Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article


Doctor of Philosophy


Health Information Science


Sedig, Kamran


Lean Thinking was pioneered during the 1980’s by the Toyota Motor Company as a method of process improvement for their production lines. Since the early 2000’s, there have been published reports of using Lean to redesign healthcare systems. Its effectiveness as a quality improvement method for healthcare has been contested due, in part, to our limited contextual understanding of how Lean affects the working conditions, and clinical workflow, of healthcare professionals. The objective of this dissertation was to explore how a Lean intervention may impact clinical work, and within what contexts.

A realist grounded theory approach was used to explore the clinical work of nurses and physicians practicing in two adult emergency medicine departments (ED) from a single teaching hospital in Canada. The hospital has 1,000 beds, and its two ED annually treat about 128,000 patients. In 2013, both sites began a large-scale, Lean-driven, system transformation that was intended to make their ED work easier, faster and better.

Three grounded theories (GT) were developed from interviews with 15 nurses and five physicians. The first GT describes ways in which the reconfigured ED disrupted professionals’ established practice routines and resulted in the intensification of their clinical work. Professionals also identified indications of deskilling of nurses’ work and described how the new, push-forward model of patient care detrimentally impacted their physical, cognitive, and emotional well-being. A major element of the Lean intervention was the construction of a three-zone, front cell at both sites. The second GT describes how the physical configuration of the front cell further intensified professionals’ clinical work by requiring them to actively search for spaces better-affording privacy and confidentiality for patient encounters. The third GT describes how professionals perceived their hospital fell short on demonstrating effective leadership throughout the development and execution of its Lean-driven plans. Of particular salience to nurses and doctors was how their institution had failed to deliver on a set of procedural and structural changes they recalled were promised to occur as a result of the Lean intervention.

Rather than support nurses and physicians in their management of the complexities that characterize emergency medicine, the physical and process-based changes introduced by the Lean intervention acted to complicate further the environment under which they delivered patient care. The GT illuminated some unintended consequences associated with accelerating patient flow on the clinical workflow and perceived well-being of healthcare professionals. This dissertation identifies some areas for reconsideration by the ED departments along with ideas for future research.

Keywords: Emergency medicine; Lean Thinking; Hospital; Grounded Theory