Effective hospital-wide lean implementation: Top-down, bottom-up or through co-creative role modeling?

John J.C.A.M. van Beers*, Desirée H. van Dun, Celeste P.M. Wilderom

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


Purpose: Lean implementations in hospitals tend to be lengthy or lack the desired results. In addressing the question, how can lean be implemented effectively in a hospital-wide setting, we examined two opposing approaches.
Design/methodology/approach: We studied two Dutch university hospitals which engaged in different lean implementation approaches during the same four-year period: top-down vs. bottom-up. Inductive qualitative analyses were made of 49 interviews; numerous documents; field notes; 13 frontline meeting observations; and objective hospital performance data. Longitudinally, we depict how the sequential events unfolded in both hospitals.
Findings: During the six implementation stages, the roles played by top, middle, and frontline managers stood out. While the top managers of one hospital initiated the organization-wide implementation, and then delegated it to others, the top managers of the other similar hospital merely tolerated the bottom-up lean activities. Eventually, only the hospital with the top-down approach achieved high organization-wide performance gains, but only in its fourth year after the top managers embraced lean in their own daily work practices and had started to co-create lean themselves. Then, the earlier developed lean infrastructure at the middle- and frontline ranks led to the desired hospital-wide leanimplementation results.
Originality: Change-management insights, including basic tenets of social learning and goal-setting theory, are shown to advance our knowledge of effective lean implementation in hospitals. We found lean implementation ‘best-oiled’ through role-modeling by top managers who use a phased-based process and engage in close cross-hierarchical or co-creative collaboration with middle as well as frontline managerial members.
Original languageEnglish
Pages (from-to)1-36
JournalInternational Journal of Lean Six Sigma
Publication statusAccepted/In press - 6 May 2021


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