الفهرس 
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Abstract
Lean is meant to continuously and incrementally improve operational processes through redesigning and standardizing work flows with the processes customers find valuable (called value-added), and hence, eliminating non-value-added waste in time, effort, or resources (7,8). This method aims to ensure quality services and to promote a customer-focused and continuous improvement culture throughout the organization. Lean has been successfully applied in the manufacturing industry and some pioneering health care institutions, resulting in improved efficiency and cost saving (9, 10). With the conceptual ease of transferring to health care delivery, lean principles have been increasingly adopted by hospitals and clinics as a management strategy and as tool for performance improvement (11, 12).
One of the main focuses of lean production is the elimination of waste, i.e. activities that bring no value to the customers. Initially, the implementation of lean should start by recognizing the types and the sources of waste in the system (13- 15). Lean categorizes eight deadly wastes known as: ”DOWNTIME”, which stands for: Defects; Overproduction; Waiting; Non-utilized resources; Transportation; Inventory; Motion; and Extra Processing (16-18).
Lean is potentially an efficient tool to improve the workflow and safety; and to reduce waste in health care organization. Occupational safety is an important concern, management often prioritizes reducing waste and cost. So, there is a necessity for some technique which reduces waste and simultaneously improves safety. Lean has been effective in reducing waste and costs. Researchers have shown that lean might improve occupational safety too (30, 31).
In the light of this, the present study examines the effect of implementation of lean strategies utilization training program for first line nurse managers on quality of environmental and occupational safety.
Aim of the study
This study aims to examine the effect of implementation of lean strategies utilization training program for first line nurse managers on quality of environmental and occupational safety.
Research Design It is a quantitative intervention study design.
Setting
The study was conducted at El-Quabbary hospital (120 beds) which is affiliated to Ministry of Health and Population. All hospital inpatient and emergency units was included in the study (N=12) as following: four intensive care units namely: coronary, general, pediatric and emergency; three medical and surgical units namely: medical, surgical, oncology; one neonate unite; one operating room; three one daycare units namely; physio therapy unit, kidney dialysis and liver center.
Subjects:
The subjects of the study encompassed two categories: First category, all FLNMs (n=12) and their senior nurses (n=12). Their inclusion criteria: They were available at the time of data collection, working in the above-mentioned settings, hold Bachelor degree of Nursing Sciences, and had at least one-year experience (n=24). Second category, all practical nurses available in the morning shift in the previously mentioned units at the time of data collection (n=36).
Tools
-Tool 1: Gemba Walk of Environmental and Occupational Health and Safety Observation Checklist.
-Tool 2: Stream Map (VSM).
-Tool 3: 5S tool.
-Tool 4: Lean Strategies Utilization Training program
Result of the study
There were no statistically significant differences between nurses’ demographic characteristics at various study units.
There were highly positive statistically significant differences in FLNM and senior nurses’ performance of total medication administration process between the three periods; before, immediately after and three months after Gemba walk strategy implementation of lean training program in each unit of the study. (p≤0.001)
There was a highly statistically significant difference between total time of VAA of two periods of before and three months after implementation of training program (p≤ 0.001).
There was a statistically significant difference in reduction of waste in time in NVA activities performed by practical nurses between the periods; before and three months later from the implementation of lean strategies training program (p≤0.001).
There was a positive statistically significant differences between 5S strategy application in the utility system management before, immediately after and three months later the implementation of lean strategies training program. (p≤0.001)
There were highly significant differences in knowledge of study subjects regarding all lean strategies training program before and after the program implementation. (p≤0.001)
There was a statistically significant relationship between VSM and all socio- demographic characteristics were. (p≤ 0.001)
There were significant relationships between Gemba walk and study subjects` qualification and job position. (p≤ 0.001)
Based on the findings of this study the following recommendations are suggested.
The following are suggested to improve utilization of lean strategies in the medication administration safety process and utility system management:
Hospital administrators should:
Ensure sufficient amount of required medication in the hospital units and pharmacy.
Ensure dispensing medication with medication order record to ensure double check.
Improve the organizational readiness for lean strategies implementation through: introduce lean approach in the healthcare settings strategic plan, policy, as well as vision, and enhance leadership behaviors, abilities and commitment to lean principals and encourage staff contributions to continuous improvement. This will ensure that the healthcare providers understand the importance of lean approach to the organization.
Transforming the administration in healthcare setting to lean management might be challenging. To mitigate these challenges, ensure leadership and management support and follow-up procedures are in place.
Provide effective education and awareness about the efficient performance of medication process.
Creating a training strategy and plan that involve educational and training programs in form of in-service training program, conferences, training sessions, plant tours and internal workshops to health care team members (physicians, administrators, ...etc) about process improvement as well as lean tools and techniques and to embed a culture of lean thinking and lean management, among hospital administrators and unit managers.
III. First line nurse managers should:
Create an ideal state VSM which should envision the absolute best the process could be; this should then be agreed by senior management as the ultimate goal of her\his value stream mapping exercise.
Providing measures to reduce interruption in units (through developing strict policy to doctors round and visiting hours, create visual sign with ”not interrupting zone” during medication administration).
Organization of space, equipment, supplies, and work areas through applying 5S.
Providing effective and continuous supervision from FLNM on staff nurses performance and documentation through daily Gemba walk and mapping each process by VSM.
Establish and implement management plans for safety, security, hazardous materials and waste, emergency management, fire safety, medical equipment, and utilities.
Introduce lean approach as a tool for quality improvement methods in quality department in the hospitals through applying Gemba walk, VSM, and 5S.
Undertaking the end to end process view to identify and eliminate waste through mapping all the steps of work process that make up the patient journey visible to everyone involved.
In order to improve the utility system management hospital managers, nursing administrators, and staff nurses work together to improve current health services process follow as well as reduce non value added activities through: utility systems management plan should include provisions for the inspection, testing, maintenance and repair.
Further studies:
3- The impact of lean strategies on improving patient care.
4- Improving the discharge procedure of patients by means of Lean Six Sigma.