Production Planning & Control

The Management of Operations

ISSN: 0953-7287 (Print) 1366-5871 (Online) Journal homepage: http://www.tandfonline.com/loi/tppc20

Prioritizing lean supply chain management

initiatives in healthcare service operations: a fuzzy
AHP approach

Dotun Adebanjo, Tritos Laosirihongthong & Premaratne Samaranayake

To cite this article: Dotun Adebanjo, Tritos Laosirihongthong & Premaratne Samaranayake
(2016): Prioritizing lean supply chain management initiatives in healthcare service operations: a
fuzzy AHP approach, Production Planning & Control, DOI: 10.1080/09537287.2016.1164909

To link to this article: http://dx.doi.org/10.1080/09537287.2016.1164909

Published online: 07 Apr 2016.

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 Production Planning & Control, 2016
http://dx.doi.org/10.1080/09537287.2016.1164909

Prioritizing lean supply chain management initiatives in healthcare service

operations: a fuzzy AHP approach
Dotun Adebanjoa, Tritos Laosirihongthongb and Premaratne Samaranayakec
a
Business School, University of Greenwich, London, UK; bFaculty of Engineering, Industrial Engineering Department, Thammasat University, Bangkok,
Thailand; cSchool of Business, Western Sydney University, Penrith, Australia

ABSTRACT ARTICLE HISTORY

The objective of this study is to investigate the perceptions of practitioners/experts about the prioritisation Received 12 July 2014
of healthcare performance measures and their relationship with lean supply chain management (LSCM) Accepted 13 February 2016
Downloaded by [University of California, San Diego] at 07:55 16 April 2016

practices. The study will also prioritise the drivers and resources required to implement LSCM in a healthcare KEYWORDS
operations context. The prioritisation is based on the relative weights of various initiatives on a range of Lean supply chain;
performance measures. Twenty-four LSCM initiatives were identified using a comprehensive literature performance measures;
review. Q-sort method was used to divide those initiatives into four categories. Fuzzy AHP was then used healthcare; Fuzzy AHP
to prioritise the four categories based on relative weight of importance of each category on three different
performance dimensions. The result shows that continuous improvement is a dominating LSCM initiative in
increasing operational and financial performance, while enterprise alignment/integration is a dominating
initiative in enhancing organisational image and operational performance. However, lack of homogeneity
among LSCM initiatives suggests that there is a need for careful consideration when implementing them in
healthcare organisations. Furthermore, customer needs and the influence of competitors actions are the
most important drivers to encourage hospitals to adopt an LSCM strategy. This is one of the first studies
to examine the prioritisation and ranking of LSCM constructs on performance within the context of the
healthcare industry.

1.Introduction Although, there is an increasing interest in LSCM implementa-

The increasing pressure on the healthcare industry due to
new competitive priorities and resource constraints has led
to increased attention on continuous improvement of prac-
tices across various impact areas including financial, process,
resources and innovation operations (Mustaffa and Potter 2009).
According to Mas (2014), the healthcare industry faces the triple
challenge of balancing better health, lower cost and improved
care. A key reason for these challenges is the limited resources
and high spending that characterises the healthcare sector.
The management of healthcare service operation has, there-
fore, become an imperative for many healthcare organisations.
Consequently, healthcare service providers and their partners
have adopted various improvement approaches such as lean
management, business process re-engineering (BPR) and Six
Sigma (Papadopoulos 2011). It is also important to note that the
drivers for these initiatives are various and include global com-
petitiveness, drive for savings and efficiencies in public services,
expanding public health challenges and optimising resources
utilisation (Jarrett 1998). Hence, this study focuses on under-
standing which LSCM initiatives are important in the health-
care industry and identifies the key performance measures that
relate to the adoption of LSCM initiatives in the industry.
tion in the healthcare industry, it is still a relatively new concept
(Burgess and Radnor 2013) and there is much to be understood
about the context in which LSCM is implemented, particularly
in emerging economy countries. The three focal points of this
study LSCM practices, LSCM performance measures and drivers
to implement LSCM practices have been alluded to in various
studies but have not been holistically examined. For example,
motivation for implementation of Lean has been attributed to
various factors including reduction in error and medical negli-
gence (Gowen, McFadden, and Settaluri 2012), pressure from
national performance targets (Radnor and Walley 2008; Burgess
and Radnor 2013) and increased capacity and better care deliv-
ery (Papadopoulos 2011). However, there has been no study
yet to identify all potential motivational factors and determine
which motivators are the most important. Similarly, various
performance measures including waiting times, length of stay,
increased capacity, increased staff morale, patient satisfaction,
medical quality and cost reduction (Esimai 2005; Lodge and
Bamford 2008; Brandao De Souza 2009; Naylor, Brooten et al.
1999) have been used in relation to LSCM in Healthcare without
a real understanding of which measures are perceived to be the
most important. For the study, performance measures refer to

CONTACT Tritos Laosirihongthong ltritos@engr.tu.ac.th

2016 Informa UK Limited, trading as Taylor & Francis Group
 2 D. Adebanjo et al.
the key performance indicators (KPIs) that result from the imple-
mentation of LSCM practices.
Overall, the implementation of LSCM practices in healthcare
operations has implied that healthcare service providers have
needed to redesign, improve and implement appropriate logistics
activities (e.g. purchasing, material and capacity planning, sched-
uling, warehousing) with the expectation of efficient and effec-
tive physical entities (pharmacy, medical devices and patients)
and real-time information (patient and medical records) flows
across many functional areas of service operations (Rahimnia and
Moghadasian 2010). These, in turn, have led to the need to meas-
ure the effects of these initiatives which have required significant
investment and changes to working practices. Given the number
of performance measures that can potentially be used in health-
care operations and the changing working environment with ever
increasing resource and budgetary constraints, understanding
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and prioritising LSCM practices assist healthcare organisations
to identify the particular practices that are most important and
influential in achieving performance success. Hence, it is easier
to identify which LSCM practices to focus on in order to achieve
specific performance outcomes for the organisations.
1.1. Study context
This study, based on the experiences of Thai healthcare organ-
isations, addresses the research gaps outlined above and, in
particular, the lack of real understanding about which measures
are perceived to be most important, thus enabling better under-
standing of the most important drivers, measures and practices
of LSCM in healthcare. Elliott and Catto-Smith (2014) reveal that
the global healthcare supply chain is facing three major chal-
lenges: (i) increasing risks, (ii) complex regulations and (iii) con-
tinuing cost pressures. In recent times, the management teams
of many hospitals in Thailand have been getting involved in col-
laborative partnerships and minimising non-value-added ser-
vice activities (i.e. non-structured data entry, transcription errors
and non-streamlined work flows) along their supply chain. As a
result, all stakeholders (i.e. manufacturers, distributors/whole-
salers, hospitals, insurance companies and third party logistic
service providers) are able to improve their competitive position
in terms of safety, cost, efficiency, effectiveness and patient-cen-
tric service levels. Following are some examples of how LSCM
practices have been implemented in Thai hospitals and their
supply chain partners.
National regulators Bureau of Health Service System
Development, Food and Drug Administration, the Comptroller
Generals Department, the Government Pharmaceutical
Organization and Thai Customs Department are working to
establish the National Drug Code (NDC) and the National Product
Catalogue (NPC) that would be used by all stakeholders men-
tioned above. For the hospitals, information and communica-
tion technologies (ICTs) are increasingly being implemented to
increase supply chain performance including supply chain visi-
bility, patients responsiveness (patient care or clinical services)
and waste elimination. The Thai hospital system comprises both
private and public hospitals. Public hospitals are tasked with
delivering value for money provided by the government as well
as from patients contribution. Private hospitals are not only in
competition with one another, but are also poised to attract
customers that would normally frequent public hospitals while
at the same time, trying to maximise returns for their sharehold-
ers. Leading private hospitals such as Bumrumgrad and Bangkok
hospitals are acknowledged as world-class hospitals and would
view themselves in competition with leading hospitals across the
world for international patients while coping with the investment
demands of being publically quoted companies. Therefore, Thai
hospitals stand to gain from improvements that initiatives such as
lean management can bring and they are increasingly adopting
such initiatives.
Within this context, this study explores the question of
whether the adoption of different LSCM practices is likely to lead
to different performance outcomes. Although the study focuses
on the practices of Thai healthcare organisations, the research
outcomes could be broadly applicable, since many healthcare
organisations worldwide face identical challenges (e.g. resource
constraint, time constraint, effective inventory management). The
study was carried out within the context of secondary health-
care operations (i.e. hospitals). This paper, therefore, investigates
the perceptions of healthcare service operations practitioners/
experts about the prioritisation of healthcare performance meas-
ures and their relationship to LSCM practices. The prioritisation
is based on understanding the factors that are most important
in achieving particular outcomes of LSCM implementation (e.g.
operational performance, financial benefits). An understanding
of such prioritisation would enable healthcare organisations
that wish to implement LSCM direct their efforts better based
on the performance outcomes that best fit with the organisations
strategic objectives. The study will also prioritise the drivers and
resources required to implement LSCM in healthcare operations
by drawing on two theoretical perspectives institutional theory
and resource-based view (RBV). The primary context of the study
is on products (e.g. medical devices, drugs) and information flow
in hospitals supply chain rather than patient flow. This paper is
organised as follows the next section reviews the relevant lit-
erature and is followed by the study aims and objectives. The
research methodology is described next, followed by the results
and research findings. Finally, conclusions and implications of the
research are presented. The emphasis of the literature review is on
the implementation of LSCM initiatives in healthcare operations
and the scope does not include a fundamental comparison of
lean, LSCM or SCM in healthcare operations. This paper primarily
builds on the well-established links between LSCM and healthcare
operations (e.g. Brandao De Souza 2009; Aronson, Abrahamsson,
and Spens 2011; Burgess and Radnor 2013).
2. Literature review
In recent times, there have been significant changes in the
healthcare industry and the field of supply chain management
(Mas 2014). According to Dahlgaard, Pettersen, and Dahlgaard-
Park (2011), healthcare operations are characterised by a sig-
nificant amount of waste. Consequently, it is an industry that
could benefit from the operational efficiencies that supply
chain principles can deliver. The impact of supply chain man-
agement in healthcare operations is evident from increas-
ing pressure to maintain efficient and effective logistics and
information flows for better outcomes in hospital operations
(Kumar, Ozdamar, and Ning Zhang 2008). It is evident from

various research activities that effective supply chain manage-
ment has contributed positively to improving organisational
performance (Lee, Lee, and Scheniederjans 2011), customer
service levels (Naylor, Naim, and Berry 1999; Mentzer, Flint,
and Hult 2001; McKone-Sweet, Hamilton, and Willis 2005) and
customer satisfaction levels (Aslanertik 2005; Savino, Manzini,
and Mazza 2015). At the same time, the importance of effec-
tive SCM and performance measurement is stressed by various
other researchers (Karvonen, Rm, and Leijala 2004; Storey et
al. 2006; Gunasekaran and Kobu 2007; Shah et al. 2008; Bhme
et al. 2013; Lega, Marsilio, and Villa 2013). These studies have
all shown that implementation of SCM practices can bring real
competitive advantages to different types of organisations in
different industries. Overall, close connection between effective
SCM and performance improvements in healthcare operations
has led to these research studies emphasising current health-
care service operations, challenges and issues and performance
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improvement using various improvement methods including a
Lean approach to healthcare.
2.1. Healthcare service operations
With regard to their functional perspectives, healthcare ser-
vice operations are very broad and involve many stakeholders
across both macro- and micro-levels. This study, reviews lean
healthcare supply chain, emphasising processes, current prac-
tices and their issues, performance measures and improvement
methods in various healthcare settings. A number of research
projects (Swinehart and Smith 2005; Pan and Pokharel 2007;
Kumar, Ozdamar, and Ning Zhang 2008; Mustaffa and Potter
2009) have identified key healthcare processes, associated
logistics and supply chains in broader hospital settings. These
studies suggest the increasingly important need to apply supply
chain management principles in healthcare settings. Similarly, a
number of studies have focused on the performance improve-
ment in healthcare operations, such as productivity improve-
ment in heart surgery through changes to the queuing system
(Karvonen, Rm, and Leijala 2004), introduction of cross-func-
tional teams for reducing patient throughput time in the emer-
gency department (Larsson et al. 2012), significance of auditing
tools for assessing supply chain performance (Bhme et al.
2013), recognising the impact of high levels of system uncer-
tainty on the critically important healthcare supplies (Bhme et
al. 2013) and a framework for assessing healthcare supply chain
performance (Lega, Marsilio, and Villa 2013). Consequently, the
healthcare supply chain could be viewed within the context of
different activities as evidenced by the definition given below:
the interrelating activities within healthcare delivery pro-
cess that was designed to provide a variety of products and services
including medical consumables, pharmaceuticals, catering, laundry
cleaning, waste management, home-care products, and general sup-
plies. (Kumar, Ozdamar, and Ning Zhang 2008, 97)
It is important to note that in hospitals, healthcare logistics and sup-
ply chain activities cover not only supporting services and processes/
functions such as purchasing and inventory control directly linked
with warehouse and pharmacy operations, but also healthcare ser-
vices operations such as patient care units, operating rooms, house-
keeping units, engineering and maintenance units, IT outsourcing
units and catering units. Many activities that could be carried out
Production Planning & Control 3
by specialised support personnel are often on the list of duties
performed by healthcare personnel. Logistics processes deal with
efficient delivery of medical supplies/devices and pharmaceutical
products to various stakeholders across the healthcare supply chain
including the final consumers, i.e. patients. The people involved vary
with the type of products/services in question: for example, stores
manage medical and office supplies; the pharmacy looks after
pharmaceutical products; and catering services manages the pro-
curement and processing of food products. It has been noted that
logistics in healthcare is poorly understood even though it accounts
for a sizeable portion of a hospitals operating budget (Swinehart and
Smith 2005; Perry and Kocaklh 2010).
2.2. Challenges and issues
Healthcare service providers are faced with many challenges and
constraints in providing efficient services to their patients. The
key issues include shortage of qualified staff, and lack of time for
various activities/operations (Samaranayake, Punnakitikashem,
and Laosirihongthong 2010). Furthermore, lack of best practices
in healthcare service operations and the management of sup-
ply chain activities also contribute to inefficiencies (Sinha and
Kohnke 2009). Hence, the main challenges in healthcare oper-
ations include (Storey et al. 2006; Shah et al. 2008; Sinha and
Kohnke 2009):
(1)Lack of resources for meeting increasing patient
demand, caused by various factors including popula-
tion growth and inadequacy of the existing hospital
system infrastructure, leading to longer waiting times;
(2)Decreasing levels of traditionally maintained on-site
storage of medical supplies, due to severe budget con-
straints, resulting in increased attention to supply chain
performance in healthcare, in an effort to reduce cost
of operations;
(3)Increasing cost of logistics activities as a proportion of
overall hospital operating budget;
(4)Potential waste of storage and inventory as a result of
overstocking, resulting in excess inventory and expira-
tion of medication;
(5)Limited technological and information technology
(IT) resources in benchmarking hospital performance,
improving performance measures for physical (materi-
als and patients) and information flows; and
(6)Benchmarking healthcare supply chains, in particular
assessing supply chain performance under high levels
of system uncertainty.
These challenges show that a key issue with healthcare oper-
ations is the management of limited resources. LSCM initiatives
are adopted to address such challenges. Therefore, successful
implementation of initiatives such as LSCM has an important rela-
tionship with the management of resources. For the purposes of
this study, it is important to examine such implementation from
the perspective of an appropriate theoretical base. Consequently,
this study adopts resource-based view as the basis for examin-
ing the implementation of LSCM in healthcare operations. This
is because RBV posits that the ability of an organisation to effec-
tively make use of the resources and competencies at its disposal
to improve its level of competitiveness (Minshall and Garnsey
 4 D. Adebanjo et al.
1999; Halley and Beaulieu 2009), where resources refer to both
human and material resources. According to RBV, the ability of
the organisation to improve its competitiveness is based on the
understanding that the resources and competencies to be lever-
aged are valuable, rare, inimitable and non-substitutable (Barney
and Griffin 1992). Within a healthcare setting, competitiveness
could be considered from different perspectives such as oper-
ational cost reduction and patient outcomes (Berwick, Nolan,
and Whittington 2008; Dahlgaard, Pettersen, and Dahlgaard-Park
2011). Based on this, the authors suggest that the efficiency of
healthcare operations can be improved by implementing initia-
tives that enable patient health issues to be completely addressed
without need to re-admission. The authors would also suggest
that efficiency can be improved by the use of technological solu-
tions such as electronic medical records and warehouse manage-
ment systems. These are likely to be important outcomes for all
types of healthcare organisations. It is clear from the challenges
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presented above that healthcare organisations need to improve
the leveraging of both financial and human resourcing if they
are to improve efficiency and reduce waste. Therefore, from an
RBV perspective, it is important to know which type of resource
is considered to be the key driver of benefits that can be gained
from LSCM implementation.
2.3. LSCM in healthcare service operations
Various methods suggested for improving supply chain per-
formance have focused on a range of specific aspects of sup-
ply chain operations such as supply chain agility for improving
responsiveness to customer demands (Kihln 2007; Aronson,
Abrahamsson, and Spens 2011) and various tools and tech-
niques such as TQM (total quality management), JIT (just in time)
and BPR (business process re-engineering) for improving per-
formance and gaining competitive advantage (Soni and Kodali
2011). Among many improvement philosophies and techniques
adopted for improving supply chain performance, lean philos-
ophy is recognised as one of the most common methods for
operations to remain competitive in an increasingly global mar-
ket (Arif-Uz-Zaman 2012). The core thrust of a lean supply chain
is to create a streamlined, highly efficient system that produces
finished products at the pace that customers demand with little
or no waste (Van Der Bij and Vissers 1999). Lean is applicable to
any supply chain seeking to improve performance by reducing
waste. For example, cost competitive supply chains can benefit
from utilising lean to remove waste and reduce costs. Similarly,
there has been some research done on performance meas-
urement in healthcare service operations and organisational
performance, aiming to improve overall healthcare logistics
(Probert et al. 1999), cost reduction (Perry and Kocaklh 2010),
system improvement using various strategies, techniques and
tools (Kumar, Ozdamar, and Ning Zhang 2008; Shah et al. 2008)
and examining supply chain innovation for improving organi-
sational performance in the healthcare industry (Lee, Lee, and
Scheniederjans 2011). Common performance measures that are
considered in many healthcare supply chains include electronic
ordering/mismatching, response time, inventory turnover, pro-
portion of rush orders, average lines per purchase order, number
of purchase orders per supplier per week, number of invoices,
proportion of low-value orders, stock-outs at the cart level, fill
rates to end users, payment by due date and supplier perfor-
mance (Nachtmann and Pohl 2009). Table 1 summarises 12
LSCM initiatives and 6 performance measures in healthcare ser-
vice operations. These initiatives and measures were identified
from previous studies on LSCM in healthcare. These studies were
identified from journal databases using keywords such as lean
management, lean performance and lean performance meas-
urement. These measures and initiatives have the potential to
impact performance in different ways. For example, total pro-
ductive maintenance keeps equipment in good working order
and minimises treatment delays as well as repair/replacement
costs, while VMI/E-procurement can reduce the costs associated
with the inventory management of healthcare supplies. With
respect to performance measures, improving inventory turno-
ver/space utilisation/length of stay enables healthcare organisa-
tions optimise their physical space, while market growth/share
enables a comparison of performance against competitors.
It is evident from Table 1 that various lean tools/methods are
being used with respect to LSCM initiatives and that the main
objective is to eliminate waste associated with processes and
logistics in order to achieve enhanced efficiencies and maximised
improvements (Hopp and Spearman 2004). The range of activi-
ties also suggests that healthcare LSCM is considered to include
some activities that are unique to the healthcare industry (e.g.
Electronic Medical Record) and this indicates that there is not
yet common agreement on the boundaries of LSCM activities in
healthcare. Some of these tools have originated from the man-
ufacturing industry which is characterised by the movement of
goods/materials as well as information flow. While healthcare
operations do not involve manufacturing activities, they are how-
ever, subject to the flow of medical devices and consumables
as well as information flow. Consequently, these lean tools and
methods could be applied to the healthcare sector.
It is also evident from Table 1 that healthcare organisations are
increasingly in competition, especially in increasing service level,
maintaining net profits and market growth, minimising waste
along supply chain and optimising internal resources utilisation.
While there is some evidence that lean tools and methods have
been introduced to streamline healthcare processes, (Aronson,
Abrahamsson, and Spens 2011), there seem to have been con-
siderable challenges with changing organisational culture and
mindset (Hines, Howleg, and Rich 2004). This could be due to var-
ious reasons, most likely the tool-focused implementation which
neglects the human aspects that are inherent in healthcare organ-
isations (Hines, Howleg, and Rich 2004). In addition, it has been
suggested that hospitals have not understood the cultural and
structural conditions necessary to successfully implement LSCM
(Dahlgaard and Dahlgaard-Park 2006). With increased tool-fo-
cused implementation, there has been significant emphasis on
adopting individual lean tools for improving a range of perfor-
mance measures across a range of industries. In this context, just
in time (JIT) is identified as the ideal method/tool for reducing
inventory in healthcare settings (Whitson 1997; Jarrett 2006),
while the vendor managed inventory (VMI) system is getting
increased attention for both inventory reduction and improved
service levels (Claassen, Wheele, and Raaij 2008). From a process
perspective, BPR is adopted for eliminating waste and focusing
on non-value-added steps (Bertolini et al. 2011). Similarly, total
productive maintenance (TPM) is regarded as one method/
 Production Planning & Control 5

Table 1.LSCM initiatives and performance measures in healthcare service operations.

LSCM initiatives in healthcare service operations References

Total productive maintenance
Kaizen/set-up time reduction/work standardisation
Quality certification
Housekeeping (5s)
Vehicle (ambulance) routing planning
Warehouse management systems
Vendor managed inventory/e-procurement
Enterprise resources planning systems for process
integration
Patientmedical services interface
EMR (electronic medical record)
Service value stream management
Facility/departmental layout design
Downloaded by [University of California, San Diego] at 07:55 16 April 2016
Papadopoulos (2011), Kumar, Ozdamar, and Ning Zhang (2008)
Piercy and Rich (2009), Naylor et al. (1999), Pan and Pokharel (2007), Swinehart and Smith (2005),
Nachtmann and Pohl (2009)
Perry and Kocaklh (2010)
Najmi, Etebari, and Emami (2012), Mustaffa and Potter (2009), Perry and Kocaklh (2010),
Samaranayake, Punnakitikashem, and Laosirihongthong (2010)
Stansfield and Manuel (2009), Probert et al. (1999)
Mustaffa and Potter (2009), Papadopoulos (2011), McKone-Sweet, Hamilton, and Willis (2005), Shah et
al. (2008)
Storey et al. (2006), Kumar, Ozdamar, and Ning Zhang (2008)
Smith and Swinehart (2001), Nachtmann and Pohl (2009)
Smith and Swinehart (2001), Probert et al. (1999), Nachtmann and Pohl (2009), Aronson, Abrahamsson,
and Spens (2011)
Storey et al. (2006), Kumar, Ozdamar, and Ning Zhang (2008), Swinehart and Smith (2005), Nachtmann
and Pohl (2009)
Probert et al. (1999), Nachtmann and Pohl (2009)
Papadopoulos (2011), Piercy and Rich (2009)

LSCM initiatives in healthcare service operations References

Staff (nurses/doctors) assignment/scheduling Kumar, Ozdamar, and Ning Zhang (2008), McKone-Sweet, Hamilton, and Willis (2005), Naylor et al.
(1999), Shah et al. (2008)
Service pull system/kanban Storey et al. (2006), Kumar, Ozdamar, and Ning Zhang (2008), Parker and DelLay (2008)
Robotics or automated systems Papadopoulos (2011), Mustaffa and Potter (2009)
Poka-yoke/visual control Kumar, Ozdamar, and Ning Zhang (2008), Pan and Pokharel (2007), Swinehart and Smith (2005),
Stansfield and Manuel (2009)
Automated dispensing machines Piercy and Rich (2009), Jarrett (1998), Kumar, Ozdamar, and Ning Zhang 2008), Storey et al. (2006).
RFID Kumar, Ozdamar, and Ning Zhang (2008), Stansfield and Manuel (2009), Probert et al. (1999), Nachtmann
and Pohl (2009)
Performance measures in healthcare service operations References
Inventory turnover/space utilization/length of stay Najmi, Etebari, and Emami (2012), Mentzer, Flint, and Hult (2001), Nachtmann and Pohl (2009)
Service level/lead-time Papadopoulos (2011), Mustaffa and Potter (2009), Van Der Bij and Vissers (1999), Nachtmann and Pohl
(2009)
Profitability/operating cost/return on investment Van Der Bij and Vissers (1999), Nachtmann and Pohl (2009), Rahman, Laosirihongthong, and Sohal
(2010)
Market growth/share Mentzer, Flint, and Hult (2001), Sinha and Kohnke (2009), Van Der Bij and Vissers (1999)
Assurance/image/reliability/eminence Najmi, Etebari, and Emami (2012), Shah et al. (2008), Nachtmann and Pohl (2009)

tool for maximising overall equipment effectiveness, leading to
improvement in overall organisational performance (Nikajima
1989). Based on a comparative study of lean and agile manufac-
turing, Christopher and Towill (2001) identified a number of lean
methods/tools, with different foci on customer, supplier, cost and
quality-related performance. Similarly, Aronson, Abrahamsson,
and Spens (2011) proposed a hybrid strategy through combining
lean and agile process strategies as the basis for applying SCM
strategies, tools and techniques for improvements. All of these
studies on lean tools and/or other tools/methods for continu-
ous improvement through waste reduction have focused mainly
on a few performance measures. In addition, most of those lean
tools/methods are implemented with little attention to human
aspects that are an integral part of healthcare organisational per-
formance. Moyano-Fuentes and Sacristan-Diaz (2012), through
a comprehensive analysis of research on lean production recog-
nise the importance of work organisation in lean environments
and the impact of the geographical context, in addition to the
traditional basis of shop floor and value chain levels of lean pro-
duction. Although there is increased adoption of lean practices
in healthcare organisations, there is very limited evidence with
regard to the effect of lean on the working environment in the
healthcare industry (Hasle et al. 2012).
From a theoretical perspective, it is important to understand
the key drivers of the adoption of LSCM in healthcare organi-
sations. From the literature, it was suggested that healthcare
organisations face a triple challenge of balancing better health,
lower cost and improved care (Mas 2014). However, it was also
suggested that there is increasing adoption of LSCM in the health-
care industry (Burgess and Radnor 2013) and the adoption of
new approaches by competing organisations may have a bearing
on the decision to adopt LSCM. This study draws on institutional
theory in order to understand the key drivers of the decision to
adopt LSCM. Institutional theory suggests that organisations will
adopt practices as a result of influence from three forces coer-
cive, mimetic and normative (Meyer and Rowan 1977). Mimetic
forces refer to the intention to mimic more successful competi-
tors by adopting identical practices, while coercive forces refer to
the adoption of practices as a result of influence from regulatory
authorities. Normative forces refer to the adoption of practices as
a result of influence from market forces such as customers (Scott
1995; Yeung, Cheng, and Lai 2006; Zhu and Sarkis 2007). This study,
therefore, argues that LSCM is being increasingly adopted by
healthcare organisations that wish to achieve process efficiency
and customer (i.e. patient) satisfaction outcomes, suggesting that
the decision to adopt LSCM may be driven by mimetic and nor-
mative forces. However, it was also noted that lean adoption may
be due to the requirement to meet national performance targets,
thereby implying coercive forces. The suggestion, therefore, is
that the adoption of LSCM in healthcare organisations may be the
result of different drivers. It is important to understand the relative
impacts of these drivers on LSCM implementation in general as
they could impact the focus of LSCM efforts as well as how the
success of implementation is measured. What is unclear from the
 6 D. Adebanjo et al.
literature however, is whether any one driver is more important
or prominent than others.
3. Study aim and objectives
In spite of large number of research activities on broader supply
chain performance and lean supply chain practices, the concept
of lean supply chain in healthcare and its performance evalua-
tion remains underdeveloped for a variety of reasons including
(i) lack of healthcare industry-specific research; and (b) deficien-
cies in performance evaluation methods (Arif-Uz-Zaman 2012).
Although there is extensive work on identifying various perfor-
mance measures and improvement methods such as lean, Six
Sigma, JIT and BPR in supply chain practices, associated mainly
with manufacturing, there is a lack of a systematic approach to
prioritising performance measures and/or improvement ini-
tiatives and metrics (Lockamy and McCormack 2004; Rahman,
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Laosirihongthong, and Sohal 2010; Cuthbertson and Piotrowicz
2011; Hasle et al. 2012). In addressing some of the issues iden-
tified, Arif-Uz-Zaman (2012) proposed a lean supply chain per-
formance evaluation method, based on fuzzy approach for
identifying overall supply chain performance under lean strat-
egy. The study suggests that there is no systematic methodology
available to enable the selection of appropriate lean strategies
in alignment with different types of supply chains and mar-
ket strategy. However, the study by Arif-Uz-Zaman (2012) was
focused on the manufacturing industry rather than the health-
care industry. According to Subramanian and Ramanathan
2012, such research on prioritising different performance meas-
ures and/or improvement initiatives across the supply chain is
particularly lacking in healthcare operations.
The main aim of this study is to investigate the perceptions
of healthcare service operations practitioners/experts about
the prioritisation of healthcare performance measures and their
relationship to LSCM practices. The study will also prioritise the
drivers and resources required to implement LSCM in the health-
care operations.
From the literature, four constructs representing LSCM were
determined. The first two constructs (waste elimination and
flow management/JIT) were derived from a previous study on
lean operations conducted by Rahman, Laosirihongthong, and
Sohal (2010). Waste elimination consisted of six items, while flow
management/JIT consisted of four items. Enterprise alignment/
integration (four items) and continuous process improvement
(four items) were identified from the studies on lean supply chain
in healthcare conducted by Aronson, Abrahamsson, and Spens
(2011), and Lee, Lee, and Scheniederjans (2011). The performance
Figure 1.Hierarchical structure in implementing LSCM in healthcare.
measurement constructs, operational performance (five items),
financial benefits (five items) and organisational image (four
items) were derived from previous studies (Karvonen, Rm, and
Leijala 2004; Aronson, Abrahamsson, and Spens 2011) and on-site
interviews with eight practitioners of five hospitals (three private
and two public) in Thailand.
Figure 1 shows the hierarchical structure that links drivers and
resources to performance and this formed the basis of this study.
The key objectives that support the main aim of this study are
as follows:
(1)Identify various LSCM initiatives based on a comprehen-
sive literature review of healthcare service operations;
(2)Identify and prioritise performance measures applica-
ble to implementing LSCM initiatives in healthcare ser-
vice operations;
(3)Determine the relative weight of importance of various
LSCM practices/strategies on different performance
measures; and
(4)Understand the important drivers of LSCM adoption
from an institutional forces perspective and the impact
of resources (resource requirements) from an RBV
perspective.
4. Research methodology
The research methodology consisted of two stages. Stage I
focused on identifying LSCM initiatives and performance meas-
ures in implementing LSCM in healthcare service operations.
This stage involved (i) determination of LSCM initiatives and
associated performance measures from a comprehensive liter-
ature review (See Table 1) and (ii) validation of LSCM and perfor-
mance measures constructs, based on data collected through
interviews with practitioners in hospitals. The literature search
was carried out using keywords such as Lean management,
Lean supply chain, lean performance, lean performance meas-
urement and supply chain performance with a primary focus
on international databases of management journals including
Scopus and ISI. Then, an official invitation letter to participate
in the study was sent to the Chief Executive Officer (CEO) or
Hospital Director, together with the research synopsis. They
were asked to suggest the most appropriate member of staff
to share their experiences in implementing lean operations
and/or supply chain management strategy in healthcare. The
letters were sent to 10 private and 7 public hospitals who had
participated in the Rapid Improvement Program in Healthcare

organised by the Thai Ministry of Public Health. Participants
were required to have had, at least, three years experiences
of implementing improvement initiatives such as lean man-
agement, supply chain management and total quality man-
agement. After that, six experts from public (3) and private (3)
hospitals in Bangkok, Thailand (Section Chiefs, Nurse Specialists,
Medical Doctors and Ward Service Heads) were nominated and
asked to assign each LSCM initiative and performance measure
into one of four improvement categories and three performance
measure dimensions, respectively, using Q-sort method (Rajesh,
Pugazhendhi, and Ganesh 2011). Consequently, the opinions of
the experts were used to sort each measure into several cate-
gories based on agreement between the experts (Boon-itt and
Paul 2006). These experts were selected based on (i) main roles
and responsibilities, (ii) management position in their hospital
and (iii) years of experience. All of these experts had attended,
at least, 5 days of in-house training on lean supply chain in
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healthcare. Furthermore, they represented a cross-section of
practitioners with management responsibilities (e.g. section
chiefs) and frontline staff (e.g. nurse specialists). Therefore, their
views were representative of the experiences of decision-mak-
ers/budget holders and operations staff (i.e. those that felt the
impact of the decisions). The study was carried out in accord-
ance with the ethical guidelines of the university that led data
collection.
In Stage II, nine healthcare practitioners and experts, consist-
ing of lean and supply chain management consultants, medical
doctors, section chiefs and academics, were invited to partici-
pate in the study. The medical doctors and section chiefs were
from the organisations that participated in the first stage. Section
chiefs had middle or senior management responsibilities in their
organisations. The academics and consultants were identified
based on their years of involvement in the field as advisers in
the implementation of LSCM initiatives in healthcare settings.
They were then asked to assign linguistic terms based on their
subjective judgment. The consultants and academics all had par-
ticular expertise in LSCM implementation in healthcare settings
with a minimum of three years of direct high-level leadership or
involvement in LSCM project implementation in their hospital.
The practitioners involved in both Stage I and Stage II were inde-
pendent of each other as they worked in different organisations.
The subjective judgments were based on pairwise comparisons
by asking which one of two elements was more important and
how much more important they judged it to be with respect to
the upper level performance. The numbers of experts used for
both the Q-sort analysis and fuzzy AHP analysis are acceptable
for this type of study and compare with other studies (Zhu, Jing,
and Chang 1999; Tam and Tummala 2001; Pan 2008; Ten Klooster,
Visser, and de Jong 2008; Wong, Boon-Itt, and Wong 2011). After
getting the answers from the experts in linguistic terms, these
linguistic judgments were then converted to triangular fuzzy sets
as defined in Table 2. In order to get a consistent and fair outcome
from the nine experts subjective judgments, the informed judg-
ments were aggregated through the geometric mean of indi-
vidual experts judgments. Then an integrated Changs extent
analysis on fuzzy AHP to LSCM in healthcare was applied. As a
result, the relative weight of importance among LSCM improve-
ment categories (constructs) on three performance measures
dimensions (constructs) was determined.
Production Planning & Control 7
Table 2.Triangular fuzzy conversion scale.
Linguistic scale Triangular fuzzy scale
Equally important (1,1,3)
Moderately important (1,3,5)
Fairly important (3,5,7)
Very strongly important (5,7,9)
Absolutely important (7,9,9)
4.1. Stage I: construct validity using Q-sort method
The Q-sort method was applied as an initial exploratory effort
to identify LSCM initiatives and the categories of performance
measures. The Q-sort method is an iterative process in which
the degree of agreement between judges forms the basis of
assessing construct validity and improving the reliability of the
constructs (Rajesh, Pugazhendhi, and Ganesh 2011). Comments
given by the panel of experts were used to sort each measure
into several categories based on agreement between judges
(Wong, Boon-Itt, and Wong 2011). The Cohen kappa coefficient
was used to indicate a consensus agreement among experts/
raters (Tractinsky and Jarvenpaa 1995). This coefficient is the
proportion of joint judgment in which there is agreement after
chance agreement is excluded (Nahm et al. 2002). The three
basic assumptions for this agreement coefficient are: (i) the units
are independent, (ii) the categories of the nominal scale are
independent and mutually exclusive and (iii) the judges operate
independently (Nahm et al. 2002). Kappa ( ) was first proposed
by Cohen (1960). Kappa is based on the indices of agreement if
there is complete agreement, = 1, if the observed agreement
is greater than or equal to chance agreement, 0, and if the
observed agreement is less than or equal to chance agreement,
0. While there is no consensus about required scores, several
studies have considered scores greater than 0.65 to be accept-
able (Landis and Koch 1977; Jarvenpaa 1989; Nahm et al. 2002).
A commonly cited scale of agreement (<0 Poor, 0.01 0.20
Slight, 0.210.40 Fair, 0.410.60 Moderate, 0.610.80 Substantial
and 0.810.99 Almost Perfect) by Viera and Garrett (2005) can
be used as better representation of acceptable levels. Thus, a
kappa of 0.65 is considered to represent a substantial level of
agreement. This is considered to be an acceptable level for this
research.
It was noted from interview data after three rounds of inter-
views with experts from three private and three government
hospitals and subsequent analysis, that 14 performance meas-
ures related to implementing LSCM in healthcare organisations,
could be classified into three categories with an acceptable level
of Cohen kappa coefficient (von Eye and von Eye 2005). These
are: (i) operational performance (=0.8521), (ii) financial benefits
(=0.8327) and (iii) organisational image (=0.8211). In addition,
23 LSCM initiatives could be classified into 4 categories, which
are: (i) continuous process improvement (=0.9106), (ii) enter-
prise alignments/integration (=0.8712), (iii) waste elimination
( = 0.8201) and (iv) flow management/JIT production system
(=0.7952).
4.2. Stage II: criterion validity analysis using fuzzy AHP
After validating the constructs of LSCM initiatives and per-
formance measures through Q-Sort method, an analytical
 8 D. Adebanjo et al.
hierarchy structure was established to determine the relative
weight of importance among LSCM constructs, based on differ-
ent performance constructs. AHP is widely used across indus-
tries for dealing with multiple criteria decision-making
problems involving subjective judgment. However, AHP is
often criticised for its inability to adequately accommodate
the inherent uncertainty and imprecision associated with map-
ping decision-maker perceptions to an exact number (Kwong
and Bai 2003). Since a multiple criteria decision-making prob-
lem is subjective and qualitative in nature, it is very difficult
for the decision-maker to express the strength of the prefer-
ences using exact numerical values (Chan and Kumar 2007).
Therefore, fuzzy AHP method, which combines traditional AHP
with fuzzy set theory, was developed for coping with uncertain
judgments (Naghadehi, Mikaeil, and Ataei 2009) and to express
preferences as fuzzy sets or fuzzy numbers which reflect the
vagueness of human thinking (Liou et al. 2011). The basic idea
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of fuzzy set theory is that an element has a degree of mem-
bership in a fuzzy set (Negoita 1985). The pairwise comparison
matrices are constructed by allocating the relative importance
values determined on the basis of Saatys 19 scale ranging
from 1 equal importance between two items/scales to 9 the
extreme importance of one item/scale over the other one. The
triangular fuzzy conversion scale used to convert such linguis-
tic scales into fuzzy scales in the evaluation model is given in
Table 2.
There are many fuzzy AHP methods proposed by different
authors (Chan and Kumar 2007; Chen and Hung 2010; Kilincci
and Onal 2011) but the common theme of all of these methods
is the use of the concepts of fuzzy set theory and hierarchical
structure analysis. In this research, Changs fuzzy extent analysis
method (Chang 1996) was applied to the evaluation model since
the steps of this approach are relatively easier than other fuzzy
AHP approaches and similar to traditional AHP. The findings from
this analysis are presented in the next section.
Figure 2.Prioritising of performance measure construct using fuzzy AHP (the relative weight).
5. Results and research findings
5.1. Performance measurement constructs
Q-Sort analysis of data collected from three rounds of inter-
views with 6 experts in the healthcare sector produced 14 per-
formance measures that could be grouped into 3 constructs: (i)
operational performance (0.8712); (ii) financial benefits (0.8644);
and (iii) organizational image (0.8916). In addition, the results
also show that 24 LSCM initiatives could be grouped into 4 con-
structs. These are: (i) Continuous process improvement (0.8023),
(ii) Enterprise alignment/integration (0.7411), (iii) Waste elim-
ination (0.7325) and (iv) Flow management/JIT (0.7164). These
four constructs are similar to those found in a recent study of
lean management in Thai manufacturing companies (Rahman,
Laosirihongthong, and Sohal 2010). This, therefore, provides fur-
ther justification for the implementation of LSCM, which is tradi-
tionally manufacturing-based, in a healthcare setting within the
Thai context and for the constructs used in this study.
As shown in Figure 2, of the three constructs of performance
measures found to apply to implementing LSCM in healthcare
operations, operational performance (relative weight = 0.514)
is the most prominent category, followed by financial benefits
(relative weight = 0.455) and organisational image (relative
weight=0.03), respectively. Organisational image, therefore, is
significantly less important that operational performance and
financial benefits. Within the operational performance construct,
inventory turnover, space utilisation and length of stay were the
dominant measures with an equal relative weight of 0.157. The
least dominant measures were lead time (relative weight=0.019)
and service level (relative weight=0.023). For the financial benefit
construct, profitability (relative weight = 0.189) and operating
cost (relative weight=0.168) were the dominant measures, while
market growth (relative weight=0.032) and market share (relative
weight=0.009) were the least important. Finally, for the organi-
sational image construct, assurance (relative weight=0.016) was

the dominant measure while eminence (relative weight=0.002)
was the least. The relative weakness of the construct implies
that the differences between its different component measures
are not as significant as the other two constructs. These results
confirm the importance of prioritising various performance
measures in implementing LSCM, and indicate a wide range of
relative weights within each category. Operational performance,
however, contributed more than 50% of the total weight. Of all
measures, profitability in the financial category has the highest
relative weight, suggesting a strong financial focus among health-
care organisations.
5.2. Linking LSCM constructs to performance
measurement constructs
Figure 3 shows the relative importance among four LSCM
constructs across three performance constructs. The result
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shows that in order to achieve operational performance, con-
tinuous process improvement (relative weight = 0.142) and
enterprise alignment/integration (relative weight = 0.140) are
the prominent practices, while flow management/JIT (rela-
tive weight = 0.115) is the least important. In general, all four
LSCM constructs do not show significant relative differences
and the implication is that all four play a significant role in
achieving operational performance. The implication is that in
order to improve operational performance, none of these four
constructs should be ignored as each of them plays an impor-
tant role with regards to operational performance. To improve
financial performance, continuous process improvement (rela-
tive weight=0.158), waste elimination (relative weight=0.137)
and flow management/JIT (relative weight = 0.132) were the
most prominent. They were significantly more influential than
enterprise alignment/integration with a relative weight of 0.029.
Finally, to enhance organisational image, enterprise alignment/
integration (relative weight = 0.012) and flow management/
Figure 3.Prioritising of LSCM constructs using fuzzy AHP (the relative weight).
Production Planning & Control 9
JIT (relative weight=0.011) are the prominent practices while
waste elimination (relative weight=0.002) and continuous pro-
cess improvement (relative weight = 0.004). This implies that
with respect to organisational image, the differences between
the fours LSCM constructs were not very significant.
Overall, these results reveal that continuous process improve-
ment is the prominent LSCM practice in enhancing two out of
three performance categories (operational and financial benefits).
It implies that in the healthcare business, the main operations are
customer and service provider interface focused. In addition, it
is important to note that enterprise alignment/integration was
in the top two prominent LSCM practices on both operational
performance and organisational image. This finding indicates that
the concept of LSCM that focuses on removing non-value-added
activities and improving the level of both internal and external
integration is important in improving the functioning of health-
care organisations.
5.3. Understand the prioritisation of the drivers of LSCM
implementation in healthcare operations
Figure 4 shows the level of importance of institutional forces
that drive hospitals to implement LSCM and the associated
resources needed. The result of fuzzy AHP analysis indicates that
customer needs (relative weight=0.465) and competitor behav-
iour (relative weight = 0.355) are the dominant forces. On the
other hand, the impact of new entrants (relative weight=0.101)
and law (relative weight = 0.080) were significantly weaker
institutional drivers of LSCM implementation. From a RBV per-
spective, management commitment (relative weight = 0.459)
in combination with team competency and capability (rela-
tive weight = 0.409) are the most important competencies to
ensure successful LSCM implementation, while financial sup-
port (relative weight=0.132) was a significantly less important
resource. Therefore, from the institutional theory point of view,
 10 D. Adebanjo et al.
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Figure 4.Prioritising of driver and resource needed in implementing LSCM using fuzzy AHP (the relative weight).
this study found that hospitals that took part in this study tend
to be driven by mimetic forces and normative forces rather
than coercive forces. Consequently, these hospitals have used
the leverage of institutional pressures to improve performance
rather than conform to regulation. However, it is important to
note that these findings are only based on a small sample of
hospitals in Thailand. As more healthcare organisations decide
to implement LSCM in their operations there will be a need and
an opportunity for larger empirical studies that will employ
statistical hypothesis tests. Such studies could adopt a more
granular view and examine the impact of individual initiatives,
an approach which was not considered in this study. There will
also be a need to research any changes with respect to coercive
forces if government policies change to increase the levels of
adoption of LSCM initiatives. There is also a need to understand
if there is any relationship between institutional pressures and
RBV adoption for example, does the prominence of different
institutional forces (mimetic, normative, coercive) lead to differ-
ent outcomes with respect to resource management.
6.Discussion
6.1. Understanding performance measurement outcomes
The findings show that operational performance measures were,
overall, prioritised over financial benefits measures. At a super-
ficial level, this would appear to concur with customer needs
(normative pressures) being identified as the most important
factor driving the implementation of LSCM. However, the level
of influence of individual measures clearly show that the top
financial benefits measures profitability and operating cost
were perceived to be more important than any of the individual
operational performance measures. Furthermore, the top three
operational performance measures (i.e. inventory turnover,
space utilisation and length of stay) all have significant impacts
on operating costs and hence, profits. Although it can be rightly
argued that length of stay can also impact customer needs,
the low priority of service level and the organisational image
measures suggests strongly that the priority measures are either
financial in nature or can impact financial performance directly.
The authors, therefore, suggest and conclude that while the
participants in this study may claim that the implementation of
LSCM was driven to a large extent by customer needs, the reality
is that the performance measures that are deemed to be most
important are the financial measures and, in particular, profita-
bility and operating cost.
With respect to the relationship between the performance
measurement constructs and the LSCM constructs, all four LSCM
constructs have relatively positive impacts on the operational
performance constructs. This suggests that operational perfor-
mance outcomes were perceived as both a function of physical
logistics (continuous improvement, waste elimination) and tech-
nology-based systems (enterprise alignment, flow management/
JIT). Similarly, financial benefits were most influenced by process
improvement, waste elimination and flow management. These
three practices drive efficiency and therefore, it is not surprising
that they impact both financial measures and operational perfor-
mance. Of these LSCM constructs, continuous process improve-
ment was ranked as the most important for both performance
measurement categories. On the other hand, organisational
image is not strongly influenced by any of the measures. This may
be because patients do not necessarily see lean when they are
in hospital. However, the technology-based systems (enterprise
alignment and flow management/JIT) were seen as more impor-
tant in driving a positive organisational image in comparison to
the physical logistics activities.
6.2. Theoretical perspectives
With regard to the drivers of LSCM from the RBV perspective, there
is a very significant difference between the highly prioritised fac-
tors of management commitment and team competencies and
capabilities in contrast to financial support. The low ranking of
financial support appears to contrast with the relatively high

importance that was attached to the financial benefits that are
expected from LSCM implementation. What the results suggest
is that leadership and technical knowledge of LSCM are particu-
larly important if LSCM is to be implemented in the healthcare
industry. Therefore, from a RBV perspective, the key competen-
cies that healthcare organisations require to be successful with
LSCM implementation relate to management commitment as
well as team competencies and capabilities. This finding concurs
with a study by Grove et al. (2010) which found that a poor under-
standing of lean principles and poor leadership were two of the
problems faced by LSCM implementation in a UK health visiting
initiative. The reasons for these easily lend themselves to a num-
ber of suggestions. Firstly, lean philosophy, tools and techniques
represent a different mindset, knowledge and working practices
to what highly specialised professionals in the healthcare indus-
try have spent many years training to do. Therefore, the success
of LSCM lies in the ability and willingness of an organisations
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management team to develop lean competencies and have the
capability to integrate these with normal work. Secondly, man-
agement commitment is necessary to drive the implementation
of LSCM as it may result in changes to operational practices.
Thirdly, management commitment to LSCM implementation
is necessary to provide the resources required for LSCM imple-
mentation. Therefore, this study argues that the ability of man-
agement to support changes in working practices through the
implementation of LSCM is a core RBV competency that can drive
success. Furthermore, RBV theory also suggests that the ability of
the medical team to understand and implement LSCM practices
in addition to their core medical skills is an almost equally impor-
tant competency for successful implementation of LSCM.
This study shows that the Institutional drivers for the adop-
tion of LSCM by Thai hospitals appear to be primarily mimetic
and normative. This finding supports the suggestion by Gowen,
McFadden, and Settaluri (2012) that the reduction in medical
errors (i.e. customer/patient welfare) is a key driver for implemen-
tation of LSCM in the US hospitals. The implication, therefore, is
that coercive forces may not be factors driving adoption of LSCM
in Thai hospitals. The study indicates that customer needs are the
most dominant factor and this suggests that Thai hospitals are
both aware of and are sensitive to the needs of their patients.
It further suggests that such identified needs can underpin the
implementation of new, significant initiatives such as LSCM.
7. Conclusions and implications
The paper identified 24 LSCM initiatives using a comprehensive
literature review and categorised them into four groups using
Q-sort method. Based on a set of data collected through inter-
views with a number of experts, the four categories were pri-
oritised using fuzzy AHP approach, which resulted in relative
weights of various performance measures of each category.
The study suggests that operational performance and gaining
of financial benefits are the most dominant performance meas-
urement categories for LSCM implementation in Thai healthcare
operations. The findings also suggest that different LSCM initia-
tives and constructs have different levels of impact on achieving
different performance measures. The study also ranked the lev-
els of impact for the three performance measurement categories
operational performance, financial benefits and organisational
Production Planning & Control 11
image. Finally, the study prioritised the theoretical drivers of
LSCM implementation from a resources-based perspective as
well as from an institutional norms perspective.
7.1. Implications for research and practice
This study has important academic and practitioner implica-
tions. For academics, the implementation of LSCM in healthcare
affects many aspects of healthcare operations and previous
studies have not adequately addressed these multi-faceted
approaches. Academic researchers also need to better under-
stand the dynamics between the unique outcomes that relate to
healthcare operations and determine how these relate to LSCM
activities. The study also indicates that there needs to be more
understanding of the relationship between theoretical per-
spectives and implementation of LSCM in healthcare settings.
For industry practitioners, there are different benefits to the
implementation of LSCM, the perceived level of importance of
these benefits are different. Therefore, plans to implement LSCM
should align the organisations strategic goals with the appro-
priate LSCM initiatives. In effect, managers need to identify the
LSCM activities that underpin their key organisational goals and
place more emphasis on these activities. Managers also need to
take into account the key factors driving the implementation of
LSCM in their organisations and understand its impact on their
resource management. Furthermore, healthcare organisations
need to be conversant with the impact of mimetic forces and
the need to be aware and keep up with improvement initiatives
deployed by competitors. Finally, managers need to ensure that
planning for the implementation of LSCM involves a considera-
tion of the combination of resources required, LSCM technical
tools and people-related factors such as management commit-
ment and team competencies.
Future studies could investigate the differences between LSCM
implementation and performance between the healthcare indus-
try and the manufacturing industry. In addition, as implementa-
tion of LSCM in services continues to grow, future studies could
examine drivers and success of LSCM in other service sectors and
particularly, the role of theoretical drivers such as institutional
forces and RBV in their implementation in such sectors.
In conclusion, the limitations of this study are presented. First,
the focus of the paper is primarily on product and information
flows and not patient flows. Secondly, the study did not take into
account the maturity of the hospitals, with respect to LSCM imple-
mentation, that were involved in this study. Finally, this study is
based on the experiences of a limited number of Thai professionals
and academics working with Thai healthcare organisations and the
authors would suggest caution be exercised with regards to gen-
eralisability of the findings, particularly beyond the Thai context.
Acknowledgement
Authors would like to thank Ms. Nuttarut Makeard and Ms. Kanyarat
Somabut, the research assistants, for conducting on-site interviews and pre-
liminary data analysis.
Disclosure statement
No potential conflict of interest was reported by the authors.
 12 D. Adebanjo et al.
Funding
This study was supported by the Higher Education Research Promotion;
National Research University Project of Thailand, Office of Higher Education
Commission; and Thammasat University.
Notes on contributors
Dotun Adebanjo is a professor in supply chain manage-
ment at the University of Greenwich. He previously spent
several years at Leatherhead Food International as a
researcher, consultant and trainer to the food industry.
Before joining Business School at University of Greenwich,
he was a senior lecturer at the University of Liverpool
Management School. His research interests are in supply
chain management, quality management and the appli-
cation of new and emerging technology to the delivery
of efficient inter-organisational relationships. He has
written a book on customer satisfaction and has published his research in
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several journals and also presented his research at leading international
conferences.
Tritos Laosirihongthong is an associate professor at
Industrial Engineering Department, Faculty of
Engineering, Thammasat University, Thailand. His
research interests are in supply chain management and
international operations strategy. He works actively with
a range of organisations in Thailand, Vietnam, Malaysia
and Australia. During 20072008, he was appointed by
ASEAN Secretariat as the ASEAN Automotive Technical
Specialist for the AusAID ASEAN SME Automotive project.
Laosirihongthong has published his research in leading
journals including Production Planning and Control, International Journal of
Production Research, Supply Chain Management: An International Journal
and International Journal of Logistics Management. He is the corresponding
author and can be contacted at: ltritos@engr.tu.ac.th
Premaratne Samaranayake is a senior lecturer at Western
Sydney University, Australia. He has around 25 years of
teaching and research experience and has published a
number of papers in top-ranked international journals
such as International Journal of Production Research,
Supply Chain Management: An International Journal,
International Journal of Operations and Production
Management and European Journal of Operational
Research. His areas of expertise include the development
of mathematical modelling for supply chain manage-
ment, production planning, business process management and enterprise
resource planning. Recently, he completed SAP Certification on Best
Practices in ERP (BPERP) and is a certified solution consultant of SAP ERP for
small- and mid-size enterprises.
ORCID
Premaratne Samaranayake http://orcid.org/0000-0002-6253-7976
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