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Lean Process Improvements at Cleveland Clinic

By: Izak Duenyas

This case study teaches students about lean process improvement projects at the Cleveland Clinic, one of the world's leading hospital systems. The majority of the case focuses on one lean improvement…

• Length: 20 page(s)
• Publication Date: May 14, 2009
• Discipline: Operations Management
• Product #: W87C95-PDF-ENG

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This case study teaches students about lean process improvement projects at the Cleveland Clinic, one of the world's leading hospital systems. The majority of the case focuses on one lean improvement project and leads the student step-by-step through the Kaizen events, and the tools, approaches and outcomes of the project. The case study ends with two short mini-cases on additional process improvement projects at the Cleveland Clinic. The detailed and concise case is ideal for a discussion about lean process improvement in the services industry.

Learning Objectives

After discussing this case study, students will be able to:

1.) describe appropriate business terms and principles appropriate to this case

2.) apply critical concepts from earlier learning to define a solution to the case

3.) successfully articulate data and information in support of the solution proposed

4.) critically analyze and discuss other responses and solutions to the case

5.) draw lessons from the case analysis

6.) generalize the learnings of this case to other business challenges and decisions in organizations other than the one analyzed in this case study

7.) demonstrate leadership and scholarship in analysis.

May 14, 2009

Discipline:

Operations Management

Geographies:

United States

Industries:

Healthcare service industry, Scientific and technical services

WDI Publishing at the University of Michigan

W87C95-PDF-ENG

• Open access
• Published: 27 November 2020

Designing process evaluations using case study to explore the context of complex interventions evaluated in trials

• Aileen Grant 1 ,
• Carol Bugge 2 &
• Mary Wells 3  

Trials volume  21 , Article number:  982 ( 2020 ) Cite this article

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6 Citations

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Process evaluations are an important component of an effectiveness evaluation as they focus on understanding the relationship between interventions and context to explain how and why interventions work or fail, and whether they can be transferred to other settings and populations. However, historically, context has not been sufficiently explored and reported resulting in the poor uptake of trial results. Therefore, suitable methodologies are needed to guide the investigation of context. Case study is one appropriate methodology, but there is little guidance about what case study design can offer the study of context in trials. We address this gap in the literature by presenting a number of important considerations for process evaluation using a case study design.

In this paper, we define context, the relationship between complex interventions and context, and describe case study design methodology. A well-designed process evaluation using case study should consider the following core components: the purpose; definition of the intervention; the trial design, the case, the theories or logic models underpinning the intervention, the sampling approach and the conceptual or theoretical framework. We describe each of these in detail and highlight with examples from recently published process evaluations.

Conclusions

There are a number of approaches to process evaluation design in the literature; however, there is a paucity of research on what case study design can offer process evaluations. We argue that case study is one of the best research designs to underpin process evaluations, to capture the dynamic and complex relationship between intervention and context during implementation. We provide a comprehensive overview of the issues for process evaluation design to consider when using a case study design.

Trial registration

DQIP - ClinicalTrials.gov number, NCT01425502 - OPAL - ISRCTN57746448

Peer Review reports

Contribution to the literature

We illustrate how case study methodology can explore the complex, dynamic and uncertain relationship between context and interventions within trials.

We depict different case study designs and illustrate there is not one formula and that design needs to be tailored to the context and trial design.

Case study can support comparisons between intervention and control arms and between cases within arms to uncover and explain differences in detail.

We argue that case study can illustrate how components have evolved and been redefined through implementation.

Key issues for consideration in case study design within process evaluations are presented and illustrated with examples.

Process evaluations are an important component of an effectiveness evaluation as they focus on understanding the relationship between interventions and context to explain how and why interventions work or fail and whether they can be transferred to other settings and populations. However, historically, not all trials have had a process evaluation component, nor have they sufficiently reported aspects of context, resulting in poor uptake of trial findings [ 1 ]. Considerations of context are often absent from published process evaluations, with few studies acknowledging, taking account of or describing context during implementation, or assessing the impact of context on implementation [ 2 , 3 ]. At present, evidence from trials is not being used in a timely manner [ 4 , 5 ], and this can negatively impact on patient benefit and experience [ 6 ]. It takes on average 17 years for knowledge from research to be implemented into practice [ 7 ]. Suitable methodologies are therefore needed that allow for context to be exposed; one appropriate methodological approach is case study [ 8 , 9 ].

In 2015, the Medical Research Council (MRC) published guidance for process evaluations [ 10 ]. This was a key milestone in legitimising as well as providing tools, methods and a framework for conducting process evaluations. Nevertheless, as with all guidance, there is a need for reflection, challenge and refinement. There have been a number of critiques of the MRC guidance, including that interventions should be considered as events in systems [ 11 , 12 , 13 , 14 ]; a need for better use, critique and development of theories [ 15 , 16 , 17 ]; and a need for more guidance on integrating qualitative and quantitative data [ 18 , 19 ]. Although the MRC process evaluation guidance does consider appropriate qualitative and quantitative methods, it does not mention case study design and what it can offer the study of context in trials.

The case study methodology is ideally suited to real-world, sustainable intervention development and evaluation because it can explore and examine contemporary complex phenomena, in depth, in numerous contexts and using multiple sources of data [ 8 ]. Case study design can capture the complexity of the case, the relationship between the intervention and the context and how the intervention worked (or not) [ 8 ]. There are a number of textbooks on a case study within the social science fields [ 8 , 9 , 20 ], but there are no case study textbooks and a paucity of useful texts on how to design, conduct and report case study within the health arena. Few examples exist within the trial design and evaluation literature [ 3 , 21 ]. Therefore, guidance to enable well-designed process evaluations using case study methodology is required.

We aim to address the gap in the literature by presenting a number of important considerations for process evaluation using a case study design. First, we define the context and describe the relationship between complex health interventions and context.

What is context?

While there is growing recognition that context interacts with the intervention to impact on the intervention’s effectiveness [ 22 ], context is still poorly defined and conceptualised. There are a number of different definitions in the literature, but as Bate et al. explained ‘almost universally, we find context to be an overworked word in everyday dialogue but a massively understudied and misunderstood concept’ [ 23 ]. Ovretveit defines context as ‘everything the intervention is not’ [ 24 ]. This last definition is used by the MRC framework for process evaluations [ 25 ]; however; the problem with this definition is that it is highly dependent on how the intervention is defined. We have found Pfadenhauer et al.’s definition useful:

Context is conceptualised as a set of characteristics and circumstances that consist of active and unique factors that surround the implementation. As such it is not a backdrop for implementation but interacts, influences, modifies and facilitates or constrains the intervention and its implementation. Context is usually considered in relation to an intervention or object, with which it actively interacts. A boundary between the concepts of context and setting is discernible: setting refers to the physical, specific location in which the intervention is put into practice. Context is much more versatile, embracing not only the setting but also roles, interactions and relationships [ 22 ].

Traditionally, context has been conceptualised in terms of barriers and facilitators, but what is a barrier in one context may be a facilitator in another, so it is the relationship and dynamics between the intervention and context which are the most important [ 26 ]. There is a need for empirical research to really understand how different contextual factors relate to each other and to the intervention. At present, research studies often list common contextual factors, but without a depth of meaning and understanding, such as government or health board policies, organisational structures, professional and patient attitudes, behaviours and beliefs [ 27 ]. The case study methodology is well placed to understand the relationship between context and intervention where these boundaries may not be clearly evident. It offers a means of unpicking the contextual conditions which are pertinent to effective implementation.

The relationship between complex health interventions and context

Health interventions are generally made up of a number of different components and are considered complex due to the influence of context on their implementation and outcomes [ 3 , 28 ]. Complex interventions are often reliant on the engagement of practitioners and patients, so their attitudes, behaviours, beliefs and cultures influence whether and how an intervention is effective or not. Interventions are context-sensitive; they interact with the environment in which they are implemented. In fact, many argue that interventions are a product of their context, and indeed, outcomes are likely to be a product of the intervention and its context [ 3 , 29 ]. Within a trial, there is also the influence of the research context too—so the observed outcome could be due to the intervention alone, elements of the context within which the intervention is being delivered, elements of the research process or a combination of all three. Therefore, it can be difficult and unhelpful to separate the intervention from the context within which it was evaluated because the intervention and context are likely to have evolved together over time. As a result, the same intervention can look and behave differently in different contexts, so it is important this is known, understood and reported [ 3 ]. Finally, the intervention context is dynamic; the people, organisations and systems change over time, [ 3 ] which requires practitioners and patients to respond, and they may do this by adapting the intervention or contextual factors. So, to enable researchers to replicate successful interventions, or to explain why the intervention was not successful, it is not enough to describe the components of the intervention, they need to be described by their relationship to their context and resources [ 3 , 28 ].

What is a case study?

Case study methodology aims to provide an in-depth, holistic, balanced, detailed and complete picture of complex contemporary phenomena in its natural context [ 8 , 9 , 20 ]. In this case, the phenomena are the implementation of complex interventions in a trial. Case study methodology takes the view that the phenomena can be more than the sum of their parts and have to be understood as a whole [ 30 ]. It is differentiated from a clinical case study by its analytical focus [ 20 ].

The methodology is particularly useful when linked to trials because some of the features of the design naturally fill the gaps in knowledge generated by trials. Given the methodological focus on understanding phenomena in the round, case study methodology is typified by the use of multiple sources of data, which are more commonly qualitatively guided [ 31 ]. The case study methodology is not epistemologically specific, like realist evaluation, and can be used with different epistemologies [ 32 ], and with different theories, such as Normalisation Process Theory (which explores how staff work together to implement a new intervention) or the Consolidated Framework for Implementation Research (which provides a menu of constructs associated with effective implementation) [ 33 , 34 , 35 ]. Realist evaluation can be used to explore the relationship between context, mechanism and outcome, but case study differs from realist evaluation by its focus on a holistic and in-depth understanding of the relationship between an intervention and the contemporary context in which it was implemented [ 36 ]. Case study enables researchers to choose epistemologies and theories which suit the nature of the enquiry and their theoretical preferences.

Designing a process evaluation using case study

An important part of any study is the research design. Due to their varied philosophical positions, the seminal authors in the field of case study have different epistemic views as to how a case study should be conducted [ 8 , 9 ]. Stake takes an interpretative approach (interested in how people make sense of their world), and Yin has more positivistic leanings, arguing for objectivity, validity and generalisability [ 8 , 9 ].

Regardless of the philosophical background, a well-designed process evaluation using case study should consider the following core components: the purpose; the definition of the intervention, the trial design, the case, and the theories or logic models underpinning the intervention; the sampling approach; and the conceptual or theoretical framework [ 8 , 9 , 20 , 31 , 33 ]. We now discuss these critical components in turn, with reference to two process evaluations that used case study design, the DQIP and OPAL studies [ 21 , 37 , 38 , 39 , 40 , 41 ].

The purpose of a process evaluation is to evaluate and explain the relationship between the intervention and its components, to context and outcome. It can help inform judgements about validity (by exploring the intervention components and their relationship with one another (construct validity), the connections between intervention and outcomes (internal validity) and the relationship between intervention and context (external validity)). It can also distinguish between implementation failure (where the intervention is poorly delivered) and intervention failure (intervention design is flawed) [ 42 , 43 ]. By using a case study to explicitly understand the relationship between context and the intervention during implementation, the process evaluation can explain the intervention effects and the potential generalisability and optimisation into routine practice [ 44 ].

The DQIP process evaluation aimed to qualitatively explore how patients and GP practices responded to an intervention designed to reduce high-risk prescribing of nonsteroidal anti-inflammatory drugs (NSAIDs) and/or antiplatelet agents (see Table  1 ) and quantitatively examine how change in high-risk prescribing was associated with practice characteristics and implementation processes. The OPAL process evaluation (see Table  2 ) aimed to quantitatively understand the factors which influenced the effectiveness of a pelvic floor muscle training intervention for women with urinary incontinence and qualitatively explore the participants’ experiences of treatment and adherence.

Defining the intervention and exploring the theories or assumptions underpinning the intervention design

Process evaluations should also explore the utility of the theories or assumptions underpinning intervention design [ 49 ]. Not all theories underpinning interventions are based on a formal theory, but they based on assumptions as to how the intervention is expected to work. These can be depicted as a logic model or theory of change [ 25 ]. To capture how the intervention and context evolve requires the intervention and its expected mechanisms to be clearly defined at the outset [ 50 ]. Hawe and colleagues recommend defining interventions by function (what processes make the intervention work) rather than form (what is delivered) [ 51 ]. However, in some cases, it may be useful to know if some of the components are redundant in certain contexts or if there is a synergistic effect between all the intervention components.

The DQIP trial delivered two interventions, one intervention was delivered to professionals with high fidelity and then professionals delivered the other intervention to patients by form rather than function allowing adaptations to the local context as appropriate. The assumptions underpinning intervention delivery were prespecified in a logic model published in the process evaluation protocol [ 52 ].

Case study is well placed to challenge or reinforce the theoretical assumptions or redefine these based on the relationship between the intervention and context. Yin advocates the use of theoretical propositions; these direct attention to specific aspects of the study for investigation [ 8 ] can be based on the underlying assumptions and tested during the course of the process evaluation. In case studies, using an epistemic position more aligned with Yin can enable research questions to be designed, which seek to expose patterns of unanticipated as well as expected relationships [ 9 ]. The OPAL trial was more closely aligned with Yin, where the research team predefined some of their theoretical assumptions, based on how the intervention was expected to work. The relevant parts of the data analysis then drew on data to support or refute the theoretical propositions. This was particularly useful for the trial as the prespecified theoretical propositions linked to the mechanisms of action on which the intervention was anticipated to have an effect (or not).

Tailoring to the trial design

Process evaluations need to be tailored to the trial, the intervention and the outcomes being measured [ 45 ]. For example, in a stepped wedge design (where the intervention is delivered in a phased manner), researchers should try to ensure process data are captured at relevant time points or in a two-arm or multiple arm trial, ensure data is collected from the control group(s) as well as the intervention group(s). In the DQIP trial, a stepped wedge trial, at least one process evaluation case, was sampled per cohort. Trials often continue to measure outcomes after delivery of the intervention has ceased, so researchers should also consider capturing ‘follow-up’ data on contextual factors, which may continue to influence the outcome measure. The OPAL trial had two active treatment arms so collected process data from both arms. In addition, as the trial was interested in long-term adherence, the trial and the process evaluation collected data from participants for 2 years after the intervention was initially delivered, providing 24 months follow-up data, in line with the primary outcome for the trial.

Defining the case

Case studies can include single or multiple cases in their design. Single case studies usually sample typical or unique cases, their advantage being the depth and richness that can be achieved over a long period of time. The advantages of multiple case study design are that cases can be compared to generate a greater depth of analysis. Multiple case study sampling may be carried out in order to test for replication or contradiction [ 8 ]. Given that trials are often conducted over a number of sites, a multiple case study design is more sensible for process evaluations, as there is likely to be variation in implementation between sites. Case definition may occur at a variety of levels but is most appropriate if it reflects the trial design. For example, a case in an individual patient level trial is likely to be defined as a person/patient (e.g. a woman with urinary incontinence—OPAL trial) whereas in a cluster trial, a case is like to be a cluster, such as an organisation (e.g. a general practice—DQIP trial). Of course, the process evaluation could explore cases with less distinct boundaries, such as communities or relationships; however, the clarity with which these cases are defined is important, in order to scope the nature of the data that will be generated.

Carefully sampled cases are critical to a good case study as sampling helps inform the quality of the inferences that can be made from the data [ 53 ]. In both qualitative and quantitative research, how and how many participants to sample must be decided when planning the study. Quantitative sampling techniques generally aim to achieve a random sample. Qualitative research generally uses purposive samples to achieve data saturation, occurring when the incoming data produces little or no new information to address the research questions. The term data saturation has evolved from theoretical saturation in conventional grounded theory studies; however, its relevance to other types of studies is contentious as the term saturation seems to be widely used but poorly justified [ 54 ]. Empirical evidence suggests that for in-depth interview studies, saturation occurs at 12 interviews for thematic saturation, but typically more would be needed for a heterogenous sample higher degrees of saturation [ 55 , 56 ]. Both DQIP and OPAL case studies were huge with OPAL designed to interview each of the 40 individual cases four times and DQIP designed to interview the lead DQIP general practitioner (GP) twice (to capture change over time), another GP and the practice manager from each of the 10 organisational cases. Despite the plethora of mixed methods research textbooks, there is very little about sampling as discussions typically link to method (e.g. interviews) rather than paradigm (e.g. case study).

Purposive sampling can improve the generalisability of the process evaluation by sampling for greater contextual diversity. The typical or average case is often not the richest source of information. Outliers can often reveal more important insights, because they may reflect the implementation of the intervention using different processes. Cases can be selected from a number of criteria, which are not mutually exclusive, to enable a rich and detailed picture to be built across sites [ 53 ]. To avoid the Hawthorne effect, it is recommended that process evaluations sample from both intervention and control sites, which enables comparison and explanation. There is always a trade-off between breadth and depth in sampling, so it is important to note that often quantity does not mean quality and that carefully sampled cases can provide powerful illustrative examples of how the intervention worked in practice, the relationship between the intervention and context and how and why they evolved together. The qualitative components of both DQIP and OPAL process evaluations aimed for maximum variation sampling. Please see Table  1 for further information on how DQIP’s sampling frame was important for providing contextual information on processes influencing effective implementation of the intervention.

Conceptual and theoretical framework

A conceptual or theoretical framework helps to frame data collection and analysis [ 57 ]. Theories can also underpin propositions, which can be tested in the process evaluation. Process evaluations produce intervention-dependent knowledge, and theories help make the research findings more generalizable by providing a common language [ 16 ]. There are a number of mid-range theories which have been designed to be used with process evaluation [ 34 , 35 , 58 ]. The choice of the appropriate conceptual or theoretical framework is, however, dependent on the philosophical and professional background of the research. The two examples within this paper used our own framework for the design of process evaluations, which proposes a number of candidate processes which can be explored, for example, recruitment, delivery, response, maintenance and context [ 45 ]. This framework was published before the MRC guidance on process evaluations, and both the DQIP and OPAL process evaluations were designed before the MRC guidance was published. The DQIP process evaluation explored all candidates in the framework whereas the OPAL process evaluation selected four candidates, illustrating that process evaluations can be selective in what they explore based on the purpose, research questions and resources. Furthermore, as Kislov and colleagues argue, we also have a responsibility to critique the theoretical framework underpinning the evaluation and refine theories to advance knowledge [ 59 ].

Data collection

An important consideration is what data to collect or measure and when. Case study methodology supports a range of data collection methods, both qualitative and quantitative, to best answer the research questions. As the aim of the case study is to gain an in-depth understanding of phenomena in context, methods are more commonly qualitative or mixed method in nature. Qualitative methods such as interviews, focus groups and observation offer rich descriptions of the setting, delivery of the intervention in each site and arm, how the intervention was perceived by the professionals delivering the intervention and the patients receiving the intervention. Quantitative methods can measure recruitment, fidelity and dose and establish which characteristics are associated with adoption, delivery and effectiveness. To ensure an understanding of the complexity of the relationship between the intervention and context, the case study should rely on multiple sources of data and triangulate these to confirm and corroborate the findings [ 8 ]. Process evaluations might consider using routine data collected in the trial across all sites and additional qualitative data across carefully sampled sites for a more nuanced picture within reasonable resource constraints. Mixed methods allow researchers to ask more complex questions and collect richer data than can be collected by one method alone [ 60 ]. The use of multiple sources of data allows data triangulation, which increases a study’s internal validity but also provides a more in-depth and holistic depiction of the case [ 20 ]. For example, in the DQIP process evaluation, the quantitative component used routinely collected data from all sites participating in the trial and purposively sampled cases for a more in-depth qualitative exploration [ 21 , 38 , 39 ].

The timing of data collection is crucial to study design, especially within a process evaluation where data collection can potentially influence the trial outcome. Process evaluations are generally in parallel or retrospective to the trial. The advantage of a retrospective design is that the evaluation itself is less likely to influence the trial outcome. However, the disadvantages include recall bias, lack of sensitivity to nuances and an inability to iteratively explore the relationship between intervention and outcome as it develops. To capture the dynamic relationship between intervention and context, the process evaluation needs to be parallel and longitudinal to the trial. Longitudinal methodological design is rare, but it is needed to capture the dynamic nature of implementation [ 40 ]. How the intervention is delivered is likely to change over time as it interacts with context. For example, as professionals deliver the intervention, they become more familiar with it, and it becomes more embedded into systems. The OPAL process evaluation was a longitudinal, mixed methods process evaluation where the quantitative component had been predefined and built into trial data collection systems. Data collection in both the qualitative and quantitative components mirrored the trial data collection points, which were longitudinal to capture adherence and contextual changes over time.

There is a lot of attention in the recent literature towards a systems approach to understanding interventions in context, which suggests interventions are ‘events within systems’ [ 61 , 62 ]. This framing highlights the dynamic nature of context, suggesting that interventions are an attempt to change systems dynamics. This conceptualisation would suggest that the study design should collect contextual data before and after implementation to assess the effect of the intervention on the context and vice versa.

Data analysis

Designing a rigorous analysis plan is particularly important for multiple case studies, where researchers must decide whether their approach to analysis is case or variable based. Case-based analysis is the most common, and analytic strategies must be clearly articulated for within and across case analysis. A multiple case study design can consist of multiple cases, where each case is analysed at the case level, or of multiple embedded cases, where data from all the cases are pulled together for analysis at some level. For example, OPAL analysis was at the case level, but all the cases for the intervention and control arms were pulled together at the arm level for more in-depth analysis and comparison. For Yin, analytical strategies rely on theoretical propositions, but for Stake, analysis works from the data to develop theory. In OPAL and DQIP, case summaries were written to summarise the cases and detail within-case analysis. Each of the studies structured these differently based on the phenomena of interest and the analytic technique. DQIP applied an approach more akin to Stake [ 9 ], with the cases summarised around inductive themes whereas OPAL applied a Yin [ 8 ] type approach using theoretical propositions around which the case summaries were structured. As the data for each case had been collected through longitudinal interviews, the case summaries were able to capture changes over time. It is beyond the scope of this paper to discuss different analytic techniques; however, to ensure the holistic examination of the intervention(s) in context, it is important to clearly articulate and demonstrate how data is integrated and synthesised [ 31 ].

There are a number of approaches to process evaluation design in the literature; however, there is a paucity of research on what case study design can offer process evaluations. We argue that case study is one of the best research designs to underpin process evaluations, to capture the dynamic and complex relationship between intervention and context during implementation [ 38 ]. Case study can enable comparisons within and across intervention and control arms and enable the evolving relationship between intervention and context to be captured holistically rather than considering processes in isolation. Utilising a longitudinal design can enable the dynamic relationship between context and intervention to be captured in real time. This information is fundamental to holistically explaining what intervention was implemented, understanding how and why the intervention worked or not and informing the transferability of the intervention into routine clinical practice.

Case study designs are not prescriptive, but process evaluations using case study should consider the purpose, trial design, the theories or assumptions underpinning the intervention, and the conceptual and theoretical frameworks informing the evaluation. We have discussed each of these considerations in turn, providing a comprehensive overview of issues for process evaluations using a case study design. There is no single or best way to conduct a process evaluation or a case study, but researchers need to make informed choices about the process evaluation design. Although this paper focuses on process evaluations, we recognise that case study design could also be useful during intervention development and feasibility trials. Elements of this paper are also applicable to other study designs involving trials.

Availability of data and materials

No data and materials were used.

Abbreviations

Data-driven Quality Improvement in Primary Care

Medical Research Council

Nonsteroidal anti-inflammatory drugs

Optimizing Pelvic Floor Muscle Exercises to Achieve Long-term benefits

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Acknowledgements

We would like to thank Professor Shaun Treweek for the discussions about context in trials.

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Aileen Grant

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Carol Bugge

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AG, CB and MW conceptualised the study. AG wrote the paper. CB and MW commented on the drafts. All authors have approved the final manuscript.

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Grant, A., Bugge, C. & Wells, M. Designing process evaluations using case study to explore the context of complex interventions evaluated in trials. Trials 21 , 982 (2020). https://doi.org/10.1186/s13063-020-04880-4

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The Lean Post / Articles / Lean Management Case Studies Library

Lean Management Case Studies Library

By Chet Marchwinski

May 16, 2014

Learn how a variety of businesses and organizations used lean management principles to solve real business problems. We’ve arranged the examples in 16 categories to help you find the ones right for your environment.

Lean Management Examples from a Variety of Businesses

The following case studies of lean management principles in action show you how a variety of real businesses solved real business problems under diverse conditions.

We’ve arranged the stories in 16 categories to help you find the examples you need. There is some overlap. For instance, a “Lean Manufacturing” case study may also appear with “Privately Held Companies.”

Lean Manufacturing

• Logistics, Supply Chain, and Warehousing
• Lean Material Handling
• Job Shops (Low-volume, High-mix Manufacturing); Tool and Die
• Lean in Government
• Lean Healthcare
• Lean Accounting
• Lean Construction
• Lean in Office and Service Processes
• Lean in Education

Problem Solving

Pull Systems

Culture Change

People Development

Privately Held Companies

Maintenance

Many of the executives who took part in these transformations are interviewed in LEI’s Senior Executive Series on Lean Leadership . After reading the case studies, be sure to get their personal perspectives on leading change. (Feel free to link to this page, but please respect the copyrights of LEI and journalists by not copying the articles.)

Are you doing something new or notable in the practice of lean management? Let us share what you learned with the lean community. For more information, contact LEI’s Director of Communications Chet Marchwinski at cmarchwinski at lean dot org

Thrustmaster Turns Around

Learn how Thrustmaster of Texas successfully adopted lean thinking and practices to make sustainable improvements in a short period of time, and how other manufacturers of highly engineered, low-volume products can follow their lead using the Lean Transformation Framework.

Lean + Circular Principals = a New True North for Manufacturer

SunPower’s lean journey resembled most others until it defined a new mission, a new True North by combining lean principals with those of the “circular economy” to launch what it is calling a CLean Transformation.

Sustain Your Lean Business System with a “Golden Triangle” After a medical device maker took a hit to margins to fight off global competition, it rebuilt them by lifting its lean operating system to a higher level and keeping it there with a “golden triangle” of sustainability.

Followup Story:

Manufacturing Balancing Act: Pull Versus ERP

In this follow-up to “Sustain Your Lean Business System with a ‘Golden Triangle,’” a case study about Phase 2 Medical Manufacturing, the company needs warehouse space to keep pace with sales growth spurred by the lean transformation. Instead, it expands a pull system by connecting the plan-for-every-part database that underpins one-piece flow production with ERP, typically associated with big batch production.

Cultivating a Lean Problem-Solving Culture at O.C. Tanner If you are in the “appreciation business”, you have to live it in your own workplace. For O.C. Tanner that meant a lean transformation had to show the company appreciated and wanted people’s problem-solving ideas. Here’s a report on that effort, including what worked and what didn’t.

Lean Partnership with Dealer Network Helps Vermeer Reduce End-to-End Inventory on Top Sellers

A lean transformation had taken heavy-equipment manufacturer Vermeer away from batch manufacturing, but batch ordering by dealers was delaying how quickly they got equipment like brush chippers. Learn how it  began converting its domestic industrial-line distribution network to lean replenishment, improving service to end customers and improving cash flow for Vermeer and its dealers.

Herman Miller’s Experiment in Excellence At Herman Miller, the lean management effort helps it build problem solvers as well as world-class office furniture. And as this case study shows, lean practices also helped it weather a brutal recession.

Build Your “House” of Production on a Stable Foundation Rigorous problem solving creates basic stability in a machining intensive facility.

A Journey to Value Streams: Reorganizing Into Five Groups Drives Lean Improvements and Customer Responsiveness An approach to creating a value -stream culture centered on autonomy, entrepreneurialism, and lean principles.

Change in Implementation Approach Opens the Door at EMCO to Greater Gains in Less Time A relatively quick, intensive project accelerates the rate of improvement and creates a showcase facility for spreading lean concepts.

Creating the Course and Tools for a Lean Accounting System A lean accounting implementation fills the frustrating disconnect between shop-floor improvements and financial statements.

For Athletic Shoe Company, the Soul of Lean Management Is Problem Solving After taking a lean tools approach to change, management re-organized the transformation around problem solving and process improvement to create a culture that engaged people while boosting performance.

Knife Company Hones Competitiveness by Bucking the Status Quo An iconic family-owned company turns to lean manufacturing to reduce costs by at least 30% to keep its U.S. operations open.

Lean Transformation Lives and Dies with Tools and Dies After a failed first try at just-in-time production , a company transforms tool maintenance, design, and fabrication to create a solid foundation for a second attempt.

Seasoned Lean Effort Avoids “Flavor-of-the-Month” Pitfall A look at how one company’s approach to what new tools it introduced, in what order, and how it prevented each new technique from being viewed as a “flavor of the month” fad.

Shifting to Value-Stream Managers: a Shop-Floor Revolution Leads to a Revolution in Plant Organization

Two years into a lean transformation, the low-hanging fruit has been plucked and progress has started to slow. Read how a Thomas & Betts plant recharged the transformation and reached higher levels of performance by using value-stream managers to span functional walls.

Using Plan-Do-Check-Act as a Strategy and Tactic for Helping Suppliers Improve

At Medtronic’s Neuromodulation business unit, the plan-do-check-act cycle is used on a strategic level to guide overall strategy for selecting and developing key suppliers as well as on a tactical level for guiding lean transformations at supplier facilities.

back to top

Logistics, Supply Chain, and Warehousing How a Retailer’s Distribution Center Exemplifies the Lean Precept “Respect for People,” and Reaps the Benefits

To make sure training engaged and resonated with people after previous attempts at a lean transformation faltered, LifeWay matched lean management tools and principles to its Bible-based culture and language.

Lean management case study series: Lean in Distribution: Go to Where the Action Is!

Starting with daily management walkabouts and standard work , this distributor had laid the groundwork for steady gains for years to come, just two years after its first kaizen workshop .

Putting Lean Principles in the Warehouse

Executives at Menlo Worldwide Logistics saw an opportunity to leapfrog the competition by embracing lean in its outsourced warehousing and receiving operations.

Lean Thinking Therapy Spreads Beyond the Shop

A company expands the lean transformation from the shop floor to international distribution, domestic shipping, and product development.

Sell One, Buy One, Make One: Transforming from Conventional to Lean Distribution

Large inventories to cover fluctuations in demand once characterized Toyota’s service parts distribution system — but no more. Here’s how one DC made the switch.

Material Handling

Following Four Steps to a Lean Material-Handling System Leads to a Leap in Performance

Creating the critical Plan for Every Part was one step in a methodical four-step implementation process to replace a traditional material-handling system.

Low-volume, High-mix Manufacturing; Tool and Die

The Backbone of Lean in the Back Shops

Sikorsky managers apply the lean concept of “every part, every interval” (EPEI) to level the mix in demand and create flow through a key manufacturing cell .

Landscape Forms Cultivates Lean to Fuel Growth Goals

With single-item orders 80% of the time, a low-volume, high-mix manufacturer decided single-piece flow cells were the best way decided the best way to add new products without having to constantly reconfigure production.

Lean Transformation Lives and Dies with Tools and Dies

After a failed first try at just-in-time production, a company transforms tool maintenance, design, and fabrication to create a solid foundation for a second attempt.

Canada Post Puts Its Stamp on a Lean Transformation

The “ inventory ” of mail already is paid for, so moving it faster doesn’t improve cash flow as in lean manufacturing. But Canada Post discovered that traditional batch-and-queue postal operations could benefit from lean principles.

Lean Thinking in Government: The State of Iowa

This story examines a kaizen event at a veterans home and more broadly at the lean effort in Iowa government.

Lean Thinking Helps City of Chula Vista with Budget Crunch

Goodrich Aerostructures’ Chula Vista plant introduces city government to lean thinking and practices so in order to maintain municipal services without resorting to further cuts in the workforce.

Using Lean Thinking to Reinvent City Government

Grand Rapids, MI, turns to lean principles to consolidate operations, eliminate wasted time and effort, and streamline to improve productivity while providing the quality of service that residents want.

Transforming Healthcare: What Matters Most? How the Cleveland Clinic Is Cultivating a Problem-Solving Mindset and Building a Culture of Improvement

The Cleveland Clinic reinvents its continuous improvement program to instill a problem-solving mindset and the skillset to solve everyday problems among the clinic’s thousands of caregivers.

View from the Hospital Floor: How to Build a Culture of Improvement One Unit at a Time

In order to do more and improve faster, the Cleveland Clinic is rolling out a methodology for building a “culture of improvement” across the 48,000-employee hospital system as this followup to the above story shows. Here’s how it works according to the people making the changes.

Dentist Drills Down to the Root Causes of Office Waste

Dentistry is a job shop that Dr. Sami Bahri is out to improve fundamentally for the benefit of patients through the application of lean principles.

Lean management case study series: Pediatric Hospital in Tough Market Pegs Growth to Lean Process Improvement

Lean improvement projects at Akron Children’s Hospital have saved millions of dollars, increased utilization of expensive assets, and reduced wait times for patients and their families.

Lean Design and Construction Project an Extension of Lean Commitment at Akron Children’s Hospital

Input from nurses, doctors, therapists, technicians, and patient parents heavily influenced design decisions..

“Pulling” Lean Through a Hospital

A thoughtful rollout of lean principles in the ER and eye-opening results created a “pull” for lean from other departments.

Best in Healthcare Getting Better with Lean

Mayo Clinic, Rochester, MN, stresses to doctors that the lean effort is aimed not at changing the moment of care, the touch moment between doctor and patient, but the 95% of the time when the patient is not in the doctor’s office

Fighting Cancer with Linear Accelerators and Accelerated Processes

Cross-functional team design and implement a lean process to dramatically increase the number of patients with brain and bone metastases receiving consultation, simulation, and first treatment on the same day without workarounds or expediting.

Massachusetts General Looks to Lean

A proton therapy treatment center, for many adults and children the best hope of beating cancer, applies lean principles to increase capacity.

New Facility, New Flow, and New Levels of Patient Care: The wait is over for patients at the Clearview Cancer Institute in Alabama

Physicians and staff have tirelessly reengineer processes and patient flow to eliminate as much waiting and waste as possible.

The Anatomy of Innovation

At a hospital in Pittsburgh, the emerging vision for the “hospital of the future” is described as giving the right patient, the right care, at the right time, in the right way, all the time.

Creating the Course and Tools for a Lean Accounting System

A lean accounting implementation fills the frustrating disconnect between shop-floor improvements and the financial statement.

Knife Company Hones Competitiveness by Bucking the Status Quo

An iconic family-owned company turns to lean manufacturing to reduce costs by at least 30% to keep its U.S. operations open.

Office and Service Processes

The “inventory” of mail already is paid for, so moving it faster doesn’t improve cash flow as in lean manufacturing. But Canada Post discovered that traditional batch-and-queue postal operations could benefit from lean principles.

Lean Landscapers

At an Atlanta landscaping company, lean practices are making inroads into a service industry in unusual yet fundamental ways.

LSG Sky Chefs Caters to New Market Realities

Business at airline caterer LSG Sky Chefs dropped 30% when airlines cut flights after the terrorist attacks on September 11, 2001. Sky Chefs responded with a rapid launch of a lean initiative.

leveraging Lean to Get the Oil Out

Aera Energy LLC, a California oil and gas company,  relies on lean principles to improve key processes, including drilling new wells, repairing existing ones, and maximizing the number of barrels of crude pumped each day.

Columbus Public Schools Use Process Thinking to Improve Academic Achievement.

Columbus, OH, public schools, experiment with lean tools and process thinking to remove wasteful activities that don’t help them help students learn.

Lean Inroads into Alabama Academia

How the University of Alabama in Huntsville integrated lean concepts throughout its industrial engineering curriculum.

Linking Lean Thinking to the Classroom

Value-stream mapping is one of many activities included in the Ford Partnership for Advanced Studies (Ford PAS), an academic program designed to link high-school classroom learning to the skills needed in college and business.

Build Your “House” of Production on a Stable Foundation

Rigorous problem solving creates basic stability in a machining intensive facility.

For Athletic Shoe Company, the Soul of Lean Management Is Problem Solving

After talking a lean tools approach to change, management re-organized the transformation around problem solving and process improvement to create a culture that engaged people while boosting performance.

Toothbrush Plant Reverses Decay in Competitiveness

The rapid introduction of a lean system, beginning with just-in-time production and pull, helps a highly automated Midwest plant fight off overseas competition by reducing lead times and inventory while augmenting the plant’s advantage in service.

A Journey to Value Streams: Reorganizing Into Five Groups Drives Lean Improvements and Customer Responsiveness

An approach to creating a value-stream culture centered on autonomy, entrepreneurialism, and lean principles.

Making Lean Leaders — Ariens internship program develops lean and leadership skills

Besides making snow-blowers, mowers, and string trimmers, Ariens Co., of Brillion, WI, makes lean leaders.

Starting with daily management walkabouts and standard work, this 84-year-old, family-owned distributor laid the groundwork for steady gains for years to come, just two years after its first kaizen workshop.

Sustain Your Lean Business System with a “Golden Triangle”

After a medical device maker took a hit to margins to fight off global competition, it rebuilt them by lifting its lean operating system to a higher level and keeping it there with a “golden triangle” of sustainability. You’ll recognize two elements of the triangle right away: visual control and standardized work . The third, accountability management or a kamishibai system, is probably less well known but just as critical.

Cultivating a Lean Problem-Solving Culture at O.C. Tanner

If you are in the “appreciation business”, you have to live it in your own workplace. For O.C. Tanner that meant a lean transformation had to show the company appreciated and wanted people’s problem-solving ideas. Here’s a report on that effort, including what worked and what didn’t.

Lean Thinking in Aircraft Repair and Maintenance Takes Wing at FedEx Express

A major check that used to take 32,715 man-hours was cut to 21,535 hours in six months. That translated into a $2 million savings, which dovetailed with the company’s emphasis on reducing costs during the recession.

Construction

Input from nurses, doctors, therapists, technicians, and patient parents heavily influenced design decisions—from incorporating emergency room hallways that protect the privacy of abused children to the number of electrical outlets in each neonatal intensive care room.

Virtual Lean Learning Experience (VLX)

A continuing education service offering the latest in lean leadership and management.

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About Chet Marchwinski

Chet has been a humble, unwashed scribe of the lean continuous improvement movement since books by Taiichi Ohno and Shigeo Shingo first hit North America in the 1980s. At LEI, he contributes to content creation, marketing, public relations, and social media. Previously, he also wrote case studies on lean management implementations in…

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55 Process Improvement Case Studies & Project Results [2023]

What are the typical project results, further reading.

Business leaders know that process improvement reduces costs and increases customer satisfaction. Therefore, businesses follow process improvement methodologies or deploy tools such as process modeling, process mining and RPA to discover, modify and automate their processes. However, it can be difficult for process experts and business analysts to understand the different process improvement approaches and the results they should expect.

Read our process improvement approaches guide for a categorization of process improvement approaches so you can rely on a framework to structure your process improvement initiatives. In this article, we share typical process improvement project results and case studies. Our aim is to provide benchmarks so business analysts and leaders can set targets for their own initiatives.

Process improvement solutions help businesses define weaknesses and take action to solve these problems. In the case studies we collected, the most common project results that we came across are as follows:

1- Improved efficiency:  Most businesses increase the efficiency of their processes by adapting process improvement methodologies. After defining their problems, companies eliminate unnecessary steps in processes, reduce their costs, and shorten process times. As a result, they achieve faster processes and higher quality output with fewer resources. 

For example, in a process mining case study, a manufacturer leveraged IBM Process Mining to analyze the procure-to-pay processes. It is claimed that the manufacturer detected and managed deviations, mismatches and early payments, which lessened maverick buying and saved $60,000 in reworking cost. The firm improved purchase order and invoice processes by automating 75% of line creation and delivery activities. As a result, the company decreased the invoice registration and approval time.

2- Enhanced customer satisfaction: The increasing quality of output and faster processes can also reflect on customer satisfaction. Process improvement solutions help businesses reduce waiting time and focus on customer value. For example, it is claimed that by adopting the Kaizen methodology, Tata Steel has shortened its response time and delivered more on-time orders to its customers.

3- Harmonization of different teams/processes:  For large companies, handling different processes simultaneously can be a big challenge. Teams should be informed about what others do, and processes need to work in sync to avoid problems. With process improvement solutions, businesses can have a full understanding of all their companies and align different processes successfully.

Here is an extended list of case studies which are collected from different resources. You can filter the list by the process improvement solution, service provider, industry, or process and investigate the achieved results.

  If you want to learn more on process improvement, these articles can also interest you:

• Process Improvement: In-depth Guide for Businesses
• Lean Process Improvement Guide for Your Business

If you still have questions about process improvement, we would like to help:

Cem has been the principal analyst at AIMultiple since 2017. AIMultiple informs hundreds of thousands of businesses (as per similarWeb) including 60% of Fortune 500 every month. Cem's work has been cited by leading global publications including Business Insider , Forbes, Washington Post , global firms like Deloitte , HPE, NGOs like World Economic Forum and supranational organizations like European Commission . You can see more reputable companies and media that referenced AIMultiple. Throughout his career, Cem served as a tech consultant, tech buyer and tech entrepreneur. He advised enterprises on their technology decisions at McKinsey & Company and Altman Solon for more than a decade. He also published a McKinsey report on digitalization. He led technology strategy and procurement of a telco while reporting to the CEO. He has also led commercial growth of deep tech company Hypatos that reached a 7 digit annual recurring revenue and a 9 digit valuation from 0 within 2 years. Cem's work in Hypatos was covered by leading technology publications like TechCrunch and Business Insider . Cem regularly speaks at international technology conferences. He graduated from Bogazici University as a computer engineer and holds an MBA from Columbia Business School.

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Process Orchestration in 2023: Top 5 Tools & Best Practices

Hi Cem, Thank you ver much for your interesting article. I am interested in getting a deeper look into some of the case studies: How exactly did they approach the problem? ….Would it be possible to get a closer look at the case studies? Thanks in advance. Adrian

Hi Adrian, please feel free to get in touch with us via [email protected] . Happy to discuss these in more detail once we know which types of case studies you are interested in

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Gagnon Associates

Management & Organizational Consulting

Case Study:  Business Process Improvement

This Case Study illustrates how Gagnon Associates used its Business Process Improvement capability to optimize a client’s new-product development process:

The Company

A formerly high-flying, enviably profitable surgical products division of a major health care company.  Makers of state-of-the-art, reusable and disposable devices for the rapidly-growing, least-invasive surgery market.

The Problem

Declining profits due to increased costs associated with a lack of discipline and lack of customer focus in screening new product ideas, initiating new-product development projects and managing the new-product life cycle in the post-introduction phase.

The Approach

Management enlists Gagnon Associates consulting support to lead the effort to:  a) assess new-product screening, new-product development, and post-product introduction processes and related issues, and b) reengineer these interrelated processes for improved efficiency/effectiveness.

Four “boundaryless,” client teams are created, including representatives from finance, R&D, marketing, sales, purchasing and other functions.  Three teams focus on one each of three previously mentioned processes.  The fourth team analyzes a recent unsatisfactory surgical pump introduction for additional insights into deficiencies in the new-product introduction process.

Over three days of an intense, highly-interactive, four-day intervention, teams work both independently and in close coordination, as needed, to:  a) define existing process deficiencies, b) reengineer processes, and c) address key process interrelationships.  Throughout, Gagnon Associates catalyzes and facilitates the process by providing online, work-group leadership as well as “just-in-time” training and coaching on underlying process reengineering tools and techniques.

The Results

Teams completely reengineer new-product screening and new-product development processes and develop a more formal process for managing the post-introduction phases of the product life-cycle.  On the fourth day of the engagement, the division’s management team reviews and approves the newly reengineered processes in an interactive forum, attended by all team members and moderated by Gagnon Associates consulting staff .

Management is so pleased with the newly redesigned processes that it commits to testing approximately 120 new product development projects currently in the pipeline against the new model and estimates that, as a result, some 40 to 50 resource-draining projects of questionable value to the customer will be eliminated.

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7 QC Tools for Process Improvement | PDF | Case Study

From Where Did the 7 QC Tools Come?

Why we use The 7 QC Tools for Process Improvement?

What is the use of 7 qc tools.

The 7 QC Tools:

• Flow Charts
• Cause and Effect Diagram (Fishbone or Ishikawa) 
• Pareto Chart
• Scatter Diagram
• Control Chart

👉  Download 7 QC Tools PDF file

[1] flow charts :.

[2] Cause and Effect Diagram :

[3] Check Sheet :

[4] Histogram :

➨ types of histogram:.

[5] Pareto Chart :

[6] Scatter Diagram :

➨ different names of the scatter diagram:, ➨ different correlation between two variables in the scatter plot:.

[7] Control Chart :

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20 comments.

very good presentation skill and to the point explaination

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How to download???

You can check the individual articles!!!

Best in short... Great work Nikunj

Thank you very much for your kind comment!!!

Simply wonderful. Thanks very much!

this is a great initiative , well done

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Thanks and happy learning!!!

Nice teaching

Thank you and Happy Learning!!!

Great good initiative 👍 a How to Download

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This is so helpful

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Process improvement case study presentation powerpoint

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