Table 3.

Barriers/ challenges, facilitators/ success factors and effective factors in implementing lean management in emergency units

Au-Cu-Ye	Challenge/barriers	Facilitators/ enablers	Effected factors
Mazzocato et al., [1]	mismatch between job tasks licensing constraints, and competence; perception of being monitored discomfort with inter-professional collaboration standardized work and reduced ambiguity connected people who were dependent on one another enhanced seamless, uninterrupted flow through the process	Empowered staff to investigate problems and to develop countermeasures using a “scientific method”.	-
Timmons et al., [23]	Resistance to lean Profession and professionalism in emergency medicine Unsustainability	-	-
Sanders JH & Karr T. [4]	variation within the processes inconsistencies among the processes and procedures signification wastes that were costing the hospital time and money lack of operational data in the hospital environment	-	-
El Sayed et al., [15]	-	active multidisciplinary process improvement committee engagement from all stakeholders direct timely feedback top management support	-
Carter et al., [24]	-	-	the Lean process aided in building a partnership with Ghanaian colleagues obtaining and maintaining senior institutional support is necessary and challenging addressing power differences among the team to obtain feedback from all team members is critical to successful Lean analysis choosing a manageable initial project is critical to influence long-term Lean use in a new environment data intensive Lean tools can be adapted and are effective in a less resourced health system several Lean tools focused on team problem solving techniques worked well in a low resource system without modification using Lean highlighted that important changes do not require an influx of resources despite different levels of resources, root causes of system inefficiencies are often similar across health care systems, but require unique solutions appropriate to the clinical setting
Rees et al., [25]	work intensification workplace resistance introducing quality methods from other domains into healthcare supportive quality-focused organizational culture executive management involvement cross-functional teams context reinforces that organizational preparedness
Dickson et al., [22]	-	management took a subordinate role placing flow ahead of efficiency adapt Lean to local conditions without following the rules or specific steps used by other EDs or hospitals	-