Communication and problem solving will be simple and fast at this level, where mid-level managers have to supervise their dedicated areas, compared with institutional implementation where the CEOs or Chief Medical Officers have to address a myriad of problems overarching the institution. Finally, the customers (patients) of a specific division may have unique characteristics that may not be shared by other patients seen in the institution. As previously mentioned, resistance to changes is driven in most companies by

lack of executive support.8 However, following a bottom-to-top approach Inhibitors,research,lifescience,medical will redefine the responsibility of the institution’s senior management to three main strategic areas; rather than committing a large amount of time and energy to the lean Inhibitors,research,lifescience,medical process, senior managers should: Identify the “vital few” areas that will benefit most from implementing lean. Therefore, the Pareto principle will be applied identifying the 20% areas that will provide 80% of institutional benefits allowing the organization to maximize the return on investment (ROI). Be committed to allocate the supporting resources necessary for the required changes, and, in turn, the area managers will be solely in charge of the process and periodically Inhibitors,research,lifescience,medical communicating progress. Be in charge to ensure effectively communicating the results of the changes to

the find protocol stakeholders in the organization, especially those who are not participating in, or affected by, the lean process. This approach will be also instrumental in institutional cultural change, allowing managers in areas that did not implement lean to observe the benefits incurred at all levels. Rather than concentrating only on operational aspects of lean

thinking, managers Inhibitors,research,lifescience,medical at the departmental/unit level will be able to reconcile operations with socio-technical aspects that respect the “human system,” i.e. take into consideration the effects of the changes on the employees with whom they have daily interactions. Therefore, in order to create “cumulative capabilities” and value, managers at all levels need to Inhibitors,research,lifescience,medical realize that their job is not only improving the processes, but developing the departmental job-force that ultimately is in charge of the implementation.3 EXAMPLE OF LEAN IMPLEMENTATION AT AN ACADEMIC HEALTHCARE INSTITUTION Case Western Reserve University School of Dental Medicine (SODM) is located in Cleveland, Ohio and enrolls yearly around 70 students who participate Dimethyl sulfoxide in a 4-year rigorous academic program towards the dental doctoral DMD degree. Clinical training includes third-and fourth-year students providing dental care; the DMD clinic has 143 operatories in which students treat yearly over 8,000 patients throughout over 30,000 encounters. In addition the school has 75 simulation operatories in which first-and second-year students learn clinical procedures on mannequins.