A critical look at Lean Thinking in healthcare.

BACKGROUND: With healthcare, Lean Thinking encounters a world, not devoid of value, but awash with sophisticated and mutually unconnected concepts of value. DESIGN: Given a shortage of systematic analysis in the literature, this paper provides a preliminary analysis of areas where the read-across from other sectors to healthcare is relatively well understood, based on a broad review of its impact on care delivery. It further proposes areas where conceptual development is needed. In particular, healthcare, with its many measures of value, presents an unusual challenge to the central Lean driver of value to the customer. CONCLUSION: We conclude that there is scope for methodological development, perhaps by defining three themes associated with value-the operational, the clinical and the experiential.

Impacts of large herbivorous mammals on bird diversity and abundance in an African savanna.

Large native mammals are declining dramatically in abundance across Africa, with strong impacts on both plant and animal community dynamics. However, the net effects of this large-scale loss in megafauna are poorly understood because responses by several ecologically important groups have not been assessed. We used a large-scale, replicated exclusion experiment in Kenya to investigate the impacts of different guilds of native and domestic large herbivores on the diversity and abundance of birds over a 2-year period. The exclusion of large herbivorous native mammals, including zebras (Equus burchelli), giraffes (Giraffa camelopardalis), elephants (Loxodonta africana), and buffalos (Syncerus caffer), increased the diversity of birds by 30%. Most of this effect was attributable to the absence of elephants and giraffes; these megaherbivores reduced both the canopy area of subdominant woody vegetation and the biomass of ground-dwelling arthropods, and both of these factors were good predictors of the diversity of birds. The canopy area of subdominant trees was positively correlated with the diversity of granivorous birds. The biomass of ground-dwelling arthropods was positively correlated with the diversity of insectivorous birds. Our results suggest that most native large herbivores are compatible with an abundant and diverse bird fauna, as are cattle if they are at a relatively low stocking rate. Future research should focus on determining the spatial arrangements and densities of megaherbivores that will optimize both megaherbivore abundance and bird diversity.

Short-term dynamics of an acacia ant community in Laikipia, Kenya.

In monospecific stands of Acacia drepanolobium in Laikipia, Kenya, virtually all but the smallest trees are occupied by one of four species of ants. Although trees are a limiting resource, all four ant species are maintained in this system. Three separate lines of evidence confirm a linear dominance hierarchy among these four ants: (1) experimentally staged conflicts, (2) natural transitions among 1773 tagged trees over a 6-month period, and (3) the average sizes of trees occupied by ants of different species. Short-term dynamics during a drying period reveal that many smaller trees (<1 m) occupied by dominant ants were subsequently abandoned, and that abandoned trees had grown more slowly than those that were not abandoned. Height growth increments over 6 months were generally independent of ant occupant, but increased with tree height. Among taller trees (>1 m), changes in ant occupation congruent with the dominance hierarchy (i.e., transitions from more subordinate ant species to more dominant ant species) occurred on trees that grew faster than average. In contrast, the (less frequent) changes in ant occupation "against" the direction of the dominance hierarchy occurred on trees that grew more slowly than average. Observed correlations between tree vigor and takeover direction suggest that colony growth of dominant ant species is either favored in more productive microhabitats, or that such colonies differentially seek out healthier trees for conquest. Colonies of dominant species may differentially abandon more slowly growing trees during (dry) periods of retrenchment, or suffer higher mortality on these trees. Subordinate ant species appear to move onto these abandoned trees and, to a lesser extent, colonize new recruits in the sapling class. These data reveal that within a simple linear dominance hierarchy, short-term variations exist that may reveal underlying mechanisms associated with coexistence.

Comparing measures of travel distances in primates: methodological considerations and socioecological implications.

Travel costs can influence numerous aspects of the lives of primates, including net energy balance (and therefore reproductive success of females) and maximum group size. Despite their potential impact, there has been no systematic comparison of different measures of travel distance. We compared three measures of travel distance in 30 min (actual distance of individuals, straight-line distance of individuals, and straight-line distance of groups) and their ratios in a small group and a large group of vervet monkeys (Cercopithecus aethiops) and between the large group of vervets and a group of patas monkeys (Erythrocebus patas) of roughly similar size. The large group of vervets traveled farther than the small group regardless of the measure used, but the ratios of the different measures were not significantly different between those groups. Patas monkeys traveled significantly farther than the large group of vervets regardless of the measure used. In both vervets and patas, straight-line distances of individuals (ISLD) and groups (GSLD) underestimated actual distances traveled by individuals (IAD), but the degree to which they did so differed between species. IAD is more accurate than the other two measures and is preferred for studies of energetics and individual reproductive success, although ISLD or GSLD may be substituted when the ratios of IAD/ISLD or IAD/GSLD do not differ between groups or species. The ratio of IAD/ISLD was larger in vervets than in patas, suggesting that individual vervets meander more over short periods of time than patas. The ratio of ISLD/GSLD was larger in patas than in vervets, suggesting that patas move at angles or across the group's center-of-mass whereas vervets move more consistently along with others in their group. This has implications for the formation of spatial subgroups and alliances within groups.

Locomotor activity differences between sympatric patas monkeys (Erythrocebus patas) and vervet monkeys (Cercopithecus aethiops): implications for the evolution of long hindlimb length in Homo.

Homo erectus is notable for its taller stature and longer lower limbs relative to earlier hominids, but the selective pressures favoring such long limbs are unclear. Among anthropoid primates, patas monkeys (Erythrocebus patas) and extant hominids share several extreme characteristics involved with foraging and movement, including the relatively longest lower limb proportions, longest daily travel distances and largest home ranges for their body or group size, occupancy of some of the driest habitats, and very efficient thermoregulatory systems. We suggest that patas monkeys are an appropriate behavioral model with which to speculate on the selective pressures that might have operated on H. erectus to increase lower limb length. Here, in a comparison of the locomotor activities of patas monkeys and sympatric, closely related vervet monkeys (Cercopithecus aethiops), we provide evidence for the hypothesis that patas use their long stride more to increase foraging efficiency while walking than to run, either from predators or otherwise.

Ants on swollen-thorn acacias: species coexistence in a simple system.

On the black cotton soils of the Laikipia ecosystem in Kenya, two swollen-thorn acacia species support nine ant species, four of which are apparently obligate plant-ants. Among the ants, there are five species of Crematogaster, two species of Camponotus, and one each of Tetraponera and Lepisota. Acacia drepanolobium is host to four ant species that are both common and mutually exclusive. These four ant species, and an additional non-exclusive ant species, tend to occur on trees of different sizes, implying a succession of ant occupants. Nonetheless, all four exclusive species occur in substantial proportions on trees of intermediate size. There is direct evidence that an early successional ant species (Tetraponera penzigi) is actively evicted by two late successional ant species in the genus Crematogaster. There was also some evidence of height differentiation among ant species resident on A. seyal. Different acacia-ant species had different direct effects on A. drepanolobium. Extrafloral nectaries were eaten and destroyed only on trees inhabited by Tetraponera. Axillary shoots were eaten only on trees inhabited by C. nigriceps (potentially another early successional ant). This was associated with more new terminal shoots and healthier leaves than other trees, but also the virtual elimination of flowering and fruiting. Different resident acacia-ant species also had characteristic relationships with other insects. Among the four mutually exclusive ant species, only Crematogaster sjostedti was associated with two species of Camponotus, at least one of which (C. rufoglaucus) appears to be a foraging non-resident. A. drepanolobium trees occupied by C. sjostedti were also far more heavily infested with leaf galls than were trees occupied by other ant species. A. drepanolobium trees occupied by C. mimosae and C. sjostedti uniquely had tended adult scale insects. This diversity of ant inhabitants, and their strikingly different relationships with their hosts and other insect species, are examples of coexisting diversity on an apparently uniform resource.

Ecology and evolution of long-lived semelparous plants.

One of the more dramatic life histories in the natural world is that characterized by a single, massive, fatal reproductive episode ('semelparity'). A wealth of increasingly sophisticated theoretical models on differential life history evolution have been produced over the last two decades. In recent years, empirical studies of the ecology of semelparous plants (and their iteroparous relatives) have begun to address many aspects of the biology of these species, and to test the assumptions and predictions of theoretical models. Semelparity in long-lived plants is one of the few natural phenomena that has yielded specific quantitative tests of mathematical evolutionary theory.

Increased thorn length in Acacia depranolobium -an induced response to browsing.

I report here longer thorns induced by large mammal herbivory on the tree Acacia depranolobium. I compared trees that had been browsed by domestic goats to trees protected from goat browsing. Thorns on browsed branches within the reach of goats (<125 cm above the ground) were significantly longer than thorns from higher branches on the same browsed trees, and significantly longer than branches at similar heights on unbrowsed trees. It appears that increased thorn length was an induced response to large mammal herbivory in Acacia depranolobium, both among and within individual trees.