Bridging organizational boundaries in complex care pathways: lessons from a Lean and Safety Management approach

Background: Complex care processes that span hospital and community settings represent a growing organizational challenge for healthcare systems, particularly in the management of chronic conditions. These pathways involve interdependent activities distributed across multiple facilities, professional groups, and levels of care, increasing the risk of fragmentation, inefficiency, and patient harm. While Lean Healthcare (LH) has been widely adopted to improve healthcare performance, its application has largely remained confined to single hospital units, with limited attention to care integration and patient safety. Evidence on how to design and implement improvement initiatives across hospital-community interfaces remains scarce. Methods: This study developed, tested, and refined an integrated Lean and Safety Management (L&SM) methodology by combining LH with Clinical Risk Management to proactively address both waste and risk throughout the care process. The methodology was designed and empirically validated through three iterative Action Research cycles conducted in a real-world healthcare setting involving complex chronic care pathways bridging hospital and community services. Data were collected through direct observation, document analysis, and stakeholder engagement, and analyzed iteratively across cycles to identify key activities, tools, barriers, and enablers of implementation. Results: The proposed L&SM methodology demonstrated its applicability and effectiveness in improving the performance of complex care processes across organizational boundaries. The findings reveal key activities, tools, barriers, and enablers for implementing L&SM across hospital-community interfaces, while also uncovering cultural and organizational dynamics that shape improvement efforts. Beyond health care, these results shed light on how organizations operating in complex, high-stakes environments can jointly pursue efficiency and patient safety while fostering a culture of continuous improvement. Conclusions: This study addresses a significant gap in the health services research literature by extending L&SM knowledge beyond hospital boundaries, addressing gaps in current literature. The research provides a structured, step-by-step methodology for implementing L&SM in complex care processes, tackling the managerial and organizational complexities of hospital-community integration, pursuing multi-dimensional performance improvement and aligning with global health priorities, thus offering an actionable guidance for healthcare managers and practitioners.