An exploration of barriers to implement Lean in the emergency level of the Brazilian public healthcare system

The overarching aim of this thesis is to understand the barriers to implement lean in the emergency level of the Brazilian public healthcare system (UHS). As one of the BRICS countries, Brazil as a developing country has challenges in terms of education, infrastructure and healthcare. Thus, this research aims to bring lean into this context and investigate the constraints of a future lean implementation in the UHS. The UHS presents several operational and non-operational problems. These problems constrain the system and affect the patients. Lean is a well-known approach that has been applied around the world with special focus in developed countries. However, these initiatives have also experienced several barriers that act to inhibit the lean journey. Scholars and practitioners have investigated these barriers, however approaches that show the deeper causes, especially in healthcare, are still scarce. Thus, this brought an opportunity to carry out original research about the barriers that constrain the lean implementation in a different context. To achieve the aim of this thesis, a qualitative and inductive approach based on a single case study in the emergency level of the UHS was undertaken. This approach is supported with the interpretivist philosophical stance adopted by the researcher. To access the data, interviews and observations were carried out; these approaches were used in different ways in four different sources of data collection: one emergency care unit (ECU); one emergency department (ED); lean management consultants; and staff members from a lean private hospital. The data from these sources was triangulated and analysed using thematic analysis. The results show that there are two types of barriers that might constrain the lean implementation in the UHS. The first type of barrier is entitled ostensible, as they are well known within the literature. The other type of barrier is entitled underlying and they have a great influence of the stakeholders behaviour and UHS management style, which act as restraining forces against process improvement. Furthermore, these underlying barriers were identified as the real causes of the ostensible barriers. This research provides both theoretical and practical contributions. The theoretical contribution brings a new body of knowledge based on findings related to identification of the underlying barriers that constraint the lean implementation in the UHS; the contextual contribution was also addressed in this study as there is no research about lean barriers in this setting; finally the field of forces in healthcare (based on force field analysis (Lewin, 1951) was developed to understand the interplay between underlying barriers, restraining forces from stakeholders and UHS, and the creation of the ostensible barriers. The practical contribution provides support for lean practitioners and management consultants about the impact of the Brazilian public administration model in the lean journey, as well as the impact of the underlying barriers in the lean journey. Finally, a set of propositions was developed based on outcomes that emerged during the development of this research.