Social Science & Medicine 71 (2010) 1332e1340

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Social Science & Medicine

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Lean healthcare: Rhetoric, ritual and resistanceq,qq

Justin J. Waring*, Simon Bishop
Nottingham University Business School, University of Nottingham, Jubilee Campus, Nottingham, NG8 1BB, United Kingdom

a r t i c l e i n f o

a b s t r a c t

Article history:
Available online 13 July 2010

This paper presents an ethnographic account of the implementation of Lean service redesign methodologies in one UK NHS hospital operating department. It is suggested that this popular management
technology, with its emphasis on creating value streams and reducing waste, has the potential to
transform the social organisation of healthcare work. The paper locates Lean healthcare within wider
debates related to the standardisation of clinical practice, the re-conguration of occupational boundaries and the stratication of clinical communities. Drawing on the technologies-in-practice perspective
the study is attentive to the interaction of both the intent to transform work and the response of
clinicians to this intent as an ongoing and situated social practice. In developing this analysis this article
explores three dimensions of social practice to consider the way Lean is interpreted and articulated
(rhetoric), enacted in social practice (ritual), and experienced in the context of prevailing lines of power
(resistance). Through these interlinked analytical lenses the paper suggests the interaction of Lean and
clinical practice remains contingent and open to negotiation. In particular, Lean follows in a line of
service improvements that bring to the fore tensions between clinicians and service leaders around the
social organisation of healthcare work. The paper concludes that Lean might not be the easy remedy for
making both efciency and effectiveness improvements in healthcare.
2010 Elsevier Ltd. All rights reserved.

Keywords:
UK
Lean healthcare
Service re-conguration
Organisation
Management

Introduction
In the current global economic climate, governments look for
ways to contain or reduce public healthcare spending, while
simultaneously assuring levels of service and, in some cases,
extending provision to marginalised groups. Policy makers and
service leaders are therefore attracted to management philosophies
that, for other industries, offer more productive and cost-effective
ways of organising and delivering services. One prominent example
is the popular application of process re-engineering methodologies,
such as Lean Thinking and Six Sigma (Radnor & Boaden, 2008).
These are characterised as reducing waste and adding customer
value through re-conguring organisational processes (Womack &
Jones, 2003). Over the last decade there has been growing international interest in the idea of Lean Healthcare, exemplied by the

q The research was funded by the Economic and Social Research Council
[RES-061-25-0040].
qq The authors would like to thank reviewers for their comments and suggestions in developing this work.
* Corresponding author. Tel.: 44 (0)115 8231275.
E-mail address: justin.waring@nottingham.ac.uk (J.J. Waring).
0277-9536/$ e see front matter 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2010.06.028

work of bodies such as US Institute for Healthcare Improvement

and the UK Institute for Innovation and Improvement.
The introduction of Lean healthcare resurfaces longstanding
debates around the changing organisation of healthcare work. For
over three decades scholars have examined the impact of reform on
clinical practice. Managers and corporate rationalisers have been
widely interpreted as countervailing powers, challenging the
dominance of groups such as medicine (Alford, 1975; Harrison &
Pollitt, 1995; Hunter, 1994; Light, 1995). More broadly it is suggested that the logic of managerialism had come to replace the
logic of professionalism in the social organisation of healthcare
(Kitchener, 2000). Contemporary healthcare reforms illustrate this
trend in three areas. The rst relates to the proliferation, and
management co-option of, evidence-based guidelines and audit
regimes, which highlight the standardisation, bureaucratisation
and re-regulation of clinical practice (Allen, 2009; Harrison, 2002;
Timmermans & Berg, 2003a, 2003b). The second relates to the reconguration of clinical work, especially professional boundaries,
to deliver more patient-centred, evidence-based services, including
new forms of clinical specialisation (Martin, Currie, & Finn, 2009).
The third relates to the re-stratication of professional groups as
clinical leaders are co-opted in managerial roles to direct the
process of change (Coburn, Rappolt, & Bourgeault, 1997; Friedson,
1994; Kitchener, 2000). In combination these changes raise

J.J. Waring, S. Bishop / Social Science & Medicine 71 (2010) 1332e1340

questions about the creeping managerialisation of healthcare, the

negotiation of jurisdictional boundaries, new forms of governance
and emerging hybrid identities (Llewellyn, 2001; McDonald,
Harrison, & Checkland, 2008; Sheaff et al., 2004; Waring & Currie,
2009)
Lean Healthcare contributes to these three trends, representing
a new focal point in the reorganisation of healthcare work. It
exemplies efforts to establish unambiguous evidence of service
performance on which service leaders can seek to further rationalise and streamline clinical practices, which in turn involves the
re-conguration of established working practices and new forms of
clinical leadership. Our paper investigates the implementation of
Lean within the English National Health Service (NHS), specically
the hospital operating department, to understand whether and
how this particular management approach interacts and transforms established ways of working. It contributes to these wider
debates, and offers a critical appraisal of Lean as the current fashion
in healthcare reform. In developing our analysis, we look to new
ways of understanding the interplay between Lean and clinical
practice and draw upon the technologies-in-practice approach
(Timmermans & Berg, 2003a). This considers how technologies
such as Lean interact with and are co-constructed in relation to
other social actors and practices within in a given socialecultural
context. Our work is therefore attentive to the way both Lean and
clinical practice are constructed in relation to each other in a situated and ongoing process of organisational change.
Lean healthcare
Process re-engineering methodologies, such as Lean and Six
Sigma, have become international management phenomenon.
Without engaging in a detailed social history, such methodologies
follow in a long history of systems management and quality
improvement with their own distinct genealogies, such as scientic
management and Total Quality Management (TQM) (Deming,
2000). With its origins in the Toyota Production Systems (TPS),
Lean Thinking has become particularly popular (Liker, 2004;
Womack & Jones, 2003). Central to its philosophy is a concern
with waste (muda) or processes that add no value to the product or
customer. This waste is elaborated in seven areas, including
transportation, inventory, motion, waiting, overproduction, over
processing and defects. To reduce this waste, ve principles of Lean
Thinking are proposed. The rst is to specify the value created by
the operational process. This should not be dominated by provider
interests, but instead should reect what the customer will value.
The second involves identifying value streams or those processes
that will ultimately add value to the product. This can be achieved
through forms of problem-solving and change management, often
through re-drawing activities that add value, while eliminating
those that do not. The third involves creating ow throughout
these processes. This means breaking down the boundaries and
divisions between organisational and occupational groups to
ensure work streams are continually attuned to the creation of
value. The fourth highlights the importance of demand or pull
through responding to the needs of customers, rather than
suppliers. And nally, it strives for perfection or the idea that Lean
Thinking should be a continuous activity embedded within the
culture of the organisation.
In practice, the application of Lean involves a range of
approaches and tools (Womack & Jones, 2003). It is widely suggested that Lean Thinking relies upon effective leadership to shape
and sustain the change process. Although attention is given to
strong central leadership, equal consideration is given to distributed leadership through champions and educators. Another
theme relates to the role of work teams and stakeholders both in

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the specication of value and the implementation of change. One of

the most celebrated ideas of Lean, and other process re-engineering methodologies, is continuous improvement (kaizen). In
short, this emphasises the importance of continually reecting
upon, measuring and changing work processes in an effort to
improve workow, reduce waste and add value. Popular variations
include the Plan-Do-Check-Act (PDAC) cycle, as well as techniques
such as process mapping and waste audits (Womack & Jones,
2003).
Over the last decade process re-engineering methodologies
have been applied widely across the public and healthcare service
(IHI, 2005; NHS Confederation, 2006; Proudlove, Moxham, &
Boaden, 2008; Radnor & Boaden, 2008; Young & McClean, 2008;
Zidel, 2006). For the UK NHS, health policies have taken a rather
eclectic approach, often blending Lean with other developments in
quality assurance and workforce development, such as patient
safety (NHS Confederation, 2006). While clearly informed by the
Lean philosophy, in practice this means Lean may take on a variety
of guises, ranging from more localised examples of PDAC to wholesystem changes (Burgess, Radnor, & Davies, 2009). Such diversity
may not necessarily be problematic, but it does suggests that in
translation to practice, Lean principles have become entangled with
other reforms and the competing voices of policy makers,
managers, clinical leaders and management consultants.
Arguably the most prominent example of Lean in the NHS is
the Institute for Innovation and Improvements Productive Series.
Of relevance to this paper, the Productive Theatre programme
comprises a series of modular activities for enhancing the smooth,
efcient and safe running of operating theatres. These include
training guides that enhance the capacity of leaders to inspire and
introduce change; resources to assist service leaders to know how
we are doing through auditing and measuring theatre usage and
waste; models and tasks to improve the organisation and scheduling of theatres; and a series of toolkits to improve theatre
preparation, safety checks, equipment planning and handover. For
example, it promotes the use of improvement techniques such as
5S. Like Kaizen, this involves the reorganisation of activities along
ve principles: sort or organise the work area (seiri); set or
order the work area (seiton); shine or ensure the cleanliness of
the work area (seiso); standardise to ensure tasks are routinely
completed (seiketsu); and sustain through fostering a disciplined
culture towards improvement (shitsuke). This approach has found
popular appeal in healthcare, often in relation to the problems of
hospital-acquired infections. One way of interpreting this bundle
of activities is that they aim to redesign clinical practices and
resources around streamlined, efcient and value-adding care
pathways.
A growing body of research examines the implementation of
Lean methodologies within healthcare, often showing the benets
to patient care and resource utilisation (Jones & Filochowski, 2006;
Joosten, Bongers, & Janssen, 2009; Kim, Spahlinger, Kin, & Billi,
2005; Radnor & Boaden, 2008; Zidel, 2006; Walley, 2003).
However, research also suggests the implementation of Lean is not
without its problems, with the process depending on factors such
as organisational readiness, a culture of continuous improvement,
effective leadership, the availability of resources and communication strategy (Radnor & Boaden, 2008). Moreover, it is shown how
in practice Lean involves considerable variability, with some
services adopting a system-wide approach, while others tentatively
adopt specic techniques from the Lean toolbox (Burgess et al.,
2009). This highlights how the wider socio-cultural and organisational context of healthcare can have a signicant bearing on how
Lean is translated from policy to practice. Reinforcing this view,
Joosten et al. (2009) suggest there is a lack of socio-technical
research that moves beyond evaluation to a more critical and

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J.J. Waring, S. Bishop / Social Science & Medicine 71 (2010) 1332e1340

theoretical understanding how of Lean interacts with pre-existing

healthcare practices.
Lean-ing on clinical practice
In developing a socio-cultural perspective, analysis in other
sectors points to some of the consequences of Lean outside of those
conveyed in managerialist visions. Research has illustrated how its
introduction can change social relations in the workplace as
managers seek to remove demarcations between areas of production (Gerrahan & Stewart, 1992); it is often accompanied by an
extension of surveillance as peers are encouraged to monitor each
others work (Moody, 1997); and productivity gains are often based
on employees losing free time, autonomy and job security (Graham,
1995).
Building upon these ideas, we suggest Lean raises further
questions about the social organisation of healthcare. It can be
argued, for instance, that while Lean might have appeal in many
industrial settings, like other management techniques it may not
easily translate into healthcare (Weiner, 2004). For example, how
and who should specify the value to be created in healthcare
(Young & McClean, 2008), and should we talk of value (in a narrow
sense of an individual patients experience) or values (in a wider
sense of collective beliefs about healthcare)? Returning to our
wider debates, Lean illustrates the desire of policy makers to reorder clinical work through the introduction of managerial
philosophies and techniques. Firstly, it involves the systematic
appraisal of existing work process to determine evidence of their
waste and inefciencies. This then provides managers and service
leaders with more robust and empirical foundations for introducing and legitimising service transformation, especially through
standardised and streamlined work practices. Secondly, to increase
productivity and efciency in line with the new evidence, existing
working practices and jurisdictions need to be re-congured.
Professional groups, such as medicine and nursing, are characterised by their jurisdictional boundaries that are institutionalised
through a range of socio-legal and regulatory pillars, while also
being maintained in practice through negotiation and boundary
work (Abbott, 1988; Gieryn, 1983). Lean thinking encourages
service leaders to rationalise and re-congure these boundaries in
an effort to create ow across more integrated value streams.
Thirdly, the implementation of Lean relies upon effective leadership to promote the ethos and values of Lean Thinking and to
ensure existing working practices are appropriately assessed and
re-congured. This requires leaders and managers to be sufciently
trained into Lean Thinking as well as able, through both formal
and informal authority, to enrol clinician and enact change. Where
service leaders are too far removed from clinical practice, and
therefore unable to effectively or legitimately undertake this work,
it is expected that local clinicians will be appointed as champions
to full these tasks. This further highlights the potential for clinicians to be drawn into management and leadership roles in the
process of making healthcare Lean.
Lean can be interpreted therefore as a new frontier in the
managerialisation of healthcare. As with similar developments in
clinical regulation, risk management and quality assurance
(Waring, 2007; Weiner, 2004) it can be anticipated that the translation of these management techniques from industry to healthcare
might have a profound impact on the social organisation of
healthcare. Moreover, Weiner (2004) argues that such management practices are often poorly suited to healthcare and have
unintended consequences for clinician practice and service quality,
redirecting their attention from patient care towards more
administrative duties. In developing this analysis, we follow
a technology-in-practice approach (Timmermans & Berg, 2003b),

where technology is conceptualised in its broadest sense,

including management technologies such as Lean. This approach
has its origins in the sociology of (scientic) knowledge and, more
recently, Science and Technology Studies (Pinch & Bijker, 1984). In
general, it counters more deterministic and reductionist works by
seeing technologies as developed and enacted within a complex
network of actors and materials (Law, 1992). This view has strong
links with concepts and ideas in Actor-Network Theory, which has
been inuential for investigating how scientic knowledge and
technologies emerge through highly contextualised and integrated
networks of actors, technologies and ideas (Latour, 2005; Law,
1992). In its broadest sense, this line of analysis is attentive to the
relationships between materials and semiotics. It highlights how
technologies have rich social genealogies that reect the values,
actions and norms of those networked actors involved in their
development. Accordingly, technologies are characterised by
interpretative exibility in the sense that they are imbued with
social and cultural meaning, but that this meaning is open to
change and reinterpretation as technologies move to new social
settings and interact with different values and beliefs. In line with
the actorenetwork approach, technology and practice are therefore
co-constructed with e technologies reshaping practice at the same
time that practice reshapes technology. As such, what becomes of
interest is the way social groups or networks interact with or form
around particular technologies and how technologies are used to
transform existing patterns of social order. With particular relevance to this study, Callon (1986) highlights how, in the context of
particular social problems, certain actors or groups worked to
impose their ideas and strategies for change across and within
networks of other actors. This translation process examines how
these actors dene the nature of a given problem in ways that
justies and locates their own centrality in its resolution. He also
highlights their capacity to dene the roles of others and mobilise
particular interests and arguments to secure their enrolment in the
change process. Similar ideas have been developed within the
healthcare context to examine, for example, how medical records,
evidence-based medicine, diagnostic machines and information
technologies interact with and reconstruct clinical practice (May &
Finch, 2009; Mol, 2005; Nicolini, 2006; Timmermans & Berg,
2003a). Heath, Luff, and Svensson (2003), for example, review the
changing roles of technologies in healthcare and highlight how in
use they impact on professional boundaries, identities and
teamwork.
This perspective foregrounds the contingent institutional work
involved in designing, developing and delivering technological
change such as Lean, including the potential for Lean and clinical
practice to mutually recreate one another, and their combined
capacity to redene institutionalised ways of working. It calls for
a detailed, contextualised understanding of how management
technologies and clinical practices interact and are mediated. This
requires attention to the way Lean is translated and interpreted by
different groups; the way it is implemented in relation to clinical
practice as ongoing social activities, and the capacity for technologies and practice to make and re-make each other. This in itself
may have unanticipated but nonetheless signicant and enduring
consequences for the existing social practice.
The study
The paper is based on an ethnographic study of the implementation of Lean Thinking within the hospital operating
department. The research was initiated in 2008 in two NHS
hospitals and continues to be developed in two further hospitals as
new service re-conguration programmes are introduced. Across
all research sites, service re-conguration projects were identied

J.J. Waring, S. Bishop / Social Science & Medicine 71 (2010) 1332e1340

that were explicitly based on the philosophy of Lean and TPS. Our
research found, however, variations in these projects encouraging
us to be attentive to different ways Lean is translated into and
impacts upon clinical practice. This paper focuses on the reconguration of two surgical lists (vascular and arthroscopy)
within one hospital setting.
The papers ndings were collected over 12 months in one
hospital operating department carried out between 2008 and 2009.
This included non-participant observations of clinical activities,
including ward areas, operating theatres, recovery rooms, clinics and
assessment rooms; and participant observations in other non-clinical
settings, including management meetings, team briengs, and rest
areas. Our observations focus on a series of meetings to dene and
design departmental strategy for Lean; team briengs to introduce
Lean to clinical groups; workshops and problem-based activities such
as mapping existing activities; and other activities where service
changes were introduced. Our role within these processes ranged
from being an external academic observer to becoming more
involved in group discussions related to service change. During our
observations we engaged staff in numerous informal conversations to
clarify issues, and conducted 42 semi-structured one-to-one interviews with nurses, operating department practitioners (ODPs),
healthcare assistants, surgeons, anaesthetists and managers. The
study received ethical approval through standard NHS procedures. In
line with this, all clinical staff were notied in writing and through
staff briengs of the study aims and methods in advance of
conducting the research, observational activities required verbal
consent from participants and interviews required written consent.
Our observations were recorded in individual eld journals
comprising rich descriptions of events, interactions and statements, together with personal reections. The research team met
weekly to reect upon observations and identify emergent
themes, whereby a common electronic record was compiled that
catalogued interpretative codes, categories and themes with
corresponding extracts of data. Interviews were transcribed and
coded through close reading by the authors. This involved
developing a common coding frame that related to our observational categories and themes. We draw upon this data to tell
the unfolding story of Lean within this operating department.
Clearly, there are limits to the detail of ethnographic analysis we
can give; as such our paper moves between empirical settings,
levels of analysis and conceptual categories to explore social
practice in the context of this organisational change (Nicolini,
2010).
Lean-in-clinical practice
Rhetoric
Our rst analytical theme foregrounds the role of rhetoric
within organisational practice or the way language is used in an
interactive space to persuade others (Farrell, 1999). Classical principles of rhetoric include the appeals to reason (logos), emotion
(pathos) and values (ethos), but more broadly it is attentive to
where, how and when arguments are articulated. A focus on
rhetoric highlights the contribution of persuasion to the negotiation of social order, the social construction of knowledge, and the
dynamics of social power (Foucault, 1980). For example, scholars of
epistemology highlight the rhetorical use of concepts such as
objectivity when scientists seek to legitimise their discoveries; yet,
ultimately, such knowledge remains shaped by the values and
ideology of the given epistemic community (Knorr-Cetina, 1983;
Scott, 1999). In the context of our study, we were attentive to the
way service leaders interpreted and articulated Lean to persuade
others as to its relevance to service improvement. In this sense, we

1335

follow Callon (1986) by looking at how these leaders persuade

clinicians of the problems facing the service and enrol them in the
processes of change.
We focus on one meeting in the early stages of the study. Titled
the Productive Theatre, this meeting was convened in the staff
lounge by the departmental manager and attended by the majority
of departmental staff and representatives from linked departments,
such as surgery and sterile services. It was led primarily by
a corporate hospital manager with responsibility for service
improvement. This person introduced themselves by describing,
initially, their medical background, but then their experience in
service improvement, which included holding post-graduate
qualications in Operations Management and working as
a management consultant. In two ways, the hospital manager
appeared to be justifying and legitimising their expertise and
leadership within this meeting and, more generally, for service reconguration.
The hospital manager proceeded to describe the aim of the
meeting as exploring ways of creating value in departmental
processes. He asked participants so why do we come to work.
what are we here for with e the emphasis on we denoting some
collective endeavour. Despite a number of clinicians suggesting that
it paid the mortgage, responses coalesced around the importance
of patient care. The manager responded by writing patient care at
the head of a large ip chart and asked so, what do patients
value? Before any answers could be given he asked: do they value
waiting in reception, do they value having their operation
cancelled, do they value having tests repeated, to which he
answered obviously no. Through this exchange the manager
appeared to articulate service value and patient care as antonymous with waste, or delays. Moreover, he apparently discovered
a moral consensus between the caring ethos of the staff and the
corporate values of volume, throughput and efciency. Elaborating
this, the hospital manager appeared to offer a diagnosis of the
problems facing the department.
Following this diagnosis, the manager started to describe ways
they could initiate improvements, arguing the NHS could learn
from organisations such as Toyota and Tesco:
These companies have found ways to change how they work,
they have reduced their waste, they have improved their safety.
We can do the same. We need to work smartly (Field notes)
He then described the changes he had helped bring about in
other hospital departments, again talking-up his expertise and
legitimising his leadership credentials. To explain the principles of
Lean, he wrote on the ip chart the seven common areas of waste
(Womack & Jones, 2003), before asking staff to give relevant
examples from departmental processes. A variety of answers were
given, including the use of the IT systems, excessive paperwork,
moving patients between departments, and checking instrumentation. Through this dialogue the manager encouraged staff into
Lean Thinking, endorsing suggestions that resonated with Lean.
That is exactly what today is about, a chance for you to question
things that havent been questioned, because you know best.
(Field notes)
In the nal section of the meeting the manager explained some
of the practical steps that could be taken. Again reference was made
to industries that had successfully utilised process mapping to
identify waste or 5S to enhance productivity. In demonstrating
these approaches staff were referred to a pre-prepared chart, which
we later determined had been designed by the clinical director. This
depicted a patients journey from the anaesthetic room to the
operating theatre, including the procedures for consent, anaesthetic preparation, airway and circulation checks, anaesthetic

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administration, patient stabilisation and transport into the theatre.

At this point the clinical director took control of the meeting
identifying delays and inefciencies in the work ow. In particular, this anaesthetist was keen to focus on problems for which
workable solutions could be found but almost exclusively in
terms of removing delays or waste. Intermittently, staff raised
thorny issues which were not so easily dened or solved through
frontline activity, such as resource constraints, ongoing concerns
over a recent hospital merger, shortages of staff and agency
workers, or alluded to known tensions between departments and
professional groups. In such instances the manager and clinical
director worked together to steer participants back to more
bounded, solvable concerns.
This initial meeting set the rhetorical tone for the introduction
of Lean. Great care was taken by the service leaders to dene the
problems of waste and inefciency and, signicantly, to link them
to staff concerns for patient care. As such they worked to bring
together the values (ethos) of management and clinicians into
a single rhetorical discourse. This enabled leaders to present Lean
as a legitimate, proven, and rational (logos) solution to the problems facing the department. Lean was promised as taking the
messy, tense, daily experiences of delays, equipment shortages and
communication breakdowns, and transforming them into the
model of an efcient stress free work process. On the one hand, it
was presented as a common-sense solution to the problems of the
department involving hard work and plain thinking, thereby
having resonance and meaning to clinicians. On the other hand, it
was presented as novel, cutting edge and shrouded in mystic jargon
from Japanese industry, which required the expertise and importantly leadership of hospital management and expert clinicians.
Reecting further upon the role of these leaders, we nd further
evidence of re-stratication and differentiation among clinicians as
only those (senior) clinicians or managers with appropriate
expertise in the philosophy and methods of Lean were presented as
able to legitimately direct or manage the change process. It reveals
how these leaders worked to justify their centrality and legitimacy,
and also to enrol like-minded allies and collaborators among
departmental staff to participate in the change process (Callon,
1986), thereby suggesting at further stratication among clinicians. It is also worth recognising, however, that those leading the
process were also characterised by signicant levels of organisational and occupational authority, including senior hospital and
departmental managers as well as a clinical director. Reecting
upon the reactions of clinicians, we were surprised how many
offered elaborate justications for Lean. The theatre managers, for
example, tended to emphasise the improvements that could be
made to patient throughput and resource utilisation; theatre sisters
and team leaders discussed it as an opportunity to better co-ordinate staff across lists, and surgical and anaesthetic groups stressed
the opportunity of reducing disruptions in their clinical work.
Although this indicated some initial support for Lean and the
enrolment of certain individuals into future change activities (discussed below), it also highlighted how Lean was interpreted in
various ways and was made by staff to t with prevailing concerns
for service organisation.
Ritual
Our second analytical theme explores the ritualistic dimensions
of social practice. In socio-cultural research, rituals are those
customary, patterned social practices that occur on an almost
taken-for-granted basis. These ritualistic practices tend to convey
symbolic, shared meanings, for example, reinforcing roles, group
membership, status, or group cohesion. Focussing on ritualistic
behaviours offers an analytical lens for exploring how routine social

practices connect both structure and agency within the context of

change. Notwithstanding this symbolic role, rituals can also
become an end in themselves where they are followed to
demonstrate compliance rather than to convey an underlying
symbolic intent. Ritualistic behaviours have been identied in
many areas of clinical practice, such as doctor-patient interaction,
ward rounds and surgery (e.g., Arluke, 1977; Freidson, 1970;
Waring, Harrison, & McDonald, 2007). Importantly, research
shows how they reinforce wider cultural norms and expectations,
for example around status differentials and notions of professionalism. In the context of this study, we were attentive to whether
and how Lean techniques, especially those centred on the reconguration of roles and responsibilities, emerge as shared
routines and rituals as they became enacted within day-to-day
practices.
We return to our ndings 2 months later. Our rst example
centres on the work of the recently created departmental working
group, comprising the departmental manager, the clinical director
and other enrolled clinicians including one theatre sister, two
theatre nurses, one ODP, one surgical and one anaesthetic representative. A range of other individuals also participated in the
working groups activities, including the aforementioned hospital
manager who provided specialist direction and toolkits, while
other medical and nursing staff were periodically asked to take part
in efciency audits. Building on the above, an initial observation
relates to how other clinicians were enrolled or recruited into this
workgroup by the service leaders and dened as champions. To
facilitate their work, the group was allocated a project room
within the department. This showcased their collective interests
and activities through, for instance, the display of large posters that
described the Seven Areas of Muda and the Principles of Lean. The
most striking feature of the room, however, was a process map
created for the vascular and arthroscopy pathways. Comprising
many hundreds of small pieces of paper each inscribed with an
activity, process or task, these maps spanned two-thirds of the
walls and depicted a horizontal ow chart of the stages involved in
the delivery of patient care. The room hosted the groups weekly
meeting, but it was also used at other times during the working
week for team members to complete tasks or hold small
submeetings.
In observing the groups rst few meetings we reected on how
quickly an accepted pattern of routines, customs and order
emerged. The weekly meeting quickly acquired a ceremonial
quality where participants took turns to recite their plans, feedback
their ndings, chart progress and share frustrations. For example, in
one meeting an ODP started by describing how they had re-ordered
the storeroom so that equipment could be more easily allocated;
the theatre sister then described how she was planning to review
the staff rota to support team stability across the two surgical lists;
and a nurse explained that they had audited the patients journey
from recovery to the ward to identify delays. In most cases these
verbal reports were accompanied by additions to the process
diagrams and charts displayed on the walls and were received with
great celebration. We were struck by how group members had
embraced the language, terminology and paraphernalia of Lean and
how these activities took on a heightened level of signicance with
process maps, spreadsheets and timelines becoming themselves
the focus of their attention. It often appeared that completing and
reporting on these tasks was as much the substance of doing Lean
as any changes to departmental practice.
Reecting upon these activities we interpreted the members of
this group as converts to Lean. Although from different occupational backgrounds, it appeared these clinicians had been
successfully enrolled into the philosophy, language and practices of
Lean. Furthermore, in undertaking these activities they

J.J. Waring, S. Bishop / Social Science & Medicine 71 (2010) 1332e1340

symbolically communicated their commitment to these values and

activities, primarily to themselves, and service leaders but more
widely to colleagues. We suggest that for this group these practices
resembled hallowed rituals, replete with symbolic meaning that
conveyed their conversion to and enrolment within Lean and their
compliance with the vision set out by hospital managers. It is worth
considering that although these individuals appeared to have fully
embraced Lean thinking, multiple motivations could be inferred,
from service dedication to increasing job variety, career advancement or greater status among the wider workforce; hence another
aspect of re-stratication.
Our second example considers how these Lean activities
impacted upon and re-congured departmental work, including
efforts to streamline booking systems, change bleep responsibilities
and redraw clinical pathways. One prominent example involved the
introduction of a theatre checklist that had been developed by the
working group. This was explicitly based on the 5S methodology
and aimed to ensure all necessary surgical resources were appropriately organised, ordered and cleaned, and clinical roles clearly
dened in advance of surgery in order to reduce delays and
wasteful activities. Its completion was designated to a theatre coordinator, but required verbal and written conrmation from other
clinicians before the start of a list, especially the anaesthetist. In
many aspects, this resembled the WHO Safe Surgery Saves Lives
Checklist, which we later found replaced this local checklist
version.
Its application initially met with enthusiasm from staff who
described it, for example, as offering guidance and reassurance.
Around a month after its introduction, however, we observed
instances where these checking activities were not always followed. This tended to occur around busy periods or messy lists.
There was no evidence that patient safety was compromised, only
that clinicians often abandoned the required procedures, such as
preparing all instrumentation or conrming staff names, and
instead returned to pre-existing practices. It was particularly
interesting to nd that in many of these situations clinicians would
still attempt to complete the checklist, albeit at a later time, even
though its contribution would be limited. For example in three
separate lists we observed that the theatre co-ordinator signed-off
the paper after the list had started and when the pace of work had
returned to normal. On another, an ODP commented to the
anaesthetist that introductory procedures had not been followed,
to which the anaesthetist ironically replied my name is Peter, I am
the anaesthetist and I am here, lets get going. In these instances,
the checklist activities were all but supercial and obsolete as
surgery had already started. However, staff still felt it important to
show that they had complied, if only through lling in the necessary paperwork.
Similar examples were found following the reorganisation of
handover between departmental areas. Here new guidelines
were introduced to specify roles and relationships, including
a list of information to exchange, as well as timings and obligations. Although clinicians showed some initial interest in
these guidelines, this appeared to be associated with determining its relevance to clinical practice and mocking the
working group. In nearly all cases, clinicians returned to their
pre-existing handover relationships, but with an additional
discussion as to who would be responsible for signing the new
paper work at a later time. Another example, was found with the
re-ordering of the theatre store, again based on the 5S methodology. Although one of the working group had spent time
assessing the most efcient ways to store equipment and
changing the existing arrangements, after several weeks we
found that it had returned to, what this particular ODP claimed
was, its former messy state.

1337

Although these activities aim to ensure operational efciency,

when implemented in practice we nd signicant tensions and
ambiguities in their use as they mix with other bureaucratic
activities or replicate and delay pre-existing clinical activities. Yet,
clinicians recognised the expectation to complete these tasks even
when they no longer held relevance to clinical activity. These
hollow rituals appeared to demonstrate clinicians symbolic
compliance to new ways of working, even though they might not
actually contribute to service delivery. Although such methods
might appear path-breaking, when they interact with practice
they can struggle to become embedded in practice, with clinicians
often returning to pre-existing roles and relationships.
Our observations revealed the different responses to Lean in
practice. Those leading the process appeared to acquire a new role
and status in departmental planning. Not only does this highlight
re-stratication among clinicians, but in practice these new roles
also acquired their own ritualistic quality, symbolising the enrolment and commitment of these converts to Lean. For clinicians not
directly involved in the project, Lean was seen in more ambiguous
terms, despite becoming an increasingly common feature of daily
practice. For these clinicians, it was often important to show
willing or compliance, but this was often supercial or hollow as
there was little sense of enrolment or conversion. This was most
evident at times of pressure and change, which characterised most
days, when clinicians returned to pre-existing practice. In this
sense, Lean has a contingent and spatial dimension. Its focus and
application remains primarily located in the project room where
the uncertainties of clinical work can be more easily controlled and
practices re-drawn in the abstract sense of a laboratory. Outside
this room, however, the realities of clinical practice render the
measures, abstractions and re-conguration of work problematic as
they interact with the normal messiness and uncertainty of
practice.
Resistance
Our third analytical theme explores how social practices are
imbued with power and resistance. This highlights the way practices can develop in opposition to the activities or interests of
others, including the mobilisation of different arguments, resources
and strategies to counter, corrupt or capture unfolding social or
organisational changes (Lozeau, Langley, & Denis, 2002; Waring &
Currie, 2009). A focus on resistance takes us beyond the structured dynamics of social power, to consider instead how power
relations are manifested in everyday practice. The two themes
discussed above indicate some of these points of conict in the
articulation and implementation of Lean into practice; in developing these further we were attentive to the more explicit forms of
resistance among clinical groups.
We return to the department 4 months after the initial departmental meeting. Since that time the working group had identied
several efciency savings, especially across the arthroscopy care
pathway. Notable examples included revised booking procedures,
the formalisation of task division within the theatre team, new
checklists, condensed handover procedures, and new discharge
responsibilities. When asked to reect upon these changes clinicians
often described how work owed with fewer delays. Moreover, the
departmental manager and theatre sisters claimed this list had
greater team stability and less reliance on agency staff, and the
clinical director stated there had been a 20% increase in patient
throughput. However, many participants also expressed a degree of
cynicism and resistance to the changes to the arthroscopy pathway
as well as Lean more broadly. This was manifested in three ways:
relating to the motives of leaders, the expertise of leaders and to the
perceived negative consequences for clinical practice.

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A signicant line of resistance related to beliefs about the

underlying motives of the working group. Clinicians often argued
that the group prioritised departmental efciency and productivity
over quality and patient experience. Although the hospital manager
had worked to link these values in the earlier meeting, over time
and when experienced in practice, this marriage appeared divorced
with clinicians struggling to appreciate how Lean served to raise
quality. As such, our participants often described the extra work
and attention needed to ensure service quality when working to
faster lists or streamlined procedures.
Theyve pushed through more cases and we have managed to
keep up with the new pace. There is less waiting around. But you
have to wonder about the safety and whether we are missing
things because we are rushing so much. I guess we just have to be
more vigilant and make sure we follow procedure. [Claire, ODP]
Participants also had reservations about the groups knowledge
and experience of departmental processes. It was argued that process
mapping and audits were completed by those lacking a detailed
understanding of how and why practices had developed as they did.
On the one hand, it was felt that recommended changes failed to
reect the expectations of frontline clinicians. On the other hand, it
was suggested that staff struggled to implement changes because of
national and professional guidelines, again demonstrating to our
participants the working groups lack of expertise in this area.
What do they actually know? [Hospital manager] has never
worked here, never set foot in the department before.
[Department manager] might know how you run the department, but she deals with the resourcing and rotas, not what we
actually do. Its ludicrous to think that I could tell them how to
do their job. [Gavin, Nurse]
Through questioning both the working groups motive and
expertise, our participants came to doubt their legitimacy to enact
change. Over the course of our observations clinicians increasingly
vocalised the view that the working group had become dominated
by managerial interests to cut costs. Moreover, members of the
group were described as the chosen ones highlighting the idea
that a higher power e the hospital manager - had appointed them.
Elaborating this view, it certainly appeared that hospital managers
had indeed devolved responsibility for service improvement to
frontline leaders, thereby avoiding direct conict with clinical staff.
Co-opting clinicians into leadership roles did little to mitigate
resistance; rather it appeared to redirect antagonism at the local
level with hostilities evident between clinicians and the working
group.
Clinicians were also critical of many of the changes to their
work. Several clinicians were concerned that new procedures
overly standardised and structured their work to the extent that
they would lose clinical skills in other areas of theatre practice. For
nurses and ODPs this could limit career development, while for
team co-ordinators there were concerns that an overly standardised and role-bound workforce would compromise the departments ability to allocate staff exibly in the light of unanticipated
changes. There were also concerns about the control of clinical roles
and responsibilities. Surgeons often remarked that the departmental manager had no business in telling me when I should
arrive in theatre. Surgeons also found it inappropriate that new
procedures required them to undertake additional checks and
paperwork in advance of surgery that were seen as not related to
my work. Similarly, many anaesthetists were hostile to being
required to complete duties that had previously been held by the
escort nurses and ODPs, and argued that pre-operative checks took
them away from their primary responsibilities.

The checklist is a great idea, I just dont see why we have to do.
Its really for nursing issues, about instrumentation and equipment. We have our own checks that work really well and frankly
it is a waste of my time. (Clarke, Anaesthetist)
When asked about the lasting impact on their practice, clinicians typically suggested that what might look like a good idea in
theory was often difcult to put into practice. Somewhat ironically, the primary resistance to change related to additional time
demands made on clinical work. However, in many instances staff
simply found it more convenient to return to their customary ways
of working, simply ignoring new guidelines for handovers, recordkeeping or clinical roles.
One particularly strong and public act of resistance was the
defacement of a large poster that graphically illustrated the new
arthroscopy and vascular care pathways. A few days after this had
been displayed in the staff lounge we found numerous, grafti-like,
handwritten comments had been added to the chart. For example, the
diagrams Legend had been sufxed in pencil with Fairy Tale; Work
of Fiction. In areas where it designated times for certain tasks, such as
thirty second for patient checks somebody had written staff need
more than thirty seconds, what we need here are more well trained
and motivated staff. In another area staff had written why dont you
tell the surgeons not to use email all the time during lists. These
comments revealed some of the frustrations staff felt about the
proposed changes and the potential for mischief to act as a form of
resistance to management change (Ackroyd & Thompson, 1999).
The lines of resistance to Lean were multidimensional, and in
our experience there was no single issue that galvanised staff into
open confrontation with the working group. Rather clinicians tended to nd fault with different aspects of the process. This
dispersed form of resistance led to simmering conict within daily
practice, whereby staff often acted defensively when new changes
were presented, but publically remained open to the possibility
that they might improve working practice.
Conclusions
At the outset we suggest Lean healthcare might represent a new
development in the reorganisation of healthcare work. In this paper
we have investigated its implementation in one operating department and found that in several ways it has the potential to contribute
to the three lines of change outlined above, including the use of
evidence-based guidelines, the re-conguration of occupational
boundaries and new forms of clinical leadership. Firstly, Lean
emphasises the importance of determining evidence of waste and
inefciency through the use of audits, process maps and PDCA
cycles. Although these may not be perceived as credible or scientic
as other methods of generating evidence-based guidelines, such as
randomised-control trials, these are articulated as a purportedly
rational and legitimate basis for generating evidence and persuading
clinicians as to their appropriateness. Secondly, this evidence is
directed towards the re-conguration of clinical practices to
produce more productive and value-adding processes. This
frequently centres on the re-alignment of established clinical roles
and boundaries to create ow or more streamlined work, as illustrated by new routines and rituals in the form of checklists, booking
systems or delineated clinical duties. Thirdly, the implementation of
Lean requires the development of leaders, both at senior management and local departmental levels. These are concerned with
dening the problems of waste and inefciency that undermine the
values of the services, as well as with enrolling other clinicians into
Lean thinking. Accordingly, we nd evidence of occupational restratication as individuals are recruited as champions of Lean. In
this way, the introduction of Lean healthcare contributes to and cuts

J.J. Waring, S. Bishop / Social Science & Medicine 71 (2010) 1332e1340

across these wider developments in the social organisation of

healthcare, presenting new challenges to and lines of power within
the healthcare division of labour.
However, by investigating how Lean interacts with and impacts
upon clinical practices we nd that this potential is not easily
realised. Specically, our technology-in-practice perspective
offers three analytical lenses for exploring how Lean is negotiated
and contingent as it unfolds in practice. Our rst lens highlights the
importance of leadership in the processes of healthcare reform,
focussing specically on how leaders articulated the values and
purpose of Lean as a means of persuading and enrolling clinicians
in the change process. Building on Callon (1986), we highlight how
senior leaders work to dene the problems of waste by linking
them to staff concerns for patient care. Through this interaction
they promote the logical and ethical benets of Lean while also
cementing their own authority and enrolling other clinicians into
the change process. Our second lens shows, however, that only
a small group of clinicians were successfully enrolled within Lean.
These champions appeared to be converted to Lean through
participation in hallowed rituals related to determining evidence
of waste and re-conguring clinical work. Like Traynors (2000)
study of evidence-based medicine, we highlight a rhetorical drive
for personal, as well as organisational, conversion based on the
logical rationality of Lean (logos), which stood in stark contrast to
the wasteful and out-dated traditions of departmental practice. It is
worth considering the possibility that rather than being enrolled
within Leans theories or practices, these converts might have
been motivated by other ambitions for career advancement and
differentiation within the workforce. Although this might reveal
the proliferation of Lean and evidence of re-stratication, in practice we found this group was relatively isolated and conned to the
project room. Service improvements that looked achievable on
paper or in controlled settings were frequently met with more
critical and contingent engagement. After some initial interest in
Lean clinicians largely regarded it as another bureaucratic or
unnecessary task that required supercial compliance. Our third
lens explores why service leaders struggled to articulate Lean and
enrol staff in the change agenda. Specically, we identify the lines
of resistance to Lean, focussing in particular on clinicians apprehensions about the motives and legitimacy of service leaders,
doubts about the evidence and knowledge on which service
transformation is to be based, and concerns about the negative
consequences for patients from changed working practices. These
lines of resistance, therefore, represent obstacles, not only to Lean,
but more broadly the emergence of new leaders, the generation of
evidence and the re-conguration of clinical practices.
Our three lines of analysis present valuable windows for
exploring organisational practice or the mediation of both human
agency and social structure. Moreover, they provide a means for
investigating how Lean and clinical practice are mutually
re-constructed. In particular, we show how Lean is transformed
from a philosophy into a specic set of activities, whereby
different social and cultural ideas are imprinted onto the eventual
manifestation. Equally, we show how clinical practices are
changed and modied in these processes, as some clinicians
adopt new responsibilities or follow new practices, while others
work to counter their inuence or engage only supercially in
new ways of working. Our study reinforces the view that the
reorganisation of healthcare work should be seen through the
interaction and mediation of different actors and social structures
over time, giving rise to new, often subtle changes. In particular,
it highlights the contingent nature of organisational change and
the ways clinicians can corrupt, game and capture attempts at
reform to maintain or extend their inuence, or counter the

1339

interests of others (Ackroyd, 1996; Waring & Currie, 2009). As

such our works contribute to the growing eld of research that is
attentive to the institutional work of making and re-making
healthcare organisations, especially the situated interplay of
managerial and professional practices.
Finally, our study makes some tentative conclusions about the
future of Lean healthcare. It is worth considering that some of the
inconsistencies found in current healthcare reforms might result, in
part, from the poor translation of models and methodologies developed in other settings, such as automotives, that gives insufcient
attention to existing practices and potential unintended consequences (Weiner, 2004). Despite the growing body of evaluative
research, there is a paucity of socio-cultural research that explores in
detail Leans implementation and interaction with existing clinical
practices. We suggest that making healthcare services Lean is likely to
be a highly contested process, as it becomes reinterpreted and
reshaped by different social actors to ensure that it ts with their
prevailing vision or aspirations for clinical practice. As such, it enters
into a social world fraught with conict and disagreement, and
unlikely to survive the translation to practice fully intact.
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