In this regard, the following facts need to be considered: (i) optimisation of the workflow to generate a continuous flow pull system, (ii) reduction in laboratory traffic and increased risk avoidance, including biological ones, (iii) harmonisation of procedures by eliminating manual activities, (iv) reduction in use of unsuitable containers, (v) improvement of sample traceability [31]. Lean methodologies could serve as a potent diagnostic and assessment tool for analysing the value chain of laboratory processes in microbiology, ensuring reliability, sustainability, efficiency and significant impact on patient outcomes, especially in process changes involving notable investment, such as TLA. Concerning publications found in the literature, some commentaries, technical notes and systematic reviews have been focused on Lean Healthcare [9; 32] and its implementation in medical [33], histology [34] and microbiology laboratories [16]. In this work, the state-of-art review is centred on clinical laboratories, where Lean methodologies have been applied. The literature review was carried out as follows. The databases used for the initial stage were SCOPUS (Elsevier) and Web of Science. The following keywords were used to perform the database search: Lean management, Lean Healthcare, Lean techniques, Lean implementation, Laboratory, Clinical Laboratory Sampling and Microbiology. English and Spanish search terms were applied to identify the most significant scientific contributions. Only the literature from 2010 or later was considered, in order to analyse the latest contributions with direct relation to Lean implementation in the healthcare context for improving laboratory processes. The database search was performed for articles until September 2023. The core results of the literature review are shown in Table 1. For each considered reference, the presented actions and main findings have been highlighted. Furthermore, the different level of Lean application has been distinguished from 1 to 5 as following: (1) Empirical study; (2) Case study analysis (Kaizen ideas identification); (3) Implementation (pilot phase and control); (4) Final implementation (KPIs analysis and lessons learnt); (5) Cost analysis (economic impact quantification). \begin{table}
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**Country** & **Title** & **Actions** & & & & & & & & & \\  
As shown in Table 1 (in alphabetical order), research results are still limited but have been increasing quickly during last years. Regarding Lean philosophy, the main actions are focused on optimising or redesigning workflow and key processes to eliminate waste, reduce errors, balance workload, standardise and simplify activities. Other suggested guidelines for clinical laboratory Lean management are presented in [55]. Searching for joint application of Lean techniques and process automation in clinical laboratories, a study presented in [47] considers the combined Lean and Total Laboratory Automation (TLA) approach in the establishment of a consolidated laboratory to address different clinical tests. The common KPI analysed in the literature is the total delivery time of realising test results at a clinical lab, which considers three main phases: pre-analytical, analytical and post-analytical. Nevertheless, not only are accurate results obtained in a timely manner, but also other added-value advantages such as personnel safety (staff protection from laboratory hazards). Final implementation results are normally presented in case studies from university teaching hospitals. Demonstrated key success factors are training and