Purpose – Lean healthcare is used in a growing number of hospitals to increase efficiency and quality of care. However, healthcare organizations encounter problems with the implementation of change initiatives due to an implementation gap: the gap between strategy and execution. From a change management perspective, the purpose of this paper is to increase scientific knowledge regarding factors that diminish the implementation gap and make the transition from the “toolbox lean” toward an actual transformation to lean healthcare. Design/methodology/approach – A cross-sectional study was executed in an operating theatre of a Dutch University Medical Centre. Transformational leadership was expected to ensure the required top-down commitment, whereas team leadership creates the required active, bottom-up behavior of employees. Furthermore, professional and functional silos and a hierarchical structure were expected to impede the workforce flexibility in adapting organizational elements and optimize the entire process flow. Findings – The correlation and regression analyses showed positive relations between the transformational leadership and team leadership styles and lean healthcare implementation. The results also indicated a strong relation between workforce flexibility and the implementation of lean healthcare. Originality/value – With the use of a recently developed change management model, the Change Competence Model, the authors suggest leadership and workforce flexibility to be part of an organization’s change capacity as crucial success factor for a sustainable transformation to lean healthcare.