can have a high impact on detecting and
eliminating waste both upstream and downstream of the value chain. (Vlachos & Bogdanovic, 2013).
3. Methodology
The research plan was carried on analyzing the concept of lean thinking as a business strategy
philosophy as well as to determine the focus areas of this concept. The research review findings from all
available research articles on lean thinking. After general literature search, it was decided to use “lean
thinking” term as the key phrase to find articles directly related with lean thinking business philosophy
avoiding “lean”, “lean management” or “total lean management” concepts. Specific search was created
by the use of limiting and refining search criteria. Limiting criteria was: ISI Web of Knowledge,
publication period 1950-2013 and “lean thinking”. The refining criteria on the search were: social
science as research domain and academic articles as document types sorted by relevance. It was decided
to produce data sheet consisting of the key focus areas of the fields of interest using Endnote 4X
software. After reading the titles, abstracts and conclusions, the following articles were included in the
review; from a timespan of 63 years, all those mentioning directly the lean thinking term in their title,
from the databases; Web of Science, Inspec, Derwent Innovations Index, Chinese Science Citation
Database and Medline.
4. Findings and discussion
The search resulted in 46 papers from year 2001-2013, 34 Web of science records, 10 Medline
records and 2 Chinese citation database records covering a wide range of areas. 2007, 2008 and year
2012 showed the highest publication rate on lean thinking, with a significant publication rate on 2008
(Appendix a). Findings from main focus areas, from highest to lowest show: Health care (with a 48% of
found records), manufacturing (17%), construction (10%), product development (7%),
training-education (7%) and supply chain (2%). Other industries (9%) are also attempting to implement
or improve LT within their domain; Government administrations, distribution centers, legal sector and
hospitality industry (Appendix b). It seems that apart from the expected manufacturing LT publications,
an especial big amount of research has been held in health care service industry LT，fields like supply
chain, hotel service, distribution, legal sector, universities, government have just started. Other new
fields could be included in the future. LT research literatures have been published extensively. Its theory
and practice has had a significant impact as well as a rapid spread into many industry sectors
considering it as a new generation guidance thinking of management revolution. It implies a complete
change in all terms inside a business and it’s considered as “the lean thinking philosophy”. It has been
successfully applied to manufacturing and operations environments as well as improving patient care in
health services, indicating also positive effects on organization culture, management support and
readiness for change from employees. Using video simulations has been judged effective for LT
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trainings.
Different type of industries and sectors as health care services, shipping industries, legal industry,
government and distribution companies have started to implement LT, but adapting it to their specific
industry characteristics.
On the negative side, adapting LT into each industry as well as establishing lean culture takes time.
There have been authors reporting difficulties in applying lean outside highly repetitive manufacturing
environments, the lack of human integration, and the lack of LT definition leads also to confusion with
other management concepts. Some industries might be applying some instruments and tools already in
lined with lean thinking principles. There have been reported also cases that found challenge related to
communication and its understanding, making it difficult accepting a lean thinking business strategy
among employees. Also a total live cycle lean thinking should be stressed considering all the processes
through the total life cycle of the product or service. In short words, the focus for future research should
be to keep the path of specific researches for each industry taking into account their particularities so
that LT can be implemented in a customized way.
Appendix
a) Lean thinking: Year Wise
b) Lean thinking: Literature Review
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