Applications of lean in human resources management in healthcare

Recent challenges brought by the coronavirus disease-2019 pandemic have underscored the importance of coping with pressures on the workforce in healthcare around the world and have emphasised the continuing need to improve quality and operation efficiency of healthcare services even in such dire circumstances. Over the years, lean thinking has gained recognition in the healthcare industry, where lean has been associated with benefits, such as improved healthcare delivery quality, reduced costs and increased effectiveness of the healthcare delivery processes. Lean thinking has also been analysed in human resources with benefits, such as increased job satisfaction and perceived job autonomy. The current narrative review was planned to analyse and discuss the application and implementation of lean strategies with a particular focus on human resource management in healthcare. The review is complemented by a case study in a private healthcare group in Turkey, aiming to demonstrate in practice the effect of lean strategies on the satisfaction of patients and relatives, the job satisfaction of the employees, and the level of turnover rates within healthcare enterprises.


Introduction
Recent challenges in the wake of the coronavirus disease-2019 (COVID-19) pandemic 30 have exposed the weaknesses of healthcare supply chains across the world, resulting in 31 a significant pressure on the delivery of health services and on its workforce (1). The 32 turbulent atmosphere once again demonstrated the importance of resilience in the 33 healthcare industry. Going forward, lean thinking will continue to be a tool for 34 healthcare managers in putting in place processes and procedures to improve the 35 quality and operational efficiency of healthcare services and productivity of its 36 workforce from a human resources (HR) management perspective (1). 37 The rapid developments in technology and the expansion of globalisation created a 38 fiercely competitive commercial environment, leading to novel approaches in 39 management, production systems, and HR (2). Historically, the concept of lean was  Studies demonstrated that the application of lean thinking in the healthcare industry 44 had been a successful process in quality improvement in the delivery of healthcare 45 services (4,5,6). The lean approach aligns with the industry's objectives of ensuring a 46 higher level of performance, and further facilitates improvement in quality, safety, 47 efficiency and appropriateness of healthcare delivery (2,3). Studies also showed the 48 benefits of lean in HR management on job satisfaction and perceived job autonomy (7, 49 8). Lean serves as a tool for the creation of a valuable platform where workers can 50 identify the essential skills, capabilities and competencies to improve their ability to 51 assist the organisations eliminate the waste and to ensure continuous improvement in 52 order to achieve productivity and efficiency (9). Yet, the application of lean to the 53 healthcare sector, with a particular focus on HR management, is not as straightforward 54 as, and certainly not similar to, the lean approach in manufacturing and production 55 sectors (10). This fact can partly be attributed to the complex organisational structure 56 that distinguishes the fast-paced nature of a healthcare environment (11). The current narrative review was planned to discuss the implementation of lean in 58 healthcare from a HR perspective. Academic literature revealed considerable 59 variability in the implementation of lean in healthcare with differences in approach. 60 We take as a starting point Radnor's observation that when lean is applied solely as a 61 broader system-wide improvement philosophy, as opposed to a narrow range of 62 specific tools, techniques, procedures and processes employed in specified 63 departments or units, it will be less likely to result in sustained improvements (11).

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Since then, its application has increasingly expanded to the developing countries (1).

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Lean management in healthcare operates as 'a set of operation philosophies and

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The effective teamwork between employees working at different segments of the 146 healthcare delivery process plays a crucial role in the productivity of the institution.

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Some studies even assert that the most valuable asset that organisations have in order 148 to achieve their goals is the employees in that organisation (28). The more effective 149 and productive the employees are, the easier it will be for enterprises to survive in a