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International Journal of Operations & Production Management

ISSN : 0144-3577

Article publication date: 1 July 2014

The advent of recession at the beginning of twenty-first century forced many organizations worldwide to reduce cost and to be more responsive to customer demands. Lean Manufacturing (LM) has been widely perceived by industry as an answer to these requirements because LM reduces waste without additional requirements of resources. This led to a spurt in LM research across the globe mostly through empirical and exploratory studies which resulted in a plethora of LM definitions with divergent scopes, objectives, performance indicators, tools/techniques/methodologies, and concepts/elements. The purpose of this paper is to review LM literature and report these divergent definitions, scopes, objectives, and tools/techniques/methodologies.

Design/methodology/approach

This paper highlights various definitions by various researchers and practitioners. A total of 209 research papers have been reviewed for the research contribution, research methodology adopted, tools/techniques/methodologies used, type of industry, author profile, country of research, and year of publication.

There are plethora of LM definitions with divergent objectives and scope. Theory verification through empirical and exploratory studies has been the focus of research in LM. Automotive industry has been the focus of LM research but LM has also been adopted by other types of industries also. One of the critical implementation factors of LM is simultaneous adoption of leanness in supply chain. LM has become an integrated system composed of highly integrated elements and a wide variety of management practices. There is lack of standard LM implementation process/framework.

Originality/value

The paper reviews 209 research papers for their research contribution, research methodology, author profile, type of industry, and tools/techniques/methodology used. Various characteristics of LM definitions are also reviewed.

• Lean manufacturing
• Lean production
• Lean literature review

Bhamu, J. and Singh Sangwan, K. (2014), "Lean manufacturing: literature review and research issues", International Journal of Operations & Production Management , Vol. 34 No. 7, pp. 876-940. https://doi.org/10.1108/IJOPM-08-2012-0315

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Copyright © 2014, Emerald Group Publishing Limited

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Investigating the influence of lean manufacturing approach on environmental performance: A systematic literature review

• ORIGINAL ARTICLE
• Open access
• Published: 28 February 2024

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• Matteo Ferrazzi 1 ,
• Stefano Frecassetti 1 ,
• Alessia Bilancia 1 &
• Alberto Portioli-Staudacher 1  

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The growing emphasis on environmental sustainability has drawn considerable attention from both academia and industry practitioners. Factors such as escalating energy costs, heightened environmental degradation, and a burgeoning market demand for eco-friendly practices have compelled businesses to reassess their strategies through a green lens. Given that Lean principles are rooted in optimising operations to minimise waste across design and production processes, their synergy with the green paradigm is evident. However, despite the intuitive connection between Lean methodologies and environmental sustainability, the scholarly exploration of their impact remains largely underdeveloped. This research seeks to bridge this gap by conducting a comprehensive systematic literature review to dissect the current understanding of Lean manufacturing practices and their influence on environmental sustainability performance. The selected papers were meticulously screened and grouped into three clusters using the PRISMA diagram methodology. The primary objective was to discern the tangible effects of Lean practices on eco-efficiency performance and explore integrating Lean manufacturing principles with broader sustainable manufacturing approaches. A structured matrix was created to categorise and visualise the identified impacts gleaned from the initial articles. Nevertheless, the review revealed significant gaps in understanding, particularly regarding the factors that shape the efficacy of Lean manufacturing tools in enhancing eco-efficiency performance. The findings underscore the need for further research to unravel these complexities and delineate the mechanisms through which Lean practices contribute to environmental sustainability. Several avenues for future research have been delineated, focusing on how Lean manufacturing practices can be leveraged to support eco-efficiency performance effectively. While the preliminary findings shed light on the promising intersection between Lean principles and environmental sustainability, they also underscore the imperative for continued scholarly inquiry to unlock the full potential of Lean methodologies in fostering a greener industrial landscape.

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1 Introduction

Lean manufacturing was developed in Japan under the name Toyota Production System [ 1 ]. The general concept became famous with the publication of the article “The machine that changed the world” in 1990 [ 2 ]. One of the main goals of Lean is to implement a continuous improvement philosophy that enables companies to reduce costs, improve processes, and eliminate waste to increase customer satisfaction [ 3 ]. Nowadays, the lean manufacturing approach is considered the most influential paradigm in manufacturing [ 4 ]; empirical evidence suggests the increased competitiveness of organisations [ 5 ] by reducing inventory and lead times and improving productivity. In this context, the lean paradigm has not only been in line with historically prevalent organisational goals, such as profitability and efficiency, but also with contemporary goals, which include improving productivity, quality, and responsiveness.

Over the decades, the lean manufacturing approach has been able to adapt to different contexts and be used for various problems in companies worldwide [ 6 ]. In recent years, many researchers [ 7 , 8 ] have investigated whether, in addition to productivity goals, the lean manufacturing approach was also useful for environmental sustainability goals in manufacturing companies. Environmental sustainability is increasingly at the centre of issues both in academia and in the interest of practitioners. In recent decades, managing operations following a logic aimed at environmental sustainability has become the managers’ mission in many manufacturing companies. Effects such as rising energy prices, increasing environmental pollution and market demand for green practices have prompted companies to rethink their strategies from a green perspective [ 9 ]. Environmental sustainability initiatives consider business improvements, which aim to transform an input into an output using as few resources as possible [ 10 ]. The first and most important positive outcome for companies that apply green thinking is reducing their environmental impact.

This is evidenced by several studies that have considered the relationship and investigated the impact of green initiatives on the performance of organisations. Green manufacturing management methods influenced by the lean manufacturing approach are as diverse as; Green manufacturing [ 11 , 12 ], a manufacturing process that helps to minimise environmental impact to protect and maintain the natural environment and resources. A circular economy [ 13 ] is a set of strategies that, in combination with the lean approach, generates new value from waste or production waste. Eco-design [ 14 ] is a methodology for designing products and their production systems with minimal environmental impact. Since Lean is an operations management approach that aims to eliminate waste in every area of factory design, production and management, its alignment with the green paradigm and its methods seem natural [ 15 ]. Some studies relate the lean manufacturing approach to green manufacturing paradigms [ 16 ]. Despite this, the big question that the academic community is asking is how an approach which has revolutionised the management of operations in manufacturing can support one of the biggest challenges facing society in recent decades; that is, empowering manufacturing companies to continue to be profitable while at the same time going about managing and limiting their environmental impact.

Indeed, despite the academic interest, also manifested by the growing number of publications on these topics and various studies investigating how lean manufacturing interacts with environmental sustainability, there are still open questions. Lines of research that explore the impact of lean manufacturing practices on environmental performance or eco-efficiency and those that explore the influence of lean manufacturing on environmental sustainability and the green manufacturing paradigm are still in primordial stages. The concept of eco-efficiency is developed in the industrial world because its practical approach makes it possible to balance environmental and economic benefits in an integrated way. Its goals are to reduce resource consumption and impact on nature while maintaining or increasing production volume. The environmental performance of a company or industry is becoming an important criterion of evaluation, as evidenced by environmental standards (ISO 14000 series). Eco-efficiency indicators are tools used to know how resources are used in a process and its impact on the environment. Indicators are defined for the manufacturing sector as the value of the output of manufactured products and the amount of resources used or pollution generated [ 17 ]. This research aims to facilitate further research on the influence of lean manufacturing on environmental sustainability performance. This paper presents a literature review of the current state of research on this emerging topic. The goal is to identify gaps in today’s literature and find future lines of research. To this end, the paper aims to systematically collect and critically analyse existing contributions on using lean manufacturing practices in manufacturing settings and the effect on environmental sustainability performance. Two main questions are proposed to guide the research:

What are the emerging topics in today’s literature on lean manufacturing practices and their influence on environmental sustainability performance?

What are the main tracks for future research on lean manufacturing and environmental sustainability?

In the following sections, the article is structured to answer the research questions proposed above. In Section 2 , researchers critically analyse the search method used to select articles from the existing literature. Section  3 , through a literature review, debates the main outcome. In Section 4 , the systematic literature review results are discussed for the development of future lines of research. Finally, Section 5 will present the answers to the research question of this article and show the limitations and future developments of this research.

2 Research method

Through the literature review proposed below, this article aims to analyse the state of the art of interaction between the two macro research topics. In particular, it seeks to investigate how the operation management approach of lean manufacturing can positively influence the sustainable performance of manufacturing organisations. An effectively conducted literature review can highlight areas where research is still primordial. Once areas are highlighted, it is easier to develop theories and, at the same time, identify areas where vague concepts still exist [ 18 ]. The literature review uses a systematic, explicit, reproducible method [ 19 ]. The research questions presented in the previous chapter were formulated to address a systematic review of the existing literature. A systematic literature review is a method that takes a precise, transparent and explicit approach that includes a series of steps to ensure appropriate rigour and transparency in the literature review process [ 20 ]. Denyer and Tranfield (2009) believe that a systematic literature review consists of the following five consecutive steps: (1) formulation of the question, (2) identification of studies, (3) selection and evaluation of studies, (4) analysis and synthesis, and (5) communication and use of results. All of these stages will be analysed in this paper [ 21 ].

According to Saunders et al. [ 22 ], for transparency, it is necessary to explain in detail how the systematic review process was conducted, particularly regarding the selection of literature and the choices made regarding the use of search terms. The next section will explore this in more detail; the steps, methods and tools used in the systematic literature review approach will be analysed.

2.1 Articles selection

The search for articles was conducted through a search string on the Scopus electronic database. The choice to use Scopus arose from the fact that this database conveys within itself the most authoritative and certified contributions from the various journals of reference in this research field. The search string used for searching in Scopus is the result of several refinements and iterative tests to be able to find the right query for the database to ensure the same time completeness and specificity. By using a systematic approach to the literature search, it was possible to have complete information on the research topic. Through a systematic search, one is assured of the current knowledge of the research topic. In this way, one can ensure that important contributions are not overlooked. The empirical context of the research is defined as Lean manufacturing and environmental sustainability, while the analysis of the environmental performance of manufacturing companies defines the theoretical lens. This research investigates how lean manufacturing practices and tools can influence environmental performance. Next, undertaking a systematic literature search means finding relevant keywords related to the topics under analysis. In this case, the choice was to capture the keywords of the two macro topics, Lean management and environmental sustainability, and consider their intersection.

In fact, on the one hand, there are some keywords which refer to the area of Lean management (“lean practices”, “lean tools”, “lean manufacturing”, “lean production”, “lean management”). In order not to exclude the contribution of significant articles dealing with manufacturing and production areas, in addition to general terms such as “lean management” and “lean production,” more specific terms such as “lean practices” and “lean tools” have been added. The same approach was used for keywords in the area of environmental sustainability. The selected keywords are “environmental sustainab*,” “eco-efficiency,” and “eco-sustainability.” Again in combination with more general terms, such as “environmental sustainab*,” more specific terms dealing with environmental performance, “eco-efficiency”, and “eco-sustainability,” were added. Once these keywords were identified, they were linked through logical constructs, creating the reference search query for this search. The query through the logical construct “AND” collects studies that are part of the intersection of the two sets of keywords described previously.

To better organise the item selection phase, the PRISMA was used. The PRISMA diagram visually summarises the screening process (Fig.  1 ). It initially identifies the number of articles found with the search query. Subsequently, it makes the screening process transparent by reporting the decisions made at the various stages of the systematic review. Once the search string was identified, filters were applied to ensure specificity and consistency with respect to the topic to be investigated by selecting only certain articles. First, no restriction was added on the studies’ publication years. According to the research, the publication years of the papers are between 2007 and 2022. Evidence shows that lean and environmental sustainability have been discussed in the academic literature since the early 1990s [ 23 ]. However, a major turning point in how organisations perceive their business’s environmental dimension can be considered the release of the ISO 14001 environmental management standard in late 1996 [ 24 ]. So, the years of research done through the database fit into this time frame. The filters were included in the sub-areas to identify the relevant scientific communities. The sub-areas of business management and engineering were included. The reason is related to the fact that industrial engineers may be interested in the benefits that lean can bring to new operational solutions to solve some sustainability problems. At the same time, managers may benefit from this research to explore new sustainable business possibilities using the influence of lean.

PRISMA diagram-systematic search

The research results included only articles, peer-reviewed published in academic journals and international conference proceedings. According to Saunders et al. [ 22 ], these sources are the most useful and reliable for literature reviews. In addition, it was decided not to exclude a priori papers not published in Q1 journals. This is because it was considered important not to exclude even minor contributions, as environmental sustainability is dynamic and constantly evolving, and excluding some papers, a priori could result in missing important information.

The final search QUERY, including keywords and filters, is written below:

TITLE-ABS-KEY ((“lean practice”OR“lean tools”OR“lean manufacturing”OR“lean production”OR“lean management”)AND(“environmental sustainab*”OR“eco-efficiency”OR“eco efficiency”OR“eco-sustainability”OR“eco sustainability”)) AND (LIMIT-TO ( DOCTYPE, “ar”) OR LIMIT-TO ( DOCTYPE, “cp”) OR LIMIT-TO ( DOCTYPE, “re”)) AND (LIMIT-TO (SUBJAREA, “ENGI”) OR LIMIT-TO ( SUBJAREA, “BUSI”)) AND (LIMIT-TO (LANGUAGE, “English”)).

2.2 Analysis and synthesis

Through the full reading, three articles [ 25 , 26 , 27 ] were discarded because they were out of the research objective of this paper as they dealt with the use of the lean approach. Still, the focus on environmental sustainability was a topic that was not central to the article. Many approaches exist to qualitatively synthesise the research developed through the proposed QUERY, including thematic/synthesis analysis, qualitative comparative analysis, and content analysis. This study presents an initial thematic analysis of the selected articles by reading them. Thematic synthesis was considered the most appropriate method to analyse the results obtained from the systematic literature review conducted in this study [ 28 ]. The Lean manufacturing approach to have better sustainable performance was not only used in manufacturing and operations areas. The research query returned several articles encapsulated into a first set through thematic synthesis. Twenty-two articles (37%) were identified, dealing with the lean manufacturing approach to environmental sustainability performance in supply chain/logistics, construction, and agriculture contexts. These articles fall under the systematic literature search but are considered low contribution because they deal with research in areas not inherent to the manufacturing and operations domain. The second thematic group of 19 articles (32%) encompasses studies showing the impact of the lean approach, particularly lean practices, on eco-efficiency performance. This study presented empirical evidence of how Lean manufacturing practices influence environmental sustainability or eco-efficiency performance. This thematic group of articles is the only part that can contribute the greatest to this research because it perfectly targets the research questions above. Finally, the last thematic group represents that group of 18 articles (30%) that show a pattern or conceptual relationship between environmental sustainability and the Lean manufacturing approach. These articles have a medium contribution to this research. On the one hand, they express the interaction between Lean manufacturing and environmental sustainability, but through studies that express very holistic conceptual models that include other types of sustainability or propose models for a transition to green manufacturing processes.

Through the full reading of the articles, 59 articles entered the literature review. As anticipated in the previous chapter, these articles were divided the three thematic groups: Group A.1, Group A.2, and Group B (the characteristics of these groups will be developed in the next sections). The articles in the literature review deal with the relevant topic, i.e., the Lean manufacturing approach and its influence on environmental sustainability and eco-efficiency performance concepts.

3.1 Sources of publication

In the graphs presented in this session, the results of the systematic literature search are represented synthetically with respect to various analyses: articles published by journals or conference proceedings (Fig.  2 ), number of publications per year (Fig.  3 ), specific journal (Fig.  4 ) and most cited authors (Fig.  5 ).

Types of articles published

Number of publications yearly trend

Journals with the highest number of publications

Most cited authors

First of all, it can be stated that the topic covered by this study is of great topicality and interest to the relevant academics. This is first demonstrated in Fig.  3 . It can be analysed how Lean manufacturing approach for environmental sustainability is a topic of great interest from the referenced academic communities mentioned above in recent years. From the graph, it can be seen that in the time frame of publication of the selected articles (2007–2022), there is a positive trend of publication growth. In particular, it can be noted that from 2017 onward, 88% (52 articles) of total publications were concentrated. This suggests that this topic is on the rise and can grow further in the coming years and attract the interests of both practitioners and academics.

Figure  2 shows that conferences have been an important medium for disseminating studies on this topic (21%) but still represent a minority of publications. Most of the studies (70%) are articles published in journals. This is likely because, in most cases, these studies enjoy depth and status suitable for journal publication. Through Fig.  4 , the number of citations per journal is shown. The research found that journal publications are distributed across 37 different journals. The total number of articles published in the 37 journals is 51; despite this fact, as many as 21 articles are enclosed in only seven. This analysis makes it possible to identify which journals are the reference journals for this particular topic. Figure  4 shows seven publications from the Journal of Cleaner Production and four from the Journal of Manufacturing Technology Management . In comparison, they have two publications each from Benchmarking , International Journal of Operations and Production Management , International Journal of Production Economics , Sustainability Switzerland , and Journal of Green Building .

Finally, Fig.  5 represents the number of publications per author. This kind of analysis is useful for identifying the leading scholars regarding this topic. In particular, it is possible to see how Bortolini, M., Mora, C. and Galicia, F.G. have four publications each, while Sarkis, J. has 3.

3.2 Systematic literature review

The systematic literature review will answer the first research question in the first chapters. Then, this paper will investigate the emerging themes in today’s literature on lean manufacturing practices and their influence on environmental sustainability performance. The future lines of research related to the literature review will be presented, thus answering the second research question.

The articles selected for the systematic literature review all refer to the impact of lean manufacturing on environmental sustainability. Despite this, a preliminary thematic classification of the various articles was necessary. This was very useful in identifying the main themes covered in the set of selected articles and detecting the contribution/relevance of multiple articles. As preliminarily presented earlier, the articles were divided into three classes (Table  1 ). First, the collected articles were divided with respect to the empirical context of reference. Group A of articles deals with lean management and environmental sustainability in manufacturing/operation contexts.

In contrast, group B of articles deals with the same topic in non-manufacturing contexts, such as supply chain/logistics, construction, and agriculture. Then, the articles in group A were divided into two subgroups (group A.1 and A.2). Group A.1 collected all the articles that deal with the impact of lean manufacturing on environmental sustainability by going to show how lean manufacturing practices had an impact on companies’ eco-efficiency performance. Group A.2, on the other hand, collects the remainder of the articles that deal with the topic of research in manufacturing/operation sectors, proposing models and studies that show how the relationship between green production paradigm integrated with the lean manufacturing approach can be effective in arriving at more sustainable production models (Fig.  6 ).

Overview scheme of article groups

The three groups of articles presented within the systematic literature review have different relevance. The three groups are categorised by importance according to the following scheme:

Group A.1 - High Significance/Impact: papers that focus on analysing the impact of lean manufacturing practices on eco-efficiency performance in manufacturing settings and analysing variables that influence the effect of lean manufacturing on environmental sustainability performance. They have greater significance because they clearly show the impact of lean manufacturing on environmental sustainability performance.

Group A.2 - Medium Significance/Impact: papers that theoretically integrate lean manufacturing techniques with green manufacturing paradigms. These papers explain how lean manufacturing practices have been modified and integrated with environmental sustainability practices to generate more sustainable manufacturing environments. These papers have medium relevance within this literature review because they show the impact of lean manufacturing on environmental sustainability at a holistic level.

Group B - Low Significance/Impact: papers that address the impact of lean manufacturing on environmental sustainability in contexts other than manufacturing. These papers have low relevance within this literature review because they do not fully address the research objective but may be useful in developing future lines of research.

In the following paragraphs, the literature will be divided into thematic groups, mainly groups A.1 and A.2, to answer the research questions in the first chapter.

3.3 Matrix: Lean practices — eco-efficiency performance

The first step in the systematic literature review starts with article group A.1. Although all the articles in this group deal with the impact of Lean manufacturing practices on eco-efficiency performance, it is necessary to create a structure to understand how this impact manifests itself. For this reason, it was decided to develop a matrix to categorise, visualise, and structure the impacts shown by each article in group A.1 (Fig.  7 ). This visualisation tool is intended to convey a discussion of the main findings of the systematic literature review. To create the matrix for categorising the impacts of lean manufacturing practices on eco-efficiency performance, it is necessary to identify the variables that will make up the vertical and horizontal axis of the matrix. For the vertical axis of the matrix, a set of variables representing lean manufacturing practices were identified. The variables identified to express the Lean manufacturing approach, which emerges from the literature reviewed in this group of articles, are related to the lean practices made explicit by Shah and Ward in 2003 in one of the most important articles on the Lean approach, “Lean manufacturing: context, practice bundles, and performance” [ 87 ]. This article was taken as a reference for identifying variables that represented lean manufacturing practices because it is considered by scholars to be one of the masterpieces in the literature dealing with topics related to lean philosophy. The practices can be summarised in 18 variables. They are listed below: Just-in-time (JIT), Kanban, 5S, Single Minute Exchange of Die (SMED), Value Stream Map (VSM), Customer engagement, Supplier collaboration, Total Productive Maintenance (TPM), Kaizen, Total Quality Management (TQM), Bottleneck removal (production smoothing), Human Resource Management (HRM), Cellular manufacturing, Continuous improvement programs, Cycle time reductions, Customer engagement, Supplier collaboration, Employee involvement, Visual management, 9th type of muda.

Article classification matrix group A.1

For the horizontal axis, variables related to eco-efficiency performance were identified to represent the impact of Lean manufacturing on environmental sustainability. Eco-efficiency performance variables were identified to complete the horizontal axis of the matrix. In order to do this, there is no single reference study recognised by the scientific community that can unambiguously guide the identification of such variables. However, studies that have already addressed the issue of eco-efficiency performance can be exploited. Indeed, it is possible to identify matrix variables related to eco-efficiency performance through the studies of Garza-Reyes & Kumar [ 88 ] and Maxime et al. [ 17 ]. Eco-efficiency metrics can be grouped according to four macro variables: natural resource use, pollution emissions, material use/consumption, and non-productive outputs [ 16 ]. These four macro variables were then divided into sub-variables according to the nature of each eco-efficiency performance. The subdivision into sub-variables is presented below:

Use of natural resources: Energy, water, oil

Pollution emissions: carbon footprint, CO2 emissions

Material use/consumption: raw materials, auxiliary materials, packaging

Non-productive outputs: production waste, defects, auxiliary production materials

Once the variables for lean practices (vertical axis) and variables for eco-efficiency performance (horizontal axis) were identified, the matrix was populated by the items included in group A.1. The matrix below also shows a colour code to identify the various effects of Lean practices on eco-efficiency performance. Numbers in black represent a positive impact, numbers in red have a negative effect, and numbers in blue have a null effect.

Each cell of the matrix expresses the impact of one variable of lean practices on one variable of eco-efficiency performance. First, it should be emphasised that in most cases analysed during this literature review, the impact of lean practices on eco-efficiency performance is positive. Only two articles present studies showing negative or null impact on eco-efficiency performance. The study by Chen et al. [ 42 ] highlights the negative effect of continuous improvement programs on water and energy consumption. The article by Resta et al. [ 30 ] presents both a negative effect of TPM on energy consumption and a null effect of Human Resource Management on energy consumption, raw material utilisation, and waste generation reduction [ 30 ]. The matrix shows how, within the systematic literature review, the effect of lean practices, identified by Shah and Ward, on eco-efficiency performance is present in many ways. Some examples represented in the matrix are SMED for carbon footprint reduction [ 34 , 44 ], VSM for energy consumption [ 29 , 33 ] for CO 2 reduction [ 35 , 43 ], and TQM for reduction of non-productive outputs such as production waste [ 42 ].

The first reflection from this review is that the matrix created shows how the lean manufacturing approach positively affects eco-efficiency performance and, consequently, environmental sustainability. Once this is consolidated, one can go deeper with the literature review.

First, a preliminary consideration is, which lean practices are most widely used to solve problems related to improved eco-efficiency performance (Fig.  8 ). The lean practices that feature most in this literature review are Value Stream Map (in 9 out of 19 articles), Total productive maintenance (in 6 out of 19 articles), Continuous improvement programs & Kaizen (in 4 out of 19 articles) and Just-in-time & 5 s (in 3 out of 19 articles). Some of these practices are also presented in the articles as modified or adapted to solve problems related to environmental sustainability. The lean practice most prone to this phenomenon is the Value Stream Map [ 37 , 43 ]. This leads to the idea that this lean practice is one of the most effective and mature practices in improving eco-efficiency performance.

Number of citations for Lean practices by eco-efficiency performance

It is also interesting to identify which eco-efficiency performances are most subject to the intervention of the lean approach to be improved (Fig.  9 ). The eco-efficiency performances that were most featured in this literature review are reduction of energy consumption (in 12 out of 19 articles), reduction of carbon footprint (in 10 out of 19 articles), reduction of raw material consumption (in 8 out of 19 articles), and reduction of production waste (in 6 out of 19 articles). The eco-efficiency performances are most subject to improvement in the literature review; those that companies consider the most critical or the most sensitive can be analysed to have a concrete improvement in the company’s environmental sustainability.

Number of citations for eco-efficiency performance impacted by lean practices

Another interesting point to make about the proposed matrix is identifying areas not covered in the literature. In fact, on the one hand, lean management practices such as Kanban, Supplier collaboration, and Customer engagement are never mentioned. While regarding eco-efficiency performance, there still seems to be little literature that analyses performance, such as defect reduction for environmental sustainability, packaging consumption reduction, and auxiliary material consumption reduction.

3.4 Integration of the lean manufacturing approach with sustainable production models

The next stage of the systematic literature review is developed by analysing the articles included in group A.2. The systematic review of these articles highlights a strong relationship between lean manufacturing and environmental sustainability. All articles in this thematic group explore the integration of lean manufacturing with sustainable production approaches. For a better critical analysis of this group of articles, it was decided to divide them into four macro sub-clusters: (1) Effective decision-making tools, (2) Overcoming barriers, (3) The Triple Bottom Line Concept and (4) Industry 4.0.

This thematic group offers studies that develop models/frameworks for creating environmentally sustainable manufacturing models. The integration between lean manufacturing-based production models and green production paradigms are concepts developed in several articles. Studies such as Bai et al. highlight the lack of effective decision-making tools that help implement lean practices for better environmental sustainability. This study, therefore, seeks to develop a new decision-making model for evaluating lean practices. The results of this study identify a set of investments in developing the lean approach to direct companies toward green production models [ 31 ].

Implementing lean and green productions share common goals, so integration between these paradigms is natural. Despite this, some scholars highlight that manufacturing companies often face barriers to implementing green production processes. This implementation involves several challenges and requires appropriate actions to overcome internal and external barriers. Some articles propose lean manufacturing as a suitable approach to support the transformation to green production systems. In particular, the article by Colombo et al. presents an inductive analysis of a textile manufacturing company that, while operating according to lean manufacturing principles, has recently initiated a green transformation project [ 54 ]. The results confirm that green transformation is an ongoing process of gradually adopting green management practices. In addition, the study suggests that the distinctive features of lean manufacturing can help organisations overcome specific barriers that arise at different stages of the green transformation process. Another example of a study for overcoming barriers to green transition is reported by Kaswan et al. [ 57 ]. This article proposes a decision-making model to help companies prioritise barriers and manage important and causal relationships among them. The results reveal that management-related barriers are ranked first, followed by environmental and organisational ones. The review of this group of articles brought out additional interesting aspects.

Several authors study the integration between lean and environmental sustainability by considering different issues. Some proposed studies do not limit the integration of lean manufacturing to environmental sustainability but introduce a more holistic concept of sustainability. These studies consider a Triple Bottom Line concept; environmental sustainability is linked to social and economic sustainability principles. Jum’a L. et al. [ 63 ] provide a model that holistically relates lean manufacturing practices to develop sustainable production processes. Another example is the article by Longoni A. & Cagliano R. [ 56 ]. This research aimed to study the involvement of multiple functions in formulating and implementing the operational strategy for supporting lean manufacturing for sustainability. The results of this study are related to the development of operational strategies and social and environmental sustainability, taking advantage of lean manufacturing support. Finally, the study written by Ferrazzi et al. [ 64 ] analyses a case study that, through the utilisation of the lean management approach, succeeded in impacting the social sustainability of the company taken into consideration. In fact, through the reconfiguration of the operations of some operators on an assembly line, the company, taking into analysis, managed to achieve better ergonomic performance for its workers [ 64 ]. These studies highlight how some authors consider lean manufacturing not only closely related to environmental sustainability. In fact, according to these studies, social and economic sustainability are inescapable and must be viewed as a fundamental factor when it comes to lean manufacturing.

Another interesting aspect that emerged in the literature review is the introduction of the concept of Industry 4.0. Articles such as Ghaithan et al. [ 51 ] expose how the paradigms of lean manufacturing, Industry 4.0 and environmental sustainability over the years are increasingly interconnected. These studies aim to identify the forms of integration between Lean, Industry 4.0, and environmental sustainability by examining the relationships among these three constructs, deepening the understanding of the topic, and evolving the construction of a framework that can help the management of industrial production processes. As presented by the authors, these studies investigate promising research areas that have not been explored. The operational contribution of such studies is that they can help managers understand the integrations between Lean practices and I4.0 technologies to achieve better operational and environmental outcomes.

4 Discussion

The literature indicates that scholars and academics are increasingly investigating the link between environmental sustainability and lean manufacturing [ 10 ]. As analysed in the literature review, on the one hand, the influence of lean manufacturing practices with the green manufacturing paradigm and how these two paradigms have been integrated over the years are being studied [ 45 ]. From another perspective, empirical evidence is expressed in the literature showing that lean manufacturing approaches positively affect eco-efficiency performance [ 7 ]. However, the literature review showed that there are still many unexplored spaces in this area of research. Following are proposed some future lines of research that can still be explored. Finally, new research questions related to the lines of research that emerged from the literature review are proposed.

4.1 Critical analysis and open issues

The systematic literature review of article group A.1 clearly showed the influence of lean practices on eco-efficiency performance. In most cases, a positive influence of lean practices is shown in the summary matrix. Despite this, it is unclear what factors influence the effect of the Lean manufacturing approach on improving eco-efficiency performance. In particular, an analysis of the current state of the literature on this topic reveals some lines of research yet to be explored. Some possible factors not yet explored in depth in the literature will be outlined below. Cherrafi et al. [ 89 ] explain that factors such as “lack of communication and cooperation,” “lack of kaizen culture,” and “poor corporate culture separating environmental and continuous improvement decisions” are barriers to greater “environmental awareness” and consequently harm sustainable performance. Studies such as Longoni A. & Cagliano R. [ 56 ] also highlight how alignment across functions and alignment of goals between top management and operators are key factors in achieving better results for environmental sustainability. These factors can be expressed as soft lean practices; they are a set of practices developed to act on the behaviours of individuals in organisations that take advantage of the lean approach [ 90 ]. Despite the great potential of soft lean practices, few studies examine how soft lean practices can achieve eco-efficiency performance. Some studies show that increased adoption of soft lean practices may be a key factor in amplifying the benefits of lean tools [ 91 ]. Future studies could investigate how lean soft practices may be a factor that fosters the positive effect of lean tools on eco-efficiency performance. Another factor that may impact the influence of lean tools on eco-efficiency performance is the company’s degree of Lean maturity. Analysis of the literature, especially in group A.1, has shown that companies with lean manufacturing systems have higher eco-efficiency performance. To date, research is unable to determine how much and how maturity in using the lean approach affects environmental performance. Some studies show that lean maturity is a factor in achieving better operational performance [ 92 ]. From this perspective, it is reasonable to think that the maturity of lean adoption may also be a determinant of better environmental performance; in fact, there are empirical studies that show that through the use of lean tools in manufacturing settings, both operational and environmental performance have benefited [ 93 ]. For these reasons, it is necessary to investigate further the role of maturity in using the Lean approach to achieve improved eco-efficiency performance.

Over the past two decades, the great push toward digitisation has also led to enormous changes in the lean manufacturing approach. Digitisation and introduction of Industry 4.0 practices have profoundly changed the use of the lean approach [ 94 ]. The literature review presents how Industry 4.0 can be a factor, through synergy with lean tools, for an impact on environmental sustainability [ 51 ]. Despite this, in the literature review, there appears to be a lack of studies showing how integrating Industry 4.0 techniques can amplify the benefit of lean practices for better eco-efficiency performance. Therefore, a line of research investigating this aspect becomes essential. As presented earlier, during the literature review, some articles present how lean practices have been modified and adapted to address environmental sustainability issues [ 43 ].

On the other hand, most articles included in the matrix expose the use of lean practices that have not been adapted and modified [ 29 ]. The literature reveals that it is unclear how some lean practices can be adjusted while others cannot. It is unclear why some lean practices have not yet been adapted for environmental sustainability issues. Above all, it is not yet clear whether the adaptation of lean practices can be a factor that affects eco-efficiency performance, especially compared to a situation where lean practices have not been modified.

Another factor to be considered for future research is contextual factors. In fact, during the systematic search of articles, no filter was added to select studies that analysed the lean approach for sustainability in predetermined context areas. This consequently led to a heterogeneity of studies showing the positive effect of lean practices on eco-efficiency performance. At this time, however, it is unclear how contextual factors, such as the company's size or the industry where it operates, could influence lean practices' impact on eco-sustainability performance. Studies in very different sectors and from companies of very different sizes are presented in the matrix. In possible future lines of research, it is interesting to study how contextual factors of companies may influence the impact of lean practices on eco-efficiency performance.

Another area of investigation for future research is related to group A.2 The current literature does not understand the relationships between various lean tools, sustainable environmental practices, and eco-efficiency performance [ 16 ]. This is clear from reviewing the articles in group A.2. The studies propose models that relate to the lean approach and green production practices but do not show how this integration manifests in environmental sustainability performance. Moreover, some scholars argue that it is necessary to study a relational model that shows which and to what extent lean tools impact various eco-efficiency performances [ 8 , 16 ]. It is unclear what the relationships are between various lean practices and eco-efficiency performance and what the interactions among them can bring higher benefits in improving eco-efficiency performance.

As a final output, a set of research questions for future lines of research related to the analysis just described are presented below.

Understanding what influences the impact of lean practices on eco-efficiency performance.

How do the soft lean factors influence the impact of lean practices on eco-efficiency performance?

How does the maturity grade of lean practices influence eco-efficiency performance?

How does the synergy between I4.0 and lean practices influence eco-efficiency performance?

How can lean practices be modified to influence eco-efficiency performance?

How can lean practices be influenced by contextual factors (such as company size and sector) for eco-efficiency performance?

How can lean practices interact with each other to lead to better eco-efficiency performance?

Which lean practices have the greatest impact on eco-efficiency performance?

Understand how integrating various lean manufacturing and sustainability practices influences eco-efficiency performance.

How can integrating Lean practices with green manufacturing paradigms improve eco-efficiency performance?

What are the lean practices that influence different eco-efficiency performances? Furthermore, what is their interaction?

How can the lean manufacturing approach holistically affect the sustainability of manufacturing companies (Triple bottom line concept)?

How can the Lean approach help manufacturing companies overcome barriers to green production models?

5 Conclusion

5.1 discussion and contribution to theory.

This study is further evidence of how environmental sustainability, one of organisations’ goals, must align with their traditional profitability and efficiency priorities. This paper has studied several aspects linking the Lean manufacturing approach and environmental sustainability, particularly how lean manufacturing practices positively impact eco-efficiency performance. Through a systematic review of the literature, the authors were able to answer the two research questions proposed in the introduction section.

In particular, to answer the first research question, the systematic literature review identified two macro areas of investigation. The first area is how the influence of Lean practices on eco-efficiency performance is manifested. To clarify this, a matrix was created to summarise and visualise the effects of lean practices on eco-efficiency performance. The second macro area is related to integrating the Lean Manufacturing approach with sustainable production models.

A series of future research lines were developed to answer the second research question. The future research questions are related to macro areas of investigation that emerged from the literature. Specifically for the first research area, it is interesting to investigate which factors impact the influence of Lean manufacturing practices on eco-efficiency performance. The factors that develop future lines of research are (1) the implementation of soft lean practices, (2) the lean maturity level of the company, (3) the implementation of Industry 4.0 practices, (4) the adaptation of Lean practices for environmental sustainability goals, and (5) the contextual factors of organisations. While related to the second area of investigation, this study proposes to investigate how the integration of Lean practices with green production paradigms can improve eco-efficiency performance and also what the interactions among various Lean practices can bring higher benefits in improving eco-efficiency performance (i.e., if there are synergetic effects).

In conclusion, the presented research can stimulate and foster the research for the relevant scientific communities, and aims to provide practitioners with information that is extremely necessary to compete in today's market. Indeed, this study provides a comprehensive overview of how Lean manufacturing can address environmental sustainability issues. In this way, practitioners can develop a deeper understanding of these issues. This study can help them formulate strategies to compete in a market increasingly focused on sustainable product development. This research may help organisations select and exploit new production models based on Lean manufacturing with better eco-efficiency performance.

5.2 Limitations and further research

Even though this paper contributes substantially to enriching the existing knowledge on the topics, it presents its limitations and pitfalls. The first limitation is that the researchers used specific keywords to identify the papers. Thus some precious contributions could have been lost in this phase or the following screening phases in which the number of articles have been selected. Also, the classification in groups of the papers has been done according to the authors’ thoughts. Thus, it presents a certain grade of subjectivity, which could be a pitfall.

Then, this study does not consider the context variables (e.g., companies’ sector, dimension, etc.) of the papers analysed. For instance, the dimension of a company or the industry in which it operates can have a huge impact on eco-efficiency performance, as well as other factors such as the presence of corporate sustainability programs massive presence of digital technologies or incentives. Thus, the researchers suggest further research, both from a theoretical and an empirical perspective, focusing on the effect brought by these elements or their inclusion in similar studies.

Another main limitation of this paper is the absence of a weighting system for the eco-efficiency variables. Here, all the variables in this paper have the same weight. For further research, studies that analyse and rank each Lean practice’s impact on eco-efficiency performance are strongly encouraged. In that way, weight and thus the importance in terms of effects on eco-efficiency performance can be given to each Lean practice.

A pitfall could also be the complete absence of the economic and time dimension. In fact, the impact on eco-efficiency of using Lean practices is considered but did not contemplate the company’s effort in terms of implementation time and monetary expenditures. It could be possible, for instance, that to achieve good results, companies have to spend a huge amount of resources before some good results are obtained. Thus, the researchers propose future research to take into consideration these factors.

A last limitation of this work is the absence of a reference seminal paper related to the eco-efficiency variables. In fact, unlike the Lean practices, where the reference paper was the one by Shah & Ward [ 6 ], no reference paper has been used for the eco-efficiency variables. The eco-efficiency variable has been a subjective choice based on screening several papers on eco-efficiency performance. Thus, further research in developing a model with the most relevant variables for eco-efficiency in manufacturing is suggested.

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All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Matteo Ferrazzi and Alessia Bilancia. The first draft of the manuscript was written by Matteo Ferrazzi and all authors commented on previous versions of the manuscript. Stefano Frecassetti was responsible for the final review. Alberto Portioli supervised the entire project. All authors read and approved the final manuscript.

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Ferrazzi, M., Frecassetti, S., Bilancia, A. et al. Investigating the influence of lean manufacturing approach on environmental performance: A systematic literature review. Int J Adv Manuf Technol (2024). https://doi.org/10.1007/s00170-024-13215-5

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The impact of lean management on frontline healthcare professionals: a scoping review of the literature

• Zeyad Mahmoud   ORCID: orcid.org/0000-0003-3331-8093 1 , 2 ,
• Nathalie Angelé-Halgand 3 ,
• Kate Churruca 1 ,
• Louise A. Ellis 1 &
• Jeffrey Braithwaite 1  

BMC Health Services Research volume  21 , Article number:  383 ( 2021 ) Cite this article

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Lean management practices are increasingly used in hospitals. However, their impacts on staff have not been systematically synthesised. This scoping review aims to synthesise the evidence on the effects of Lean Management practices on frontline healthcare professionals.

A search was conducted in February 2020 on multiple databases to identify relevant sources. Studies had to satisfy the following inclusion criteria to be considered: published in English or French, peer-reviewed, empirical, studied the use of Lean in a healthcare setting and focused on its impacts on frontline workers. The studies included were heterogeneous in terms of participants. Findings were coded and classified using a thematic analysis. The quality and methodological rigour of the reviewed articles were assessed to establish a level of confidence in their findings.

Of 998 identified articles, 17 were included in the review. The findings were coded into four themes: (1) Morale, motivation and job satisfaction ( n  = 9, 2) work intensification, job strain, anxiety, stress and dehumanisation ( n  = 7, 3) teamwork, communication and coordination ( n  = 6); and (4) learning, innovation and personal development ( n  = 3). Overall, the articles reported positive ( n  = 11), negative ( n  = 3) and mixed ( n  = 3) impacts of Lean on frontline healthcare professionals.

This review is the first to synthesise and highlight the gaps in the existing literature examining the impacts of Lean on frontline health professionals. The review revealed a range of both positive, negative and mixed effects, and points to the need for more empirical research to identify the underlying reasons leading to these outcomes.

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The basic premise of Lean Management (LM)—which has its origins in the automotive industry—is that greater efficiency can be achieved through a process of continuous improvement aimed at eliminating waste and maximising value-adding activities [ 1 , 2 , 3 , 4 ]. Also referred to as the Toyota Production System, or TPS, LM constitutes a radical transformation of traditional mass-production methods [ 3 , 4 ]. Instead of focusing on producing large volumes of standardised goods, LM emphasises waste elimination as a way of improving the flexibility of productive resources and addressing variability in customer demands [ 1 ].

It is challenging to retain a singular and straightforward definition of LM and what it encompasses due to the vast discrepancies between the definitions used by various authors writing on the subject [ 5 ]. However, for the purpose of this review, we use Radnor et al’s definition of Lean as a “management practice based on the philosophy of continuously improving processes by either increasing customer value or reducing non-value adding activities (muda), process variation (mura), and poor work conditions (muri)” [ 6 ]. Generally, LM is considered to be the “antidote” to waste in organisations [ 3 ]. Waste, defined as tasks and processes that do not contribute to the creation of value but consume organisational resources, is associated with inefficiencies, reduced flexibility and the generation of unnecessary costs [ 3 ]. Ohno, the developer of LM, identified seven sources of waste (summarized in Table  1 ) and pioneered managerial and organisational tools and techniques to help organisations get rid of them (e.g., Value Stream Mapping, 5S, Kanban, Standardisation, Process map) [ 2 ]. While the tools of Lean are numerous, they are broadly designed to help organisations understand their customer needs, identify the value-adding activities essential to producing services and products desired by their customers, create production flow by reducing unnecessary delays and interruptions, reduce inventory and overproduction, and continuously improve and refine their productive processes [ 8 ].

It did not take long for LM to migrate from Toyota and the car manufacturing industry into service-delivery organisations and then public institutions [ 5 , 9 , 10 , 11 ]. LM has indeed been linked to a host of positive organisational outcomes across-the-board, including improved quality of goods and services, reduced costs and increased productivity [ 12 ]. In healthcare, evidence of LM implementation can be found on the micro (operational), meso (strategic) and macro (policy) levels. It has been implemented in a variety of settings including operating rooms, emergency departments, mental health centres, pharmacy services, information departments, and ambulatory care clinics [ 13 , 14 ]. Overall, LM has been associated with reduced waiting times in emergency departments [ 15 , 16 ], fewer medical errors [ 17 ], and improved clinical pathways [ 18 ].

In healthcare, previous literature reviews have identified different approaches to LM implementation [ 13 , 19 , 20 , 21 ]. On one hand, LM is considered as a comprehensive organisational philosophy aimed at systematically addressing waste at all levels [ 21 ]. On the other hand, LM is seen as a toolbox with organisations often implementing one or two LM practices to address waste in a single process or on a small scale (e.g., one ward, or a specific unit) [ 8 ]. Whilst piecemeal implementation of LM could be effective in reaching desired performance and efficiency goals, there is little evidence on the long-term sustainability of such gains [ 19 ]. In particular, these approaches often overlook crucial elements of LM implementation such as employee engagement and participation.

Against a backdrop of increasingly scarce human, material and financial resources [ 14 ], LM has rapidly grown in popularity amongst health practitioners and managers interested in improving the efficiency of their services [ 22 ]. It is within this context of proliferation, that we set out to investigate how health professionals experience LM practices and are impacted by them. This is particularly important in light of recent conceptual developments calling for a more holistic approach to the adoption of LM which takes into account both technical and people-oriented strategies [ 20 , 21 , 23 ]. As demonstrated by a growing number of reviews, going beyond the technicalities of LM is a key factor in its successful implementation within organisations [ 19 , 24 ]. Addressed to policymakers, managers, quality improvement personnel and researchers, this review aims to identify articles addressing the effects of LM on the health workforce and characterise the impacts discussed therein. This scoping review was guided by the following research question:

RQ1: What are the impacts of LM interventions on frontline healthcare professionals?

A scoping review was conducted to gain a deeper understanding of how LM impacts frontline healthcare professionals. Findings of the review are reported in accordance with the PRISMA-SCR guideline [ 25 ]. This choice of methodology is justified by the emerging nature of the evidence on the impact of LM on the health workforce [ 26 ]. The aim of this review is to provide a comprehensive overview of the existing literature and put forward a research agenda for future research on this topic. With that aim in mind, a review strategy was developed and approved by all members of the research team prior to systematically searching the following academic databases in February 2020: Scopus, Emerald, EBSCO business premier and PubMed. The search strategy was not published or registered in an open platform. The choice of databases allowed for the identification of relevant publications in the fields of health science, as well as management studies where LM originated. Papers were searched by combining a set of topic-related keywords (Lean approach, Lean process, Lean method, Lean transformation, Lean philosophy, Lean principles, Lean practices, Lean process improvement, Lean management, Lean healthcare, Lean thinking, Lean production, Lean six sigma, Toyota production system) and a group of setting-related keywords (health care, healthcare, hospital). Only peer-reviewed articles were searched; news articles, conference proceedings, magazines, trade publications and book chapters were excluded using the exclusion parameters of the online databases during the search phase. No starting date was specified, and articles published up to 29 February 2020 were included. Table  2 portrays the use of the search strategy using Scopus database as an example. Additional file  1 includes an example of the search string used to query PubMed and Scopus.

Search results from each of the databases were aggregated and imported into an Endnote library, and duplicate entries were removed. Abstracts had to satisfy the following inclusion criteria (Table  3 ) to be considered in the review: published in English or French, peer-reviewed, empirical, studied the use of LM (i.e., reporting on the use of at least one LM activity) in a healthcare setting (i.e., any facility where healthcare services are delivered) and focused on its outcomes on frontline healthcare workers (i.e., with the primary aim of reporting impacts or effects of LM on staff working at a healthcare setting). Articles discussing the experiences of managers, lean consultants or internal lean champions were excluded due to the role played by these actors in the implementation or the promotion of Lean practices. To ensure consensus on the retained articles, 5% of the identified abstracts were randomly assigned to a second reviewer for assessment using the inclusion criteria. Interrater reliability was subsequently calculated using Cohen’s kappa [ 27 ].

Data charting and analysis

Full-text analysis was conducted independently by the first author on the retained articles using a data summarising sheet. The sheet was developed and approved by the research team. It recorded essential information including the country of study, language, publication year, publication journal, study setting (e.g., academic hospital, emergency department), reported Lean tools or principles (e.g., value stream mapping, 5S, visual follow-up boards, pull production, Kanban), data collection methods (e.g., interviews, focus groups, observations, surveys), theoretical framework, and staff related findings.

Staff-related outcomes were analysed and synthesised following a three-stage thematic analysis approach [ 28 ]. In the first stage, 48 different codes emerged from the findings of the included studies. They were consequently grouped into four different descriptive themes: Morale, motivation and job satisfaction; work intensification, job strain, anxiety, stress and dehumanisation; teamwork, communication and coordination; and learning, innovation and personal development. Analytical themes emerged throughout the data collection and analysis process. They were mapped to the four-fold classification of the findings. Descriptive data from the articles were summarised using numerical counts.

Risk of bias

The quality of articles was evaluated using Hawker et al.’s Quality Assessment Tool [ 29 ]. The tool allows the scoring of papers based on the quality (good (4 points), fair (3 points), poor (2 points) or very poor (1 point) of nine key attributes: abstract and title; introduction and aims; method and data; sampling; data analysis; ethics and bias; findings/results; transferability/generalisability; and, implications and usefulness. Papers can be attributed a maximum score of 36 points (high quality) or a minimum score of 9 points (very low quality). To complement the tool, Lorenc et al. [ 30 ] presented a tiered classification of articles depending on their overall quality score: “high quality” (30–36 points), “medium quality” (24–29 points), and “low quality” (9–24 points). This classification was subsequently adapted by J Braithwaite, J Herkes, K Ludlow, L Testa and G Lamprell [ 31 ] slightly reducing the cut-off score for low quality articles to 23 instead of 24 points which increased the transparency of the tool. Quality assessment was conducted to indicate the level of confidence with which findings should be taken. Given the emerging nature of this area of study, quality scores were not used to exclude articles from the review.

Out of 998 identified abstracts, 953 were excluded for not meeting the inclusion criteria at title/abstract stage. The Cohen’s Kappa for the 5% randomly assigned abstracts was 0.78, indicating a substantial agreement between reviewers. The full-text review of the articles corresponding to the remaining 45 abstracts resulted in the exclusion of 28 studies for not investigating the impact of LM on frontline healthcare workers (i.e., not discussing effects of LM on staff, not reporting on how staff experienced LM interventions, or discussing staff outcomes as an incidental or secondary finding). In total, 17 studies were included in the final analysis [ 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 ]. Figure  1 is a graphic representation of the search strategy results using the PRISMA flow chart [ 49 ].

Systematic Review Search Strategy

The articles included in the review ( n  = 17) were published between 1995 and 2018, with the majority being published in 2014 ( n  = 4, 23.5%) [ 42 , 43 , 45 , 47 ] and 2018 ( n  = 4, 23.5%) [ 32 , 35 , 38 , 48 ]. All the publications were in English, except one in French [ 38 ], and the largest proportion of the studies ( n  = 5, 29.4%) were conducted in Sweden [ 37 , 39 , 44 , 45 , 46 ]. Over half of the publications were in health services journals ( n  = 9, 53%) [ 32 , 33 , 35 , 37 , 39 , 42 , 45 , 48 , 50 ] . Five studies (29.4%) were published in nursing [ 40 , 47 ], surgical [ 34 ] and quality in healthcare journals [ 44 , 46 ]. Only three studies (17.6%) were published in a management or social science journal [ 38 , 41 , 43 ]. The full list of journals is presented in Table  4 .

Most of the studies used either qualitative research methods ( n  = 8, 47.1%) [ 38 , 41 , 42 , 43 , 44 , 46 , 48 , 50 ] or quantitative ( n  = 7, 41.2%) [ 32 , 34 , 35 , 37 , 40 , 45 , 47 ], with two studies (11.8%) using a mixed-methods approach [ 33 , 39 ]. Case studies were the most common research design ( n  = 10, 58.8%) [ 32 , 37 , 38 , 39 , 41 , 42 , 43 , 46 , 48 , 50 ], followed by Pre/Post evaluation studies ( n  = 7, 41.2%) [ 33 , 34 , 35 , 40 , 44 , 45 , 47 ]. Seven studies (41.2%) used a theoretical framework to provide a conceptual foundation for their findings [ 32 , 37 , 38 , 39 , 40 , 44 , 45 ].

Regarding the research sites, most of the studies were conducted in acute care settings (emergency departments ( n  = 7, 41.2%) [ 39 , 42 , 43 , 44 , 45 , 47 , 48 ], operating theatres ( n  = 2, 11.8%) [ 34 , 38 ], and intensive care units ( n  = 1, 5.9%) [ 34 , 38 ]. Most of the studies ( n  = 13, 76.5%) reported on the use of multiple Lean techniques simultaneously [ 33 , 34 , 35 , 38 , 39 , 40 , 41 , 43 , 44 , 45 , 46 , 47 , 48 , 50 ]. Only two of the studies did not make any mention of the Lean techniques used in the examined sites [ 32 , 42 ]. Visual management was the most reported LM technique ( n  = 9) [ 37 , 38 , 39 , 40 , 43 , 44 , 45 , 46 , 48 ], followed by workspace redesign ( n  = 6) [ 35 , 38 , 39 , 43 , 44 , 48 ], standardisation ( n  = 5) [ 34 , 37 , 38 , 39 , 40 ], and value stream mapping ( n  = 4) [ 33 , 37 , 44 , 45 ]. Descriptive information on the studies and a summary of their findings are presented in Additional file  2 .

Risk of bias and quality assessment

Hawker et al.'s (2002) Quality Assessment Tool [ 29 ] was used to evaluate the quality and methodological rigour of the reviewed articles because it is suitable for assessing studies with various designs. Table  5 presents an overview of the quality assessment of the articles reviewed. Articles were classified as either high, medium or low quality based on Braithwaite et al.’s (2017) cut-off values. Detailed quality scores are reported in Additional file  3 .

Overall findings

Morale, motivation and job satisfaction.

Nine articles (52.9%) found impacts of LM on staff’s morale, motivation, and job satisfaction. In a recent study, LM was associated with improved morale and job satisfaction amongst primary care physicians and medical assistants in a US not-for-profit clinic [ 35 ]. Survey data collected in the clinic suggested higher levels of work-satisfaction and personal motivation at work amongst participants after the LM intervention. The intervention included a physical workplace redesign as well as LM-inspired workflow improvements that were associated with increases in employee engagement and participation in decision making.

Similar results were also reported in a U.S. teaching hospital and were considered to be the result of LM’s philosophical foundations which promote giving employees ownership of their work and valuing their perspective [ 34 ]. Employee participation, supportive leadership and regular staff meetings were correlated with improvements in job content (i.e., level of influence at work, opportunities for development, the meaning of work, commitment and recognition) in another study conducted in two Swedish cardiac wards [ 45 ]. The bottom-up problem-solving approach at the heart of LM and the use of collaborative tools such as value stream mapping were shown to promote employee participation and were considered catalysts for improved wellbeing when they were supported by other resources and used by all professional groups [ 37 ].

Nurses in a private medical centre also indicated increased levels of job satisfaction after LM principles were applied in their telemetry unit [ 40 ]. Amongst the reported benefits of this intervention was an 85% reduction in the distances walked by staff members during their shifts. The LM-inspired reform also contributed to a decrease in overtime, allowed nurses to routinely take their breaks and created conditions that enabled them to follow their professional values.

A study conducted in two Swedish hospitals and one health municipality showed that work standardisation and the use of 5S were positively correlated with improved job satisfaction among staff [ 37 ]. Similar findings were reported in a Senegalese hospital that used 5S, a method of LM, to declutter and to improve the hygiene and the overall cleanliness of the workplace [ 50 ]. In a New Zealand study, morale improvements were also experienced by staff working across three emergency departments that adopted the LM tools of 5S, standardisation and value stream mapping [ 42 ].

In Australia, job satisfaction improved after the implementation of LM in two public hospitals as it enabled service workers to benefit from new professional status, greater task variety and access to new career paths [ 41 ]. Job reconfigurations undertook as part of the same intervention also allowed individual staff members to gain greater peer recognition which further contributed to improved job satisfaction.

Increased satisfaction of intensive care nurses and pharmacy technicians was reported after LM tools were used to reconfigure the continuous renal replacement therapy workflow at a major academic hospital in the US [ 33 ]. In this case, the rise in satisfaction scores was attributed to a decrease in nurses’ workload (measured by the number of phone calls to the pharmacy), as well as enhanced production planning by the pharmacy staff.

Work intensification, job strain, anxiety, stress and dehumanisation

Seven of the reviewed studies (41.2%) suggested that LM led to work intensification, job strain, anxiety, work-related stress and dehumanisation. In a Swedish study, the adoption of LM led to a significant imbalance between the job resources at the disposal of staff and their job demands, leading to a deterioration of work conditions over time [ 37 ].

Similarly, O’Donnell (1995) critically assessed the impact of a LM-inspired reform on the services staff at two Australian hospitals [ 41 ]. His research showed that LM led to considerable work stress and intensification due to the elimination of slack and the amalgamation of professional roles. Higher levels of peer-surveillance were also reported as staff increasingly monitored each other’s performance. Furthermore, multiskilling was criticised for being a façade behind which pressure was put on teams to execute labour-intensive tasks. The author noted that in one of the studied hospitals, the adoption of LM was accompanied by forms of managerial coercion, forcing employees to adhere to the new proposed work organisation by, for example, threats of closure and intensification of work conditions for resisting staff.

Evidence of work intensification was also found in a study examining LM in an Australian emergency department [ 43 ]. Even though the increase in workloads was attributed to macro-level issues of budgetary pressures being exercised on public healthcare institutions, the authors indicated that LM could lead to work intensification merely by allowing organisations to increase their service capacity while maintaining the same levels of resources.

More recently, wide-scale survey data collected by Hung and colleagues (2018) showed a significant increase in levels of workplace stress, burnout and emotional exhaustion amongst physicians and non-physicians following the implementation of LM at a large ambulatory care facility [ 35 ]. Decreased levels of personal accomplishment were mainly reported among the clinical population indicating a negative self-evaluation of the care-related activities they conducted following the LM intervention. Despite the report of positive effects on engagement, teamwork and participation in decision making, the authors’ results indicate that in the studied context, LM did not seem to improve efficiency without negatively impacting hospital staff. Similar findings were reported in three emergency departments in New Zealand where increased levels of work intensification where reported despite improvements in morale [ 42 ].

Looking at the use of LM in a French operating theatre (OT), Mahmoud et al. (2018) revealed LM promotes and embodies thoughts that may lead to the instrumental use and dehumanisation of individuals [ 38 ]. Using Honneth’s [ 51 ] concept of reification, the authors characterised experiences of dehumanisation in three forms of relationships in which operating theatre nurses were engaged (i.e., with other nurses, with the organisation, with patients). In the OT, reification was associated with staff being solely focused on achieving pre-set goals that they objectify their colleagues in the process. It was promoted at the organisational level when individuals felt reduced to a set of skills and were used instrumentally to achieve organisational goals. Reification was also apparent when the human side of care was relegated to the background as patients became increasingly considered as income-generating resources.

In another study, Zebrowski et al. (2018) explored the impact of LM on the clinical work of emergency nurses and physicians in Canada [ 48 ]. The authors found that LM was associated with a decline in morale, an increase in physical, emotional and cognitive stress which exposed the nurses to high risks of developing burnout.

Teamwork, communication and coordination

Six of the articles (35.3%) included in the review indicated that LM was positively associated with improvements in teamwork, communication, and coordination amongst staff members. In three case, these improvements were attributed to a physical workplace redesign which involved combining workstations of care team members [ 35 , 39 , 44 ]. The new stations allowed staff to spend less time locating each other while acting as a convenient platform for sharing patient information leading to enhanced communication and collaboration.

Coordination between staff was also improved as a result of work standardisation, continuous flow and the use of a team-based approach in a Swedish hospital. These LM tools were shown to have reduced misunderstandings, errors and duplications [ 39 ]. Leadership rounds (i.e. Gemba walks) in a UK hospital were linked to better relationships and teamwork between managers and staff [ 47 ]. The rounds provided managers with an in-depth understanding of the challenges faced by the teams. Visual Management tools such as whiteboards also facilitated both synchronous and asynchronous communication between staff and managers [ 46 ].

Improvements in teamwork were also self-reported by staff after LM was applied to the perioperative otolaryngologic workflow in an American university hospital [ 34 ]. Participants in this study reported improvements in the six dimensions of the validated Safety Attitudes Questionnaire (SAQ) [ 52 ], including teamwork, when the survey was administered before and after the LM intervention.

Learning, innovation and personal development

Three of the reviewed studies (17.6%) examined the impact of LM on the learning and personal development opportunities available to staff as well as their innovation skills. Survey data collected in an academic operating theatre showed that the implementation of LM had no impact on the intraoperative teaching activities [ 34 ]. The authors of this study argued that LM could provide additional high-value training opportunities by increasing the capacity of the operating theatres and reducing low-value, time-consuming activities such as unnecessary or redundant administrative work. However, the authors did not provide any data in support of this hypothesis.

In a Senegalese hospital, the adoption of LM was shown to have helped foster a mutual learning environment in which employees engaged in peer-education activities. These participants highlighted the ways that LM helped them enhance their physical work-conditions [ 50 ]. Another study revealed that LM had a significant positive effect on the innovation skills of employees [ 32 ]. The study was conducted using a self-administered questionnaire completed by 400 employees working in 11 private and two public hospitals.

Overall, the articles reviewed alternately described the relationship between LM and employee outcomes as positive, negative, or mixed (i.e., both positive and negative in the same setting). On the one hand, LM was found to have helped improve teamwork, communication and coordination between staff [ 34 , 35 , 39 , 44 , 46 , 47 ]. It was shown to potentially provide staff with increased learning and personal development opportunities [ 34 , 36 ] and was linked to improved innovation skills, morale, motivation and job satisfaction [ 32 , 33 , 34 , 35 , 37 , 40 , 41 , 42 , 45 , 50 ].

On the other hand, LM was correlated with higher levels of stress, job strain, anxiety, work intensification and dehumanisation [ 35 , 37 , 38 , 41 , 43 , 48 ]. The inconsistent outcomes of Lean are exemplified by studies that simultaneously found an association between LM interventions and both positive and negative employee outcomes [ 35 , 37 , 41 ]. Table  6 provides an overview of the review results classifying them according to the studies’ overall assessment of LM’s impact on staff.

Beyond the limited range of research conducted on the human outcomes of LM in healthcare, the review also reveals the lack of both methodological diversity and rigour that characterises the existing literature. Most of the included studies ( n  = 10, 58.8%) lacked a theoretical conceptualisation of the staff related outcomes of LM and were constrained by reporting descriptive results with relatively limited analytical reach.

Furthermore, despite examining the use of multiple LM tools and techniques, only one of the studies considered Lean holistically, as an organisational, system-wide approach designed to target waste and improve the production of value [ 38 ]. The majority of the studies, instead, focused on assessing the outcomes of using specific Lean-related tools or techniques. Accordingly, a large number of the studies adopted an evaluation design that, while useful, substantially limits the generalisability of the results and the conclusions that can be drawn about the impact of LM on staff. Generalisability was also hindered by the adoption of single case study designs, often conducted in one country, as well as by the absence of theoretical framing of the study or results, or both.

Most of the articles in this review exclusively reported positive employee-related outcomes of LM ( n  = 11, 64.8%), perhaps reflecting what has been described as a persistent bias towards the publication of LM related success stories [ 20 , 23 ]. In contrast, three studies found that LM was only associated with adverse outcomes for employees [ 38 , 43 , 48 ]. It is important to note that none of these studies was able to identify a causal relationship between LM and negative workforce experiences. Instead, the authors highlighted the importance of considering the role played by broader financial and budgetary constraints to which health systems are subject, as well as how LM tools and practices were implemented within the studied organisations. A closer examination of these two areas has the potential for resolving what seems to be the paradox of LM, in that it was originally described as an approach based on worker engagement and input [ 1 ] yet in some instances appears to be detrimental to their wellbeing.

More broadly, this review calls for more critical assessments of LM’s impact on healthcare professionals (Table  7 ). Such assessments would involve identifying the reasons why LM is associated with positive outcomes in some instances, negative ones in others and sometimes mixed outcomes, simultaneously, within the one setting. It is currently impossible to pinpoint the reasons for these inconsistent outcomes, given the absence of information in the reviewed articles on the context surrounding the adoption and implementation of LM. It is hoped that future researchers use robustly designed comparative studies that would allow for such critical analyses to be conducted. Such studies should favour qualitative research methodologies to capture the context surrounding the use of LM as well as aspects pertaining to its implementation and how it is experienced by staff.

The results of this review are reflective of the broader literature on LM and its impact on staff working in other industries. In a recent review, F Magnani, V Carbone and V Moatti [ 53 ] also pointed to the restricted number of studies focusing on the impact of LM on employees. They highlighted the inconsistent nature of the research findings on this topic. Further work that holistically examines LM and encompasses its sociotechnical and human dimensions is therefore crucially needed, especially given the demonstrated potential of this approach that can help increase the capacity and improve the efficiency of health systems.

This review has limitations that should be considered. With a primary focus on the impact of LM on frontline healthcare professionals, the review did not report on findings from research examining the experiences of other professionals working in the health systems (e.g. managers, directors, managers, lean consultants or other staff championing Lean initiatives). The findings of the review were also limited to those of published peer-reviewed journal articles written in English or French. Future researchers may choose to attend to other types of academic and non-academic publications in different languages to identify new information on this topic.

In conclusion, this review constitutes the first attempt to synthesise and critically reflect on the published academic literature examining the impact of LM on frontline healthcare professionals. The review highlighted the contested and inconclusive nature of the research on this topic. While some researchers identified positive impacts of LM, others found more mixed results. Overall, studies that holistically examine cases of Lean implementation in healthcare by attending to its sociotechnical and human dimensions remain scarce. Future researchers should prioritise qualitative and comparative research designs that can help address what seems to be a persistently underexploited area of empirical research.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Abbreviations

• Lean management

Preferred reporting items for systematic review and meta-analysis

Operating theatre

Safety attitude questionnaire

Toyota production system

United States

United Kingdom

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Acknowledgements

The authors would like to thank Christie Barnwell for independently reviewing 5% of the selected abstracts against the selection criteria and for assisting with appraising the quality of the included articles.

This work was supported by a Macquarie University Research Excellence Cotutelle Scholarship (Award number: 2017734). JB is supported by multiple grants, including the National Health and Medical Research Council (NHMRC) Partnership Grant for Health Systems Sustainability (ID: 9100002). The funder had no role in the design, analysis and drafting of the manuscript.

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This research was carried out in the framework of the doctoral studies of ZM under the supervision of NAH, LE, KC and JB who provided conceptual assistance on the topic and acted as arbitrators and advisors where necessary. ZM did the abstract and full-text review of the articles, the quality assessment, and prepared drafts of the manuscript. All authors reviewed manuscript drafts and agreed with the final submitted version.

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Mahmoud, Z., Angelé-Halgand, N., Churruca, K. et al. The impact of lean management on frontline healthcare professionals: a scoping review of the literature. BMC Health Serv Res 21 , 383 (2021). https://doi.org/10.1186/s12913-021-06344-0

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The impact of lean management on frontline healthcare professionals: a scoping review of the literature

Zeyad mahmoud.

1 Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Rd, Sydney, NSW 2109 Australia

2 Université de Nantes, LEMNA, F-44000 Nantes, France

Nathalie Angelé-Halgand

3 Université de la Nouvelle Calédonie, LARGE, Nouvelle Calédonie, France

Kate Churruca

Louise a. ellis, jeffrey braithwaite, associated data.

All data generated or analysed during this study are included in this published article and its supplementary information files.

Lean management practices are increasingly used in hospitals. However, their impacts on staff have not been systematically synthesised. This scoping review aims to synthesise the evidence on the effects of Lean Management practices on frontline healthcare professionals.

A search was conducted in February 2020 on multiple databases to identify relevant sources. Studies had to satisfy the following inclusion criteria to be considered: published in English or French, peer-reviewed, empirical, studied the use of Lean in a healthcare setting and focused on its impacts on frontline workers. The studies included were heterogeneous in terms of participants. Findings were coded and classified using a thematic analysis. The quality and methodological rigour of the reviewed articles were assessed to establish a level of confidence in their findings.

Of 998 identified articles, 17 were included in the review. The findings were coded into four themes: (1) Morale, motivation and job satisfaction ( n  = 9, 2) work intensification, job strain, anxiety, stress and dehumanisation ( n  = 7, 3) teamwork, communication and coordination ( n  = 6); and (4) learning, innovation and personal development ( n  = 3). Overall, the articles reported positive ( n  = 11), negative ( n  = 3) and mixed ( n  = 3) impacts of Lean on frontline healthcare professionals.

This review is the first to synthesise and highlight the gaps in the existing literature examining the impacts of Lean on frontline health professionals. The review revealed a range of both positive, negative and mixed effects, and points to the need for more empirical research to identify the underlying reasons leading to these outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06344-0.

The basic premise of Lean Management (LM)—which has its origins in the automotive industry—is that greater efficiency can be achieved through a process of continuous improvement aimed at eliminating waste and maximising value-adding activities [ 1 – 4 ]. Also referred to as the Toyota Production System, or TPS, LM constitutes a radical transformation of traditional mass-production methods [ 3 , 4 ]. Instead of focusing on producing large volumes of standardised goods, LM emphasises waste elimination as a way of improving the flexibility of productive resources and addressing variability in customer demands [ 1 ].

It is challenging to retain a singular and straightforward definition of LM and what it encompasses due to the vast discrepancies between the definitions used by various authors writing on the subject [ 5 ]. However, for the purpose of this review, we use Radnor et al’s definition of Lean as a “management practice based on the philosophy of continuously improving processes by either increasing customer value or reducing non-value adding activities (muda), process variation (mura), and poor work conditions (muri)” [ 6 ]. Generally, LM is considered to be the “antidote” to waste in organisations [ 3 ]. Waste, defined as tasks and processes that do not contribute to the creation of value but consume organisational resources, is associated with inefficiencies, reduced flexibility and the generation of unnecessary costs [ 3 ]. Ohno, the developer of LM, identified seven sources of waste (summarized in Table  1 ) and pioneered managerial and organisational tools and techniques to help organisations get rid of them (e.g., Value Stream Mapping, 5S, Kanban, Standardisation, Process map) [ 2 ]. While the tools of Lean are numerous, they are broadly designed to help organisations understand their customer needs, identify the value-adding activities essential to producing services and products desired by their customers, create production flow by reducing unnecessary delays and interruptions, reduce inventory and overproduction, and continuously improve and refine their productive processes [ 8 ].

Ohno’s seven sources of waste in organisations

Source: P Arunagiri and A Gnanavelbabu [ 7 ]

It did not take long for LM to migrate from Toyota and the car manufacturing industry into service-delivery organisations and then public institutions [ 5 , 9 – 11 ]. LM has indeed been linked to a host of positive organisational outcomes across-the-board, including improved quality of goods and services, reduced costs and increased productivity [ 12 ]. In healthcare, evidence of LM implementation can be found on the micro (operational), meso (strategic) and macro (policy) levels. It has been implemented in a variety of settings including operating rooms, emergency departments, mental health centres, pharmacy services, information departments, and ambulatory care clinics [ 13 , 14 ]. Overall, LM has been associated with reduced waiting times in emergency departments [ 15 , 16 ], fewer medical errors [ 17 ], and improved clinical pathways [ 18 ].

In healthcare, previous literature reviews have identified different approaches to LM implementation [ 13 , 19 – 21 ]. On one hand, LM is considered as a comprehensive organisational philosophy aimed at systematically addressing waste at all levels [ 21 ]. On the other hand, LM is seen as a toolbox with organisations often implementing one or two LM practices to address waste in a single process or on a small scale (e.g., one ward, or a specific unit) [ 8 ]. Whilst piecemeal implementation of LM could be effective in reaching desired performance and efficiency goals, there is little evidence on the long-term sustainability of such gains [ 19 ]. In particular, these approaches often overlook crucial elements of LM implementation such as employee engagement and participation.

Against a backdrop of increasingly scarce human, material and financial resources [ 14 ], LM has rapidly grown in popularity amongst health practitioners and managers interested in improving the efficiency of their services [ 22 ]. It is within this context of proliferation, that we set out to investigate how health professionals experience LM practices and are impacted by them. This is particularly important in light of recent conceptual developments calling for a more holistic approach to the adoption of LM which takes into account both technical and people-oriented strategies [ 20 , 21 , 23 ]. As demonstrated by a growing number of reviews, going beyond the technicalities of LM is a key factor in its successful implementation within organisations [ 19 , 24 ]. Addressed to policymakers, managers, quality improvement personnel and researchers, this review aims to identify articles addressing the effects of LM on the health workforce and characterise the impacts discussed therein. This scoping review was guided by the following research question:

RQ1: What are the impacts of LM interventions on frontline healthcare professionals?

A scoping review was conducted to gain a deeper understanding of how LM impacts frontline healthcare professionals. Findings of the review are reported in accordance with the PRISMA-SCR guideline [ 25 ]. This choice of methodology is justified by the emerging nature of the evidence on the impact of LM on the health workforce [ 26 ]. The aim of this review is to provide a comprehensive overview of the existing literature and put forward a research agenda for future research on this topic. With that aim in mind, a review strategy was developed and approved by all members of the research team prior to systematically searching the following academic databases in February 2020: Scopus, Emerald, EBSCO business premier and PubMed. The search strategy was not published or registered in an open platform. The choice of databases allowed for the identification of relevant publications in the fields of health science, as well as management studies where LM originated. Papers were searched by combining a set of topic-related keywords (Lean approach, Lean process, Lean method, Lean transformation, Lean philosophy, Lean principles, Lean practices, Lean process improvement, Lean management, Lean healthcare, Lean thinking, Lean production, Lean six sigma, Toyota production system) and a group of setting-related keywords (health care, healthcare, hospital). Only peer-reviewed articles were searched; news articles, conference proceedings, magazines, trade publications and book chapters were excluded using the exclusion parameters of the online databases during the search phase. No starting date was specified, and articles published up to 29 February 2020 were included. Table  2 portrays the use of the search strategy using Scopus database as an example. Additional file  1 includes an example of the search string used to query PubMed and Scopus.

Search strategy used in Scopus database

Search results from each of the databases were aggregated and imported into an Endnote library, and duplicate entries were removed. Abstracts had to satisfy the following inclusion criteria (Table  3 ) to be considered in the review: published in English or French, peer-reviewed, empirical, studied the use of LM (i.e., reporting on the use of at least one LM activity) in a healthcare setting (i.e., any facility where healthcare services are delivered) and focused on its outcomes on frontline healthcare workers (i.e., with the primary aim of reporting impacts or effects of LM on staff working at a healthcare setting). Articles discussing the experiences of managers, lean consultants or internal lean champions were excluded due to the role played by these actors in the implementation or the promotion of Lean practices. To ensure consensus on the retained articles, 5% of the identified abstracts were randomly assigned to a second reviewer for assessment using the inclusion criteria. Interrater reliability was subsequently calculated using Cohen’s kappa [ 27 ].

Criteria for included studies

Data charting and analysis

Full-text analysis was conducted independently by the first author on the retained articles using a data summarising sheet. The sheet was developed and approved by the research team. It recorded essential information including the country of study, language, publication year, publication journal, study setting (e.g., academic hospital, emergency department), reported Lean tools or principles (e.g., value stream mapping, 5S, visual follow-up boards, pull production, Kanban), data collection methods (e.g., interviews, focus groups, observations, surveys), theoretical framework, and staff related findings.

Staff-related outcomes were analysed and synthesised following a three-stage thematic analysis approach [ 28 ]. In the first stage, 48 different codes emerged from the findings of the included studies. They were consequently grouped into four different descriptive themes: Morale, motivation and job satisfaction; work intensification, job strain, anxiety, stress and dehumanisation; teamwork, communication and coordination; and learning, innovation and personal development. Analytical themes emerged throughout the data collection and analysis process. They were mapped to the four-fold classification of the findings. Descriptive data from the articles were summarised using numerical counts.

Risk of bias

The quality of articles was evaluated using Hawker et al.’s Quality Assessment Tool [ 29 ]. The tool allows the scoring of papers based on the quality (good (4 points), fair (3 points), poor (2 points) or very poor (1 point) of nine key attributes: abstract and title; introduction and aims; method and data; sampling; data analysis; ethics and bias; findings/results; transferability/generalisability; and, implications and usefulness. Papers can be attributed a maximum score of 36 points (high quality) or a minimum score of 9 points (very low quality). To complement the tool, Lorenc et al. [ 30 ] presented a tiered classification of articles depending on their overall quality score: “high quality” (30–36 points), “medium quality” (24–29 points), and “low quality” (9–24 points). This classification was subsequently adapted by J Braithwaite, J Herkes, K Ludlow, L Testa and G Lamprell [ 31 ] slightly reducing the cut-off score for low quality articles to 23 instead of 24 points which increased the transparency of the tool. Quality assessment was conducted to indicate the level of confidence with which findings should be taken. Given the emerging nature of this area of study, quality scores were not used to exclude articles from the review.

Out of 998 identified abstracts, 953 were excluded for not meeting the inclusion criteria at title/abstract stage. The Cohen’s Kappa for the 5% randomly assigned abstracts was 0.78, indicating a substantial agreement between reviewers. The full-text review of the articles corresponding to the remaining 45 abstracts resulted in the exclusion of 28 studies for not investigating the impact of LM on frontline healthcare workers (i.e., not discussing effects of LM on staff, not reporting on how staff experienced LM interventions, or discussing staff outcomes as an incidental or secondary finding). In total, 17 studies were included in the final analysis [ 32 – 48 ]. Figure  1 is a graphic representation of the search strategy results using the PRISMA flow chart [ 49 ].

Systematic Review Search Strategy

The articles included in the review ( n  = 17) were published between 1995 and 2018, with the majority being published in 2014 ( n  = 4, 23.5%) [ 42 , 43 , 45 , 47 ] and 2018 ( n  = 4, 23.5%) [ 32 , 35 , 38 , 48 ]. All the publications were in English, except one in French [ 38 ], and the largest proportion of the studies ( n  = 5, 29.4%) were conducted in Sweden [ 37 , 39 , 44 – 46 ]. Over half of the publications were in health services journals ( n  = 9, 53%) [ 32 , 33 , 35 , 37 , 39 , 42 , 45 , 48 , 50 ] . Five studies (29.4%) were published in nursing [ 40 , 47 ], surgical [ 34 ] and quality in healthcare journals [ 44 , 46 ]. Only three studies (17.6%) were published in a management or social science journal [ 38 , 41 , 43 ]. The full list of journals is presented in Table  4 .

List of journals included in the review

Most of the studies used either qualitative research methods ( n  = 8, 47.1%) [ 38 , 41 – 44 , 46 , 48 , 50 ] or quantitative ( n  = 7, 41.2%) [ 32 , 34 , 35 , 37 , 40 , 45 , 47 ], with two studies (11.8%) using a mixed-methods approach [ 33 , 39 ]. Case studies were the most common research design ( n  = 10, 58.8%) [ 32 , 37 – 39 , 41 – 43 , 46 , 48 , 50 ], followed by Pre/Post evaluation studies ( n  = 7, 41.2%) [ 33 – 35 , 40 , 44 , 45 , 47 ]. Seven studies (41.2%) used a theoretical framework to provide a conceptual foundation for their findings [ 32 , 37 – 40 , 44 , 45 ].

Regarding the research sites, most of the studies were conducted in acute care settings (emergency departments ( n  = 7, 41.2%) [ 39 , 42 – 45 , 47 , 48 ], operating theatres ( n  = 2, 11.8%) [ 34 , 38 ], and intensive care units ( n  = 1, 5.9%) [ 34 , 38 ]. Most of the studies ( n  = 13, 76.5%) reported on the use of multiple Lean techniques simultaneously [ 33 – 35 , 38 – 41 , 43 – 48 , 50 ]. Only two of the studies did not make any mention of the Lean techniques used in the examined sites [ 32 , 42 ]. Visual management was the most reported LM technique ( n  = 9) [ 37 – 40 , 43 – 46 , 48 ], followed by workspace redesign ( n  = 6) [ 35 , 38 , 39 , 43 , 44 , 48 ], standardisation ( n  = 5) [ 34 , 37 – 40 ], and value stream mapping ( n  = 4) [ 33 , 37 , 44 , 45 ]. Descriptive information on the studies and a summary of their findings are presented in Additional file  2 .

Risk of bias and quality assessment

Hawker et al.'s (2002) Quality Assessment Tool [ 29 ] was used to evaluate the quality and methodological rigour of the reviewed articles because it is suitable for assessing studies with various designs. Table  5 presents an overview of the quality assessment of the articles reviewed. Articles were classified as either high, medium or low quality based on Braithwaite et al.’s (2017) cut-off values. Detailed quality scores are reported in Additional file  3 .

Quality assessment of included studies

a Cut-off values determined by Braithwaite et al. [ 23 ]

Overall findings

Morale, motivation and job satisfaction.

Nine articles (52.9%) found impacts of LM on staff’s morale, motivation, and job satisfaction. In a recent study, LM was associated with improved morale and job satisfaction amongst primary care physicians and medical assistants in a US not-for-profit clinic [ 35 ]. Survey data collected in the clinic suggested higher levels of work-satisfaction and personal motivation at work amongst participants after the LM intervention. The intervention included a physical workplace redesign as well as LM-inspired workflow improvements that were associated with increases in employee engagement and participation in decision making.

Similar results were also reported in a U.S. teaching hospital and were considered to be the result of LM’s philosophical foundations which promote giving employees ownership of their work and valuing their perspective [ 34 ]. Employee participation, supportive leadership and regular staff meetings were correlated with improvements in job content (i.e., level of influence at work, opportunities for development, the meaning of work, commitment and recognition) in another study conducted in two Swedish cardiac wards [ 45 ]. The bottom-up problem-solving approach at the heart of LM and the use of collaborative tools such as value stream mapping were shown to promote employee participation and were considered catalysts for improved wellbeing when they were supported by other resources and used by all professional groups [ 37 ].

Nurses in a private medical centre also indicated increased levels of job satisfaction after LM principles were applied in their telemetry unit [ 40 ]. Amongst the reported benefits of this intervention was an 85% reduction in the distances walked by staff members during their shifts. The LM-inspired reform also contributed to a decrease in overtime, allowed nurses to routinely take their breaks and created conditions that enabled them to follow their professional values.

A study conducted in two Swedish hospitals and one health municipality showed that work standardisation and the use of 5S were positively correlated with improved job satisfaction among staff [ 37 ]. Similar findings were reported in a Senegalese hospital that used 5S, a method of LM, to declutter and to improve the hygiene and the overall cleanliness of the workplace [ 50 ]. In a New Zealand study, morale improvements were also experienced by staff working across three emergency departments that adopted the LM tools of 5S, standardisation and value stream mapping [ 42 ].

In Australia, job satisfaction improved after the implementation of LM in two public hospitals as it enabled service workers to benefit from new professional status, greater task variety and access to new career paths [ 41 ]. Job reconfigurations undertook as part of the same intervention also allowed individual staff members to gain greater peer recognition which further contributed to improved job satisfaction.

Increased satisfaction of intensive care nurses and pharmacy technicians was reported after LM tools were used to reconfigure the continuous renal replacement therapy workflow at a major academic hospital in the US [ 33 ]. In this case, the rise in satisfaction scores was attributed to a decrease in nurses’ workload (measured by the number of phone calls to the pharmacy), as well as enhanced production planning by the pharmacy staff.

Work intensification, job strain, anxiety, stress and dehumanisation

Seven of the reviewed studies (41.2%) suggested that LM led to work intensification, job strain, anxiety, work-related stress and dehumanisation. In a Swedish study, the adoption of LM led to a significant imbalance between the job resources at the disposal of staff and their job demands, leading to a deterioration of work conditions over time [ 37 ].

Similarly, O’Donnell (1995) critically assessed the impact of a LM-inspired reform on the services staff at two Australian hospitals [ 41 ]. His research showed that LM led to considerable work stress and intensification due to the elimination of slack and the amalgamation of professional roles. Higher levels of peer-surveillance were also reported as staff increasingly monitored each other’s performance. Furthermore, multiskilling was criticised for being a façade behind which pressure was put on teams to execute labour-intensive tasks. The author noted that in one of the studied hospitals, the adoption of LM was accompanied by forms of managerial coercion, forcing employees to adhere to the new proposed work organisation by, for example, threats of closure and intensification of work conditions for resisting staff.

Evidence of work intensification was also found in a study examining LM in an Australian emergency department [ 43 ]. Even though the increase in workloads was attributed to macro-level issues of budgetary pressures being exercised on public healthcare institutions, the authors indicated that LM could lead to work intensification merely by allowing organisations to increase their service capacity while maintaining the same levels of resources.

More recently, wide-scale survey data collected by Hung and colleagues (2018) showed a significant increase in levels of workplace stress, burnout and emotional exhaustion amongst physicians and non-physicians following the implementation of LM at a large ambulatory care facility [ 35 ]. Decreased levels of personal accomplishment were mainly reported among the clinical population indicating a negative self-evaluation of the care-related activities they conducted following the LM intervention. Despite the report of positive effects on engagement, teamwork and participation in decision making, the authors’ results indicate that in the studied context, LM did not seem to improve efficiency without negatively impacting hospital staff. Similar findings were reported in three emergency departments in New Zealand where increased levels of work intensification where reported despite improvements in morale [ 42 ].

Looking at the use of LM in a French operating theatre (OT), Mahmoud et al. (2018) revealed LM promotes and embodies thoughts that may lead to the instrumental use and dehumanisation of individuals [ 38 ]. Using Honneth’s [ 51 ] concept of reification, the authors characterised experiences of dehumanisation in three forms of relationships in which operating theatre nurses were engaged (i.e., with other nurses, with the organisation, with patients). In the OT, reification was associated with staff being solely focused on achieving pre-set goals that they objectify their colleagues in the process. It was promoted at the organisational level when individuals felt reduced to a set of skills and were used instrumentally to achieve organisational goals. Reification was also apparent when the human side of care was relegated to the background as patients became increasingly considered as income-generating resources.

In another study, Zebrowski et al. (2018) explored the impact of LM on the clinical work of emergency nurses and physicians in Canada [ 48 ]. The authors found that LM was associated with a decline in morale, an increase in physical, emotional and cognitive stress which exposed the nurses to high risks of developing burnout.

Teamwork, communication and coordination

Six of the articles (35.3%) included in the review indicated that LM was positively associated with improvements in teamwork, communication, and coordination amongst staff members. In three case, these improvements were attributed to a physical workplace redesign which involved combining workstations of care team members [ 35 , 39 , 44 ]. The new stations allowed staff to spend less time locating each other while acting as a convenient platform for sharing patient information leading to enhanced communication and collaboration.

Coordination between staff was also improved as a result of work standardisation, continuous flow and the use of a team-based approach in a Swedish hospital. These LM tools were shown to have reduced misunderstandings, errors and duplications [ 39 ]. Leadership rounds (i.e. Gemba walks) in a UK hospital were linked to better relationships and teamwork between managers and staff [ 47 ]. The rounds provided managers with an in-depth understanding of the challenges faced by the teams. Visual Management tools such as whiteboards also facilitated both synchronous and asynchronous communication between staff and managers [ 46 ].

Improvements in teamwork were also self-reported by staff after LM was applied to the perioperative otolaryngologic workflow in an American university hospital [ 34 ]. Participants in this study reported improvements in the six dimensions of the validated Safety Attitudes Questionnaire (SAQ) [ 52 ], including teamwork, when the survey was administered before and after the LM intervention.

Learning, innovation and personal development

Three of the reviewed studies (17.6%) examined the impact of LM on the learning and personal development opportunities available to staff as well as their innovation skills. Survey data collected in an academic operating theatre showed that the implementation of LM had no impact on the intraoperative teaching activities [ 34 ]. The authors of this study argued that LM could provide additional high-value training opportunities by increasing the capacity of the operating theatres and reducing low-value, time-consuming activities such as unnecessary or redundant administrative work. However, the authors did not provide any data in support of this hypothesis.

In a Senegalese hospital, the adoption of LM was shown to have helped foster a mutual learning environment in which employees engaged in peer-education activities. These participants highlighted the ways that LM helped them enhance their physical work-conditions [ 50 ]. Another study revealed that LM had a significant positive effect on the innovation skills of employees [ 32 ]. The study was conducted using a self-administered questionnaire completed by 400 employees working in 11 private and two public hospitals.

Overall, the articles reviewed alternately described the relationship between LM and employee outcomes as positive, negative, or mixed (i.e., both positive and negative in the same setting). On the one hand, LM was found to have helped improve teamwork, communication and coordination between staff [ 34 , 35 , 39 , 44 , 46 , 47 ]. It was shown to potentially provide staff with increased learning and personal development opportunities [ 34 , 36 ] and was linked to improved innovation skills, morale, motivation and job satisfaction [ 32 – 35 , 37 , 40 – 42 , 45 , 50 ].

On the other hand, LM was correlated with higher levels of stress, job strain, anxiety, work intensification and dehumanisation [ 35 , 37 , 38 , 41 , 43 , 48 ]. The inconsistent outcomes of Lean are exemplified by studies that simultaneously found an association between LM interventions and both positive and negative employee outcomes [ 35 , 37 , 41 ]. Table  6 provides an overview of the review results classifying them according to the studies’ overall assessment of LM’s impact on staff.

A classification of LM impacts on healthcare workers results

Beyond the limited range of research conducted on the human outcomes of LM in healthcare, the review also reveals the lack of both methodological diversity and rigour that characterises the existing literature. Most of the included studies ( n  = 10, 58.8%) lacked a theoretical conceptualisation of the staff related outcomes of LM and were constrained by reporting descriptive results with relatively limited analytical reach.

Furthermore, despite examining the use of multiple LM tools and techniques, only one of the studies considered Lean holistically, as an organisational, system-wide approach designed to target waste and improve the production of value [ 38 ]. The majority of the studies, instead, focused on assessing the outcomes of using specific Lean-related tools or techniques. Accordingly, a large number of the studies adopted an evaluation design that, while useful, substantially limits the generalisability of the results and the conclusions that can be drawn about the impact of LM on staff. Generalisability was also hindered by the adoption of single case study designs, often conducted in one country, as well as by the absence of theoretical framing of the study or results, or both.

Most of the articles in this review exclusively reported positive employee-related outcomes of LM ( n  = 11, 64.8%), perhaps reflecting what has been described as a persistent bias towards the publication of LM related success stories [ 20 , 23 ]. In contrast, three studies found that LM was only associated with adverse outcomes for employees [ 38 , 43 , 48 ]. It is important to note that none of these studies was able to identify a causal relationship between LM and negative workforce experiences. Instead, the authors highlighted the importance of considering the role played by broader financial and budgetary constraints to which health systems are subject, as well as how LM tools and practices were implemented within the studied organisations. A closer examination of these two areas has the potential for resolving what seems to be the paradox of LM, in that it was originally described as an approach based on worker engagement and input [ 1 ] yet in some instances appears to be detrimental to their wellbeing.

More broadly, this review calls for more critical assessments of LM’s impact on healthcare professionals (Table  7 ). Such assessments would involve identifying the reasons why LM is associated with positive outcomes in some instances, negative ones in others and sometimes mixed outcomes, simultaneously, within the one setting. It is currently impossible to pinpoint the reasons for these inconsistent outcomes, given the absence of information in the reviewed articles on the context surrounding the adoption and implementation of LM. It is hoped that future researchers use robustly designed comparative studies that would allow for such critical analyses to be conducted. Such studies should favour qualitative research methodologies to capture the context surrounding the use of LM as well as aspects pertaining to its implementation and how it is experienced by staff.

Key recommendations for future research

The results of this review are reflective of the broader literature on LM and its impact on staff working in other industries. In a recent review, F Magnani, V Carbone and V Moatti [ 53 ] also pointed to the restricted number of studies focusing on the impact of LM on employees. They highlighted the inconsistent nature of the research findings on this topic. Further work that holistically examines LM and encompasses its sociotechnical and human dimensions is therefore crucially needed, especially given the demonstrated potential of this approach that can help increase the capacity and improve the efficiency of health systems.

This review has limitations that should be considered. With a primary focus on the impact of LM on frontline healthcare professionals, the review did not report on findings from research examining the experiences of other professionals working in the health systems (e.g. managers, directors, managers, lean consultants or other staff championing Lean initiatives). The findings of the review were also limited to those of published peer-reviewed journal articles written in English or French. Future researchers may choose to attend to other types of academic and non-academic publications in different languages to identify new information on this topic.

In conclusion, this review constitutes the first attempt to synthesise and critically reflect on the published academic literature examining the impact of LM on frontline healthcare professionals. The review highlighted the contested and inconclusive nature of the research on this topic. While some researchers identified positive impacts of LM, others found more mixed results. Overall, studies that holistically examine cases of Lean implementation in healthcare by attending to its sociotechnical and human dimensions remain scarce. Future researchers should prioritise qualitative and comparative research designs that can help address what seems to be a persistently underexploited area of empirical research.

Acknowledgements

The authors would like to thank Christie Barnwell for independently reviewing 5% of the selected abstracts against the selection criteria and for assisting with appraising the quality of the included articles.

Abbreviations

Authors’ contributions.

This research was carried out in the framework of the doctoral studies of ZM under the supervision of NAH, LE, KC and JB who provided conceptual assistance on the topic and acted as arbitrators and advisors where necessary. ZM did the abstract and full-text review of the articles, the quality assessment, and prepared drafts of the manuscript. All authors reviewed manuscript drafts and agreed with the final submitted version.

This work was supported by a Macquarie University Research Excellence Cotutelle Scholarship (Award number: 2017734). JB is supported by multiple grants, including the National Health and Medical Research Council (NHMRC) Partnership Grant for Health Systems Sustainability (ID: 9100002). The funder had no role in the design, analysis and drafting of the manuscript.

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The authors declare no conflicts of interest.

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Publication | Aug 01, 2015 | Elizabeth Hoffecker, Kendra Leith, Kim Wilson,

Lean Research offers a guiding framework for conducting research and evaluation built upon four principles of good research practice. In order for research to reduce burden on participants and maximize value for stakeholders, it should be: 1) rigorous, regardless of methodologies employed; 2) respectful towards research subjects, implementing partners, and others engaged in the research process; 3) relevant to research subjects, partners, and decision-makers; and 4) right-sized, in terms of protocols and costs compared to the potential usefulness and impact of the study.

The four principles of Lean Research are not new but are often pitted against each other as trade-offs. Lean Research emphasizes conducting research in ways that reflect and exemplify all four principles and challenges researchers to identify opportunities to implement them in an integrated fashion. As a broad framework and approach to social science research, Lean Research can be applied regardless of whether the methods are quantitative, qualitative, or mixed.

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The job of the manager has become unmanageable. Organizations are becoming flatter every year. The average manager’s number of direct reports has increased by 2.8 times over the last six years, according to Gartner research. In the past few years alone, many managers have had to make a series of pivots — from moving to remote work to overseeing hybrid teams to implementing return-to-office mandates.

• Swagatam Basu is senior director of research in the Gartner HR practice and has spent nearly a decade researching leader and manager effectiveness. His work spans additional HR topics including learning and development, employee experience and recruiting. Swagatam specializes in research involving extensive quantitative analysis, structured and unstructured data mining and predictive modeling.
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How can I plan what to eat or drink when I have diabetes?

How can physical activity help manage my diabetes, what can i do to reach or maintain a healthy weight, should i quit smoking, how can i take care of my mental health, clinical trials for healthy living with diabetes.

Healthy living is a way to manage diabetes . To have a healthy lifestyle, take steps now to plan healthy meals and snacks, do physical activities, get enough sleep, and quit smoking or using tobacco products.

Healthy living may help keep your body’s blood pressure , cholesterol , and blood glucose level, also called blood sugar level, in the range your primary health care professional recommends. Your primary health care professional may be a doctor, a physician assistant, or a nurse practitioner. Healthy living may also help prevent or delay health problems  from diabetes that can affect your heart, kidneys, eyes, brain, and other parts of your body.

Making lifestyle changes can be hard, but starting with small changes and building from there may benefit your health. You may want to get help from family, loved ones, friends, and other trusted people in your community. You can also get information from your health care professionals.

What you choose to eat, how much you eat, and when you eat are parts of a meal plan. Having healthy foods and drinks can help keep your blood glucose, blood pressure, and cholesterol levels in the ranges your health care professional recommends. If you have overweight or obesity, a healthy meal plan—along with regular physical activity, getting enough sleep, and other healthy behaviors—may help you reach and maintain a healthy weight. In some cases, health care professionals may also recommend diabetes medicines that may help you lose weight, or weight-loss surgery, also called metabolic and bariatric surgery.

Choose healthy foods and drinks

There is no right or wrong way to choose healthy foods and drinks that may help manage your diabetes. Healthy meal plans for people who have diabetes may include

• dairy or plant-based dairy products
• nonstarchy vegetables
• protein foods
• whole grains

Try to choose foods that include nutrients such as vitamins, calcium , fiber , and healthy fats . Also try to choose drinks with little or no added sugar , such as tap or bottled water, low-fat or non-fat milk, and unsweetened tea, coffee, or sparkling water.

Try to plan meals and snacks that have fewer

• foods high in saturated fat
• foods high in sodium, a mineral found in salt
• sugary foods , such as cookies and cakes, and sweet drinks, such as soda, juice, flavored coffee, and sports drinks

Your body turns carbohydrates , or carbs, from food into glucose, which can raise your blood glucose level. Some fruits, beans, and starchy vegetables—such as potatoes and corn—have more carbs than other foods. Keep carbs in mind when planning your meals.

You should also limit how much alcohol you drink. If you take insulin  or certain diabetes medicines , drinking alcohol can make your blood glucose level drop too low, which is called hypoglycemia . If you do drink alcohol, be sure to eat food when you drink and remember to check your blood glucose level after drinking. Talk with your health care team about your alcohol-drinking habits.

Find the best times to eat or drink

Talk with your health care professional or health care team about when you should eat or drink. The best time to have meals and snacks may depend on

• what medicines you take for diabetes
• what your level of physical activity or your work schedule is
• whether you have other health conditions or diseases

Ask your health care team if you should eat before, during, or after physical activity. Some diabetes medicines, such as sulfonylureas  or insulin, may make your blood glucose level drop too low during exercise or if you skip or delay a meal.

Plan how much to eat or drink

You may worry that having diabetes means giving up foods and drinks you enjoy. The good news is you can still have your favorite foods and drinks, but you might need to have them in smaller portions  or enjoy them less often.

For people who have diabetes, carb counting and the plate method are two common ways to plan how much to eat or drink. Talk with your health care professional or health care team to find a method that works for you.

Carb counting

Carbohydrate counting , or carb counting, means planning and keeping track of the amount of carbs you eat and drink in each meal or snack. Not all people with diabetes need to count carbs. However, if you take insulin, counting carbs can help you know how much insulin to take.

Plate method

The plate method helps you control portion sizes  without counting and measuring. This method divides a 9-inch plate into the following three sections to help you choose the types and amounts of foods to eat for each meal.

• Nonstarchy vegetables—such as leafy greens, peppers, carrots, or green beans—should make up half of your plate.
• Carb foods that are high in fiber—such as brown rice, whole grains, beans, or fruits—should make up one-quarter of your plate.
• Protein foods—such as lean meats, fish, dairy, or tofu or other soy products—should make up one quarter of your plate.

If you are not taking insulin, you may not need to count carbs when using the plate method.

Work with your health care team to create a meal plan that works for you. You may want to have a diabetes educator  or a registered dietitian  on your team. A registered dietitian can provide medical nutrition therapy , which includes counseling to help you create and follow a meal plan. Your health care team may be able to recommend other resources, such as a healthy lifestyle coach, to help you with making changes. Ask your health care team or your insurance company if your benefits include medical nutrition therapy or other diabetes care resources.

Talk with your health care professional before taking dietary supplements

There is no clear proof that specific foods, herbs, spices, or dietary supplements —such as vitamins or minerals—can help manage diabetes. Your health care professional may ask you to take vitamins or minerals if you can’t get enough from foods. Talk with your health care professional before you take any supplements, because some may cause side effects or affect how well your diabetes medicines work.

Research shows that regular physical activity helps people manage their diabetes and stay healthy. Benefits of physical activity may include

• lower blood glucose, blood pressure, and cholesterol levels
• better heart health
• healthier weight
• better mood and sleep
• better balance and memory

Talk with your health care professional before starting a new physical activity or changing how much physical activity you do. They may suggest types of activities based on your ability, schedule, meal plan, interests, and diabetes medicines. Your health care professional may also tell you the best times of day to be active or what to do if your blood glucose level goes out of the range recommended for you.

Do different types of physical activity

People with diabetes can be active, even if they take insulin or use technology such as insulin pumps .

Try to do different kinds of activities . While being more active may have more health benefits, any physical activity is better than none. Start slowly with activities you enjoy. You may be able to change your level of effort and try other activities over time. Having a friend or family member join you may help you stick to your routine.

The physical activities you do may need to be different if you are age 65 or older , are pregnant , or have a disability or health condition . Physical activities may also need to be different for children and teens . Ask your health care professional or health care team about activities that are safe for you.

Aerobic activities

Aerobic activities make you breathe harder and make your heart beat faster. You can try walking, dancing, wheelchair rolling, or swimming. Most adults should try to get at least 150 minutes of moderate-intensity physical activity each week. Aim to do 30 minutes a day on most days of the week. You don’t have to do all 30 minutes at one time. You can break up physical activity into small amounts during your day and still get the benefit. 1

Strength training or resistance training

Strength training or resistance training may make your muscles and bones stronger. You can try lifting weights or doing other exercises such as wall pushups or arm raises. Try to do this kind of training two times a week. 1

Balance and stretching activities

Balance and stretching activities may help you move better and have stronger muscles and bones. You may want to try standing on one leg or stretching your legs when sitting on the floor. Try to do these kinds of activities two or three times a week. 1

Some activities that need balance may be unsafe for people with nerve damage or vision problems caused by diabetes. Ask your health care professional or health care team about activities that are safe for you.

Stay safe during physical activity

Staying safe during physical activity is important. Here are some tips to keep in mind.

Drink liquids

Drinking liquids helps prevent dehydration , or the loss of too much water in your body. Drinking water is a way to stay hydrated. Sports drinks often have a lot of sugar and calories , and you don’t need them for most moderate physical activities.

Avoid low blood glucose

Check your blood glucose level before, during, and right after physical activity. Physical activity often lowers the level of glucose in your blood. Low blood glucose levels may last for hours or days after physical activity. You are most likely to have low blood glucose if you take insulin or some other diabetes medicines, such as sulfonylureas.

Ask your health care professional if you should take less insulin or eat carbs before, during, or after physical activity. Low blood glucose can be a serious medical emergency that must be treated right away. Take steps to protect yourself. You can learn how to treat low blood glucose , let other people know what to do if you need help, and use a medical alert bracelet.

Avoid high blood glucose and ketoacidosis

Taking less insulin before physical activity may help prevent low blood glucose, but it may also make you more likely to have high blood glucose. If your body does not have enough insulin, it can’t use glucose as a source of energy and will use fat instead. When your body uses fat for energy, your body makes chemicals called ketones .

High levels of ketones in your blood can lead to a condition called diabetic ketoacidosis (DKA) . DKA is a medical emergency that should be treated right away. DKA is most common in people with type 1 diabetes . Occasionally, DKA may affect people with type 2 diabetes  who have lost their ability to produce insulin. Ask your health care professional how much insulin you should take before physical activity, whether you need to test your urine for ketones, and what level of ketones is dangerous for you.

Take care of your feet

People with diabetes may have problems with their feet because high blood glucose levels can damage blood vessels and nerves. To help prevent foot problems, wear comfortable and supportive shoes and take care of your feet  before, during, and after physical activity.

If you have diabetes, managing your weight  may bring you several health benefits. Ask your health care professional or health care team if you are at a healthy weight  or if you should try to lose weight.

If you are an adult with overweight or obesity, work with your health care team to create a weight-loss plan. Losing 5% to 7% of your current weight may help you prevent or improve some health problems  and manage your blood glucose, cholesterol, and blood pressure levels. 2 If you are worried about your child’s weight  and they have diabetes, talk with their health care professional before your child starts a new weight-loss plan.

You may be able to reach and maintain a healthy weight by

• following a healthy meal plan
• consuming fewer calories
• being physically active
• getting 7 to 8 hours of sleep each night 3

If you have type 2 diabetes, your health care professional may recommend diabetes medicines that may help you lose weight.

Online tools such as the Body Weight Planner  may help you create eating and physical activity plans. You may want to talk with your health care professional about other options for managing your weight, including joining a weight-loss program  that can provide helpful information, support, and behavioral or lifestyle counseling. These options may have a cost, so make sure to check the details of the programs.

Your health care professional may recommend weight-loss surgery  if you aren’t able to reach a healthy weight with meal planning, physical activity, and taking diabetes medicines that help with weight loss.

If you are pregnant , trying to lose weight may not be healthy. However, you should ask your health care professional whether it makes sense to monitor or limit your weight gain during pregnancy.

Both diabetes and smoking —including using tobacco products and e-cigarettes—cause your blood vessels to narrow. Both diabetes and smoking increase your risk of having a heart attack or stroke , nerve damage , kidney disease , eye disease , or amputation . Secondhand smoke can also affect the health of your family or others who live with you.

If you smoke or use other tobacco products, stop. Ask for help . You don’t have to do it alone.

Feeling stressed, sad, or angry can be common for people with diabetes. Managing diabetes or learning to cope with new information about your health can be hard. People with chronic illnesses such as diabetes may develop anxiety or other mental health conditions .

Learn healthy ways to lower your stress , and ask for help from your health care team or a mental health professional. While it may be uncomfortable to talk about your feelings, finding a health care professional whom you trust and want to talk with may help you

• lower your feelings of stress, depression, or anxiety
• manage problems sleeping or remembering things
• see how diabetes affects your family, school, work, or financial situation

Ask your health care team for mental health resources for people with diabetes.

Sleeping too much or too little may raise your blood glucose levels. Your sleep habits may also affect your mental health and vice versa. People with diabetes and overweight or obesity can also have other health conditions that affect sleep, such as sleep apnea , which can raise your blood pressure and risk of heart disease.

NIDDK conducts and supports clinical trials in many diseases and conditions, including diabetes. The trials look to find new ways to prevent, detect, or treat disease and improve quality of life.

What are clinical trials for healthy living with diabetes?

Clinical trials—and other types of clinical studies —are part of medical research and involve people like you. When you volunteer to take part in a clinical study, you help health care professionals and researchers learn more about disease and improve health care for people in the future.

Researchers are studying many aspects of healthy living for people with diabetes, such as

• how changing when you eat may affect body weight and metabolism
• how less access to healthy foods may affect diabetes management, other health problems, and risk of dying
• whether low-carbohydrate meal plans can help lower blood glucose levels
• which diabetes medicines are more likely to help people lose weight

Find out if clinical trials are right for you .

Watch a video of NIDDK Director Dr. Griffin P. Rodgers explaining the importance of participating in clinical trials.

What clinical trials for healthy living with diabetes are looking for participants?

You can view a filtered list of clinical studies on healthy living with diabetes that are federally funded, open, and recruiting at www.ClinicalTrials.gov . You can expand or narrow the list to include clinical studies from industry, universities, and individuals; however, the National Institutes of Health does not review these studies and cannot ensure they are safe for you. Always talk with your primary health care professional before you participate in a clinical study.

This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. NIDDK translates and disseminates research findings to increase knowledge and understanding about health and disease among patients, health professionals, and the public. Content produced by NIDDK is carefully reviewed by NIDDK scientists and other experts.

NIDDK would like to thank: Elizabeth M. Venditti, Ph.D., University of Pittsburgh School of Medicine.

Read our research on: Gun Policy | International Conflict | Election 2024

Regions & Countries

1. the partisanship and ideology of american voters.

The partisan identification of registered voters is now evenly split between the two major parties: 49% of registered voters are Democrats or lean to the Democratic Party, and a nearly identical share – 48% – are Republicans or lean to the Republican Party.

The partisan balance has tightened in recent years following a clear edge in Democratic Party affiliation during the last administration.

• Four years ago, in the run-up to the 2020 election, Democrats had a 5 percentage point advantage over the GOP (51% vs. 46%).

The share of voters who are in the Democratic coalition reached 55% in 2008. For much of the last three decades of Pew Research Center surveys, the partisan composition of registered voters has been more closely divided.

Partisans and partisan leaners in the U.S. electorate

About two-thirds of registered voters identify as a partisan, and they are roughly evenly split between those who say they are Republicans (32% of voters) and those who say they are Democrats (33%). Roughly a third instead say they are independents or something else (35%), with most of these voters leaning toward one of the parties. Partisan leaners often share the same political views and behaviors as those who directly identify with the party they favor.

The share of voters who identify as independent or something else is somewhat higher than in the late 1990s and early 2000s. As a result, there are more “leaners” today than in the past. Currently, 15% of voters lean toward the Republican Party and 16% lean toward the Democratic Party. By comparison, in 1994, 27% of voters leaned toward either the GOP (15%) or the Democratic Party (12%).

Party identification and ideology

While the electorate overall is nearly equally divided between those who align with the Republican and Democratic parties, a greater share of registered voters say they are both ideologically conservative and associate with the Republican Party (33%) than say they are liberal and align with the Democratic Party (23%).

A quarter of voters associate with the Democratic Party and describe their views as either conservative or moderate, and 14% identify as moderates or liberals and are Republicans or Republican leaners.

The partisan and ideological composition of voters is relatively unchanged over the last five years.

(As a result of significant mode differences in measures of ideology between telephone and online surveys, there is not directly comparable data on ideology prior to 2019.)

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Table of contents, behind biden’s 2020 victory, a voter data resource: detailed demographic tables about verified voters in 2016, 2018, what the 2020 electorate looks like by party, race and ethnicity, age, education and religion, interactive map: the changing racial and ethnic makeup of the u.s. electorate, in changing u.s. electorate, race and education remain stark dividing lines, most popular.

About Pew Research Center Pew Research Center is a nonpartisan fact tank that informs the public about the issues, attitudes and trends shaping the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. Pew Research Center does not take policy positions. It is a subsidiary of The Pew Charitable Trusts .

UCF Graduate Programs Reach New Heights in U.S. News Rankings Through Research Excellence, Impactful Community Engagement

UCF’s emergency management program ranks No. 1 in the nation, and programs in education and public affairs climbed in U.S. News & World Report ’s Best Graduate Schools rankings.

By Mark Schlueb ’93 ’21MA | April 9, 2024

UCF is a leading metropolitan research university known for helping students unleash their potential and advancing innovation in our community and state. Led by world-class faculty members with unrivaled industry experience, UCF’s graduate programs continue to earn top national recognitions for accomplishing those goals and more.

More than 9,000 UCF students enroll in UCF’s graduate programs to advance their careers or launch new ones. And many are thriving on campus and after graduation in programs ranked among the best in the nation.

U.S. News & World Report has recognized UCF’s exceptional faculty and graduate programs in its 2024 list of Best Graduate Schools. UCF’s emergency management program ranks No. 1 in the nation, and four programs rank in the top 25. Nine graduate programs placed in the top 50 nationally, including five in public affairs, three in education and one in health. U.S. News will release rankings for the engineering and medicine categories at a later date.

“UCF’s world-class faculty excel at providing our graduate students with the knowledge and skills they need to thrive as innovative leaders and creators,” says President Alexander N. Cartwright. “The U.S. News rankings demonstrate that our students graduate well-prepared to unleash their potential in individual, business, and government sectors that are growing in Florida and vital to our economy, health, and quality of life.”

UCF Grads Shape Emergency Responses Nationwide

UCF has a proven track record in emergency management. The university’s Master of Emergency and Crisis Management program — which is offered the College of Community Innovation and Education — has climbed the rankings over seven consecutive years. The homeland security program and its faculty researchers enable students to navigate increasingly complex manmade and natural disasters, while learning from past disasters to improve their preparedness and response in the future.

Graduates of the program go on to become leaders in directing and implementing emergency responses in Florida and throughout the country, including in Boston and Washington, D.C. They are saving lives, helping communities prepare as well as possible to navigate disasters, and putting into practice the lessons they learned from outstanding faculty who contribute to  national research and regional solutions related to crises .

“Our students are equipped to assist communities and organizations in every phase of emergency management — from preparedness and mitigation to response and recovery,” says  Claire Connolly Knox, professor in UCF’s School of Public Administration.

“We are thrilled to be ranked No. 1 and nationally recognized again as a leader in emergency and crisis management,” she adds. “This honor highlights the innovative and community-focused research by our faculty and continuous engagement with community partners invested in our outstanding students and alumni.”

Other highlights include:

• 12 in Education — Student Counseling and Personnel Services
• 15 in Public Affairs — Nonprofit Management, up three spots since last year
• 21 in Public Affairs — Public Management and Leadership, up five spots since last year
• 27 in Public Affairs — Public Finance and Budgeting
• 32 in Education — Curriculum and Instruction
• 41 in Health — Physical Therapy
• 42 in Best Education Schools, up four spots since last year
• 47 in Public Affairs
• 59 in Nursing — Doctor of Nursing Practice

UCF’s many strong rankings are a testament to the excellence of UCF’s faculty, who bring to the classroom extensive experience in academia, industry and research, as well as to the university’s commitment to help students unleash their potential in a culture focused on collaboration and finding solutions that benefit our society.

UCF students who have graduated from the nonprofit management program have gone on to make a big impact by helping communities in Florida and beyond. In one example, more than 12 years ago, program graduate Eric Camarillo ’16 ’19MNM launched faith-based nonprofit organization SALT Outreach Inc. in Central Florida to help provide services to the homeless, including mobile shower trailers, laundry, clothing, haircuts, mail services and help with employment. SALT has grown to more than 30 staff members who help hundreds of people every day.

“Throughout the School of Public Administration, our faculty, staff and advisory boards have worked hard to ensure we are offering students in Central Florida, across the country and around the globe a world-class, innovative education,” says Doug Goodman, professor and school director. “We are honored to be recognized as leaders in emergency management, nonprofit management, public leadership management and public finance and budgeting, fields that are critical to the health and well-being of our citizens and the success of our communities.”

The Best Graduate Education Schools category includes graduate-level educator preparation and advancement programs, such as teacher education, school counseling and psychology, educational leadership, and curriculum and instruction, all offered through the College of Community Innovation and Education. The college offers graduate students numerous opportunities to collaborate closely with expert faculty, from receiving mentorship and support in research and scholarship to engaging in robust internships and field experiences with school district, nonprofit and agency partners. Some faculty members also lead federally funded projects that offer tuition assistance and prepare students to work with students in high-need schools.

UCF’s continued rise has also drawn praise from other outlets:

• In February, U.S. News & World Report released its best online program national rankings, which placed UCF tied at No. 7 in the nation for best online bachelor’s programs. Of the 14 UCF national rankings from U.S. News , six online programs made the top 10, two made the top 15 and three were in the top 50. UCF has ranked in the top 20 overall Best Online Programs for the past seven years.
• In March, The Princeton Review and PC Gamer recognized UCF’s game design programs among the best in the world. The graduate Florida Interactive Entertainment Academy is ranked No. 1 in the world for the fourth time in five years. The undergraduate game design program, Games and Interactive Media (GaIM) in UCF’s Nicholson School of Communication and Media, achieved its highest ranking ever, advancing to No. 5 in the world.
• Sports Business Journal named Orlando the No. 1 Best Sports Business City for event hosting, including the NBA, Orlando City and Orlando Pride Soccer, the nation’s premier tennis center, college football bowl games, the NFL Pro Bowl, U.S. Olympic Marathon Trials, the Arnold Palmer Invitational — and, of course, the UCF Knights. With its inaugural season in the Big 12 Conference in 2023, UCF has skyrocketed to unprecedented success as the youngest Power Four program in the country. With one of the country’s  top graduate sports business programs , UCF has also provided a pipeline of talented graduates to some of the nation’s biggest sports brands.

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Founded to help fuel talent for the nearby space industry , UCF continues to build its reputation as SpaceU. Here's a look at the early days of UCF's space ties and journey to new frontiers.