The United States spent over $2.75 trillion on health care in 2013, as compared to costs of $714 billion in 1990, and $253 billion in 1980. Despite having the most expensive healthcare system in the world, the United States ranks last or near last among 11 developed countries on dimensions of quality, efficiency, and access to care, according to a Commonwealth Fund Report (Davis et al., 2014). It is imperative that the healthcare industry pursues strategies to control costs, improve quality, and enhance efficiency. In more than a decade, lean thinking has been implemented by an increasing number of hospitals in the United States. Lean thinking implementation initiatives tend to be driven by the need to reduce costs, and to improve quality and efficiency (Brandao de Souza, 2009; Radnor et al., 2012). Anecdotal evidence shows that lean thinking has been successful in some U.S. hospitals (e.g. Virginia Mason, ThedaCare, Johns Hopkins, and Mayo Clinic). However, it is noted that lean is still in an early stage of development and has not been effectively implemented by a large number of healthcare organizations (Brandao de Souza; Min 2014). This doctoral dissertation is motivated by challenges facing the healthcare industry and the low degree of lean implementation in healthcare industry. The dissertation consists of three independent manuscripts on lean implementation in U.S. hospitals. Manuscript one empirically investigates the characteristics of hospitals that are implementing lean thinking and the performance consequences of lean implementation. Using a panel data set of lean hospitals across the United States and performing two-stage analysis, I find that lean thinking implementation is significantly associated with competition, resource availability and outsourcing. Moreover, there is strong evidence that the association between lean implementation and nonfinancial performance is a function of the "match" between lean implementation and hospital's characteristics. With respect to financial performance, I find weak support for hypothesis that the relationship between lean implementation and current financial performance is contingent on hospital characteristics. Manuscript two addresses a research gap in the accounting literature by empirically investigating the relationship between board composition and healthcare outcomes in lean hospitals. Using a cross-sectional sample from U.S. short-term, general, acute care hospitals, I find that compared to hospitals with lean implementation in some departments, hospitals with lean implementation across hospitals are likely to have higher patient satisfaction, and higher quality of care in terms of Pneumonia and Stroke. In regard to board independence, I find a positive but not statistically significant relationship between degree of board independence and patient satisfaction / quality of care. Moreover, in regard to physician involvement on the board, I find that lean hospitals with physician on the board are likely to have higher patient satisfaction, and higher quality of care in terms of Heart Failure and Pneumonia. Manuscript three applies a unique two-stage probit least squares (2PSLS) approach (Maddala, 1983) to examine the relationship between lean implementation and managerial ability. Using a panel data set from U.S. short-term, general, acute care hospitals from 2000 to 2015, I find a simultaneous relationship between lean implementation and managerial ability. I further quantify the simultaneity bias by comparing the 2PSLS regression results to those results under a unidirectional approach. I find that the estimation under a unidirectional approach substantially underestimates the effect of lean implementation on managerial ability, as well as the reverse direction effect.