We drew from the conceptualization that sustainability is the continuation or the integration of new practice within an organization whereby it has become a routine part of care delivery and continues to deliver desired outcomes, whereby the ways of thinking and attitudes behind processes and outcomes have changed and the new practice has become the new way of working. Our research aim was to generate, test and refine a program theory on the sustainability of Lean efforts in pediatric healthcare using a realist approach. ![]() Phase 3, reported in this paper, was a realist evaluation to test and refine our program theory and context (C) + mechanism (M) = outcome (O) configurations (CMOcs) developed during phase 1 and 2 of this research. Phase 2 consisted of a realist review to further develop and refine our initial program theory. Phase 1 consisted of initial program theory development. This paper presents the final phase of a multi-phase realist investigation on the sustainability of Lean efforts in pediatric healthcare. ![]() Sustainability is an important yet understudied area of implementation research. Understanding these factors that contribute to its lasting effect are as important as understanding how to implement Lean in the first place. The majority of previous research on Lean implementation in healthcare has not addressed the contextual factors and mechanisms that influence the sustainability of Lean efforts. It has also been conceptualized in multiple ways (e.g., a philosophy or management system versus quality improvement (QI) tools). Lean has been implemented in a variety of healthcare settings (e.g., emergency departments, outpatient clinics, pediatric care), through a variety of implementation approaches (e.g., mandated at macro level, driven by frontline staff at meso level of a system), targeting various levels of healthcare systems (macro, meso or micro). Lean is increasingly recognized as a potential approach to improve problems in healthcare. Lean is a quality management system aimed at maximising value for customers by reducing waste (e.g., overproduction, wait times, unnecessary inventory and motion) and reconfiguring organizational processes. Future work is needed to continue to develop the science on the sustainability of interventions for healthcare improvement. This research illuminates important contextual factors and mechanisms to the process of Lean sustainment that can be applicable to those implementing systems changes. Overall, there was variation between leadership and frontline staff’s perceptions on how embedded Lean was in their contexts, and the degree to which participants supported Lean sustainability. The mandated, top-down, externally led nature of implementation and lack of customization to context served as potential pitfalls. Specifically, the language, messaging and training approaches used triggered mechanisms of innovation fatigue, poor ‘sense-making’ and a lack of engagement for frontline staff. The implementation approach used influenced mechanisms and outcomes for sustainability, more so than Lean itself. Failure to trigger these mechanisms resulted in resistance. Sense-making and staff engagement were prominent mechanisms to the sustainment of Lean efforts. These configurations illustrated a ‘ripple-effect’ from implementation outcomes to contexts for sustainability. Five CMOcs emerged from our realist interview data. We conducted thirty-two interviews across the four cases. Interview data was analyzed using an integrated approach of CMOc categorization coding, CMOc connecting and pattern matching. Guided by a realist evaluation framework, we conducted qualitative realist interviews with various stakeholder groups across four pediatric hospital units ‘cases’ at one acute hospital. We employed a case study research design. We used the context (C) + mechanism (M) = outcome (O) configurations (CMOcs) heuristic to explain under what contexts, for whom, how and why Lean efforts are sustained or not sustained in pediatric healthcare. ![]() ![]() We conducted a realist evaluation on the sustainability of Lean in pediatric healthcare. However, no research has been done on the sustainability of these Lean efforts. Research has been conducted on the implementation processes of this system-wide Lean implementation. In 2012, the Saskatchewan Ministry for Health mandated a system-wide Lean transformation.
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