Factors critical to the success of Six-Sigma quality program and their influence on performance indicators in some of Lebanese hospitals

Modeling critical success factors for sustainable LSS implementation in hospitals: an empirical study

Purpose

The objective of this paper is to investigate, assess and develop a hierarchical model to evaluate the interrelationship of critical success factors (CSFs) that influence the deployment of Sustainable LSS framework in hospitals. Further, developed model has been validated to investigate its applicability in hospitals towards sustainable LSS implementation.

Design/methodology/approach

“Interpretive Structural Modeling” (ISM) has been utilized to develop a convenient hierarchy and contextual relationship of key CSFs throughout the implementation pathway in Indian healthcare industry through systematic literature review and expert opinion, which is ensured by a taxonomy of CSFs using MICMAC (“Matrice d' Impacts Croisés-Multiplication Appliquée á un Classement”) and questionnaire-based survey to empirically validate the model through utilizing “Structural Equation Modelling” (SEM).

Findings

In this study, 17 keys CSFs to sustainable LSS implementation in healthcare industry have been investigated, and modeled. “Social and environmental responsibility,” “Financial return and project success stories,” “Top management involvement and leadership to implement Sustainable LSS,” “Availability of required resources, and their efficient utilization” are found to be the most essential CSFs for successful sustainable LSS implementation in healthcare industry. Further, classification of CSFs has been done for better interpretation of their nature using MICMAC approach. Moreover, the applicability of the proposed model has been empirically assessed utilizing SEM.

Research limitations/implications

The scrutiny of data reveals that the initial inputs from experts throughout the ISM pathway could trigger biased inputs into the study and generalization of the results into others, it might be viable that this propounded model might trigger distinct outcomes for contrasting types of healthcare organizations.

Practical implications

This model on sustainable LSS would support the decision-makers, practitioners and researchers to predict key CSFs through deployment and support the existing academic research on sustainable LSS. Accordingly, the focus on the CSFs of the sustainable LSS can be prioritized to diminish waste, and enhance patient satisfaction and safety.

Originality/value

This paper is an original contribution of analysis of CSFs in Indian healthcare industry utilizing an integrated ISM-MICMAC and SEM approach.

Prioritizing enablers for service quality in healthcare sector - a DEMATEL approach

PURPOSE

The Healthcare sector is one of the important sectors of the Service Industry. It is believed that in this sector, the customer server relationship is very critical, and even the slightest gap in the people quality may have a huge impact on the delivered service quality. Some of these enablers are doctors, nursing staff and support staff. Furthermore, the nonpeople quality enablers such as diagnostic services, facilities, hygiene levels and so on are also likely to impact the delivered service quality. It was also felt that the degree of impact each enabler has on the service quality could vary. Therefore there is a need for structured and deep analysis. The paper attempts to identify, analyze and prioritize the enablers that impact the delivered service quality.

DESIGN/METHODOLOGY/APPROACH

The enablers have been identified through literature review and inputs from experts in the healthcare fraternity. The authors have explored different decision-making tools such as analytic hierarchy process (AHP), analytic network process (ANP), stepwise weight assessment ratio analysis, Hybrid Model and DEMATEL (Decision-Making Trial and Evaluation Laboratory) for the analysis of data in this paper. Based on the strengths of the approach and careful considerations by focus group discussions, DEMATEL was chosen as the best option. It is simple, unique, sparingly used in the healthcare sector, effective in prioritizing and gives meaningful insights on importance, cause and effect factors. DEMATEL approach converts the complex problem with interrelated factors into a clear structure that makes simple interrelationships among factors in the form of cause and effects digraph, and hence, the authors chose to use it. A case study in one of the hospitals has also been conducted to demonstrate the applicability of the developed index. The case study very strongly validates the developed index.

FINDINGS

This research paper has found that there are people quality enablers such as the doctor, nursing staff, support staff and nonpeople quality enablers such as facilities, diagnostic services and hygiene levels maintenance, which impact the delivered service quality. It also concludes that the delivered service quality depends not only on the quality but also on the availability of these enablers. The inputs received from the experts have been run through the DEMATEL methodology and importance computed for each. The top five priority enablers are Quality of Doctor, Availability of Doctor, Quality of Support Staff, Quality of Nursing Staff and Availability of Support Staff.

RESEARCH LIMITATIONS/IMPLICATIONS

The weights of the enablers have been obtained using the DEMATEL tool. These weights have been calculated using the inputs from 22 experts, which meets the statistical requirement (Skulmoski, 2007). However, a larger group of experts can be reached, and based on the inputs received from them, the tool can be revalidated for repeatability and reproducibility. Using Fuzzy DEMATEL can also be explored for further analysis.

PRACTICAL IMPLICATIONS

The proposed framework to assess the service quality level of a healthcare organization is based on a sound approach of DEMATEL. The service index arrived, thereafter, can be used to rate the delivered service quality by any healthcare organization. It can be used to compare the similar type of healthcare organizations across locations. This Index can facilitate improvements in the healthcare organization through internal and external benchmarking. It also helps the organization to know the gaps, understand the root cause, improve upon them and become the best in class. This Index uses the inputs from the end customers to calculate the rating, which makes it more reliable and accurate. The overall scores obtained from the Index can provide the ranking to the healthcare providing organizations and options to customers to choose from best. The service quality index can be used by an organization to continuously monitor their delivered service quality scores and improve them to become the best in class. The research paper highlights the significant role played by the people quality and its strong impact/contribution on the delivered service quality. Hence, it is believed that it will encourage the healthcare organizations to prioritize the improvement and upgrade of the people quality over the nonpeople quality aspect.

ORIGINALITY/VALUE

Putting people and nonpeople quality enablers in one single model and assigning weights to them using the DEMATEL approach is a new application in healthcare. Developing an Index to measure the delivered service quality in the healthcare sector is also different and new.

What makes an effective Quality Improvement Manager? A qualitative study in the New Zealand Health System

PURPOSE

Quality improvement is an international priority, and health organisations invest heavily in this endeavour. Little, however, is known of the role and perspectives of Quality Improvement Managers who are responsible for quality improvement implementation. We explored the quality improvement managers' accounts of what competencies and qualities they require to achieve day-to-day and long-term quality improvement objectives.

DESIGN

Qualitative exploratory design using an interpretivist approach with semi-structured interviews analysed thematically.

SETTING AND PARTICIPANTS

Interviews were conducted with 56 quality improvement managers from 15 (out of 20) New Zealand District Health Boards. Participants were divided into two groups: traditional and clinical quality improvement managers. The former group consisted of those with formal quality improvement education-typically operations managers or process engineers. The latter group was represented by clinical staff-physicians and nurses-who received on-the-job training.

RESULTS

Three themes were identified: quality improvement expertise, leadership competencies and interpersonal competencies. Effective quality improvement managers require quality improvement experience and expertise in healthcare environments. They require leadership competencies including sense-giving, taking a long-term view and systems thinking. They also require interpersonal competencies including approachability, trustworthiness and supportiveness. Traditional and clinical quality improvement managers attributed different value to these characteristics with traditional quality improvement managers emphasising leadership competencies and interpersonal skills more than clinical quality improvement managers.

CONCLUSIONS

We differentiate between traditional and clinical quality improvement managers, and suggest how both groups can be better prepared to be effective in their roles. Both groups require a comprehensive socialisation and training process designed to meet specific learning needs.

Using Lean Six Sigma in small and medium-sized enterprises for low-cost/high-effect improvement initiatives: a case study

Purpose

The purpose of this paper is the implementation of Lean Six Sigma (LSS) in a manufacturing small and medium-sized enterprise (SME) in Greece in order to understand the contribution of LSS in its process improvement and to identify the parameters playing a crucial role in LSS adoption by SMEs. The ability to achieve high-effect improvements without cost investment is also examined to cope with low investment margin that is a characteristic of SMEs.

Design/methodology/approach

This case study is based on the combination of Define, Measure, Analyze, Improve and Control (DMAIC) phases with the Yin's method for case studies for a complete and efficient implementation and presentation of the project.

Findings

The analysis of this case study revealed that by accomplishing specific critical success factors for the fulfillment of the LSS project, the company attained important benefits by utilizing only the working hours of employees. It was also found that the improvements of LSS projects can be measured using other metrics which can indirectly be translated into monetary terms.

Practical implications

The paper can be a useful guide of how SMEs can achieve high-impact improvements with low or no investment cost utilizing LSS initiatives in small-scale projects.

Originality/value

According to the literature, there is a need for more case studies concerning LSS implementation in SMEs. Examples of how low-cost/high-effect improvement initiatives can be implemented have not been adequately presented before. The assessment of the impact of improvement initiatives with non-monetary measures is also innovative.

Why is Quality Improvement so Challenging? A Viable Systems Model Perspective to Understand the Frustrations of Healthcare Quality Improvement Managers

The challenges facing Quality Improvement Managers (QIMs) are often understood and addressed in isolation from wider healthcare organisation within which quality improvement initiatives are embedded. We draw on Stafford Beer's Viable System Model (VSM) to shed light on how the viability of quality improvement depends on the effective functioning of five critical quality improvement systems and the extent to which these systems are integrated within the healthcare organisation. These systems are System 1 (Operations), System 2 (Coordination), System 3 (Operational Control), System 4 (Development) and System 5 (Policy). Our analysis draws on interviews with 56 QIMs working in 15 of New Zealand's 20 District Health Boards. We use VSM to identify the sources of problems in QI implementation. These include changes in direction for QI initiatives; myopic behaviour resulting from fragmented systems of care; difficulties in managing and monitoring QI activities given variable staff engagement and inadequate resourcing; pressure for quick results rather developing QI capabilities; and a lack of strategic embeddedness. A viable QI system requires QI approaches that are (1) implemented at an organisation-wide level; (2) well-resourced and carefully monitored; (3) underpinned by a long-term vision; and (4) supported by QIMs with the necessary power and influence to integrate QI subsystem within the wider healthcare organisation.

Implementing a Lean Six Sigma standardized toolset in a manufacturing company: a case study

Purpose

The first purpose of this paper is the implementation of Lean Six Sigma (LSS) in a manufacturing company operating in South East Europe in order to understand the importance of critical success factors (CSFs) in LSS adoption and to find out the benefits that the company gained. The second purpose is to propose a standardized toolset based on DMAIC phases, for the application of LSS in small scale projects, in order to facilitate LSS adoption by more manufacturing companies.

Design/methodology/approach

This case study is based on the interlacement of the Yin's method about case studies and the DMAIC method for the improved deployment of LSS.

Findings

The analysis of this case study shows that the company attained to benefit financially, operationally and organizationally from the implementation of LSS. The already existing mentality of CI inside the company helped the project procedure and the application of changes and improvements fulfilling LSS adoption CSFs.

Practical implications

The paper constructs a toolset and studies the role of CSFs in order to achieve the desirable benefits in a manufacturing environment, constituting a guide for future LSS initiatives.

Originality/value

As stated by literature reviews, even though there are several papers concerning LSS implementation in the manufacturing sector, there is a need for more case studies papers, such as this one, in order to enrich the literature. In this paper, it is also the first time that a specific toolset for small scale projects is proposed based on to DMAIC which can be implemented in further LSS projects.

Effect of Lean Six Sigma on quality performance in Malaysian hospitals

PURPOSE

The purpose of this paper is to investigate the effects of Lean Six Sigma (LSS) and workforce management on the quality performance of Malaysian hospitals. This paper also investigates the direct and indirect relationships between top management commitment and quality performance of the healthcare organisations in Malaysia.

DESIGN/METHODOLOGY/APPROACH

This study applied stratified random sampling to collect data from 15 different hospitals in Peninsular Malaysia. The self-administered survey questionnaires were distributed among 673 hospital staff (i.e. doctors, nurses, pharmacists, and medical laboratory technologists) to obtain 335 useful responses with a 49.47 per cent valid response rate. The research data were analysed based on confirmatory factor analysis and structural equation modelling by using AMOS version 23 software.

FINDINGS

The research findings indicated that LSS and workforce management have a significant impact on quality performance of the Malaysian hospitals, whereas senior management commitment was found to have an insignificant relationship with quality performance. The research findings indicate that senior management commitment has no direct significant relationship with quality performance, but it has an indirect significant relationship with quality performance through the mediating effects of LSS and workforce management.

RESEARCH LIMITATIONS/IMPLICATIONS

This research focussed solely on healthcare organisations in Malaysia and thus the results might not be applicable for other countries as well as other service organisations.

ORIGINALITY/VALUE

This research provides theoretical, methodological, and practical contributions for the LSS approach and the research findings are expected to provide guidelines to enhance the level of quality performance in healthcare organisations in Malaysia as well as other countries.

V, R. R. Critical success factors of TQM, Six Sigma, Lean and Lean Six Sigma

Purpose

The purpose of this paper is to review the existing literature on the critical success factors (CSFs) of various continuous improvement (CI) like total quality management (TQM), Lean, Six Sigma and Lean Six Sigma (LSS), and perform a content analysis (CA) leading to an agenda for future research.

Design/methodology/approach

CA is based on literature review of 41 papers published in peer-reviewed scholarly journals. A four-stage methodology is used by the authors, with Stage 1 featuring relevant material collection; Stage 2 presenting a descriptive analysis; Stage 3 outlining the category selection; and Stage 4 featuring the material evaluation using clustering and Pareto analysis.

Findings

The CA revealed various research implications and directions for the future. The number of studies in the literature regarding CSF assessment is found to be far from substantial while compared to CI implementation. Assessment methodologies developed have been ranging from qualitative to quantitative models. Key gaps were identified and directions for CSF assessment are proposed which requires further validation.

Research limitations/implications

Only articles that appeared in peer-reviewed journals were analyzed; conference papers, reports, manuals and white papers from practice were excluded. Another limitation of the paper would be the scope of CA limited to four CI constructs – TQM, Lean, Six Sigma and LSS. Research implications indicate that the future studies in this domain would be intensive toward analyzing the vital CSFs for enterprise organizational excellence and not merely process excellence.

Practical implications

This review study can serve as a resource for both researchers and practitioners to understand the importance of CSFs and positioning CSFs for the successful implementation of CI programs.

Originality/value

The CA on the existing literature on CSFs for CI presents a unique, systematic effort to identify an agenda for future research. This study is the apparently the first of its kind on CSF assessment.

Measuring Lean Six Sigma and quality performance for healthcare organizations

Purpose

This study aims to investigate applications of Lean Six Sigma approaches and quality performance in Malaysian hospitals. It identifies five dimensions of Lean Six Sigma conformance (i.e. continuous quality improvement, Lean management initiatives, Six Sigma initiatives, patient safety and teamwork) and quality performance of the hospitals based on demographics such as gender, types of hospital and working experience.

Design/methodology/approach

This study distributed 1,007 self-administered survey questionnaires to hospital staff resulting in 438 useful responses with 43.5 per cent response rate. Research data were analysed based on reliability analysis, exploratory factor analysis (EFA), independent samples t-tests and one-way ANOVA using SPSS version 23.

Findings

Research findings indicate that there are significant differences between public and private hospital staff on Lean management initiatives, Six Sigma initiatives, patient safety and teamwork. Private hospital staff perceives Lean management initiatives, Six Sigma initiatives, patient safety and teamwork more favourably compared to public hospital staff. The present study findings also indicate that senior hospital staff (more than 10 years working experience) perceives patient safety and teamwork more favourably compared to other working experience groups.

Research limitation/implications

The research focused solely on the Malaysian health sector, and thus, the results might not be applicable to other countries.

Originality/value

This research provides theoretical, methodological and practical contributions for the Lean Six Sigma approach and the research findings are expected to provide guidelines to enhance the level of quality performance in healthcare organisations in Malaysia as well as other countries.

Personality characteristics and Six Sigma: a review

Purpose

From two bodies of literature, the purpose of this paper is to generate theory for an updated conceptual model of drivers of Six Sigma project success by integrating extant psychology theory and empirical general team project results with a history of eight recent Six Sigma projects and extant Six Sigma literature. The new theory emphasizes the need for project leads to process information simultaneously, as well as develop prioritization abilities. Also, the new theory reverses the relations of three existing theories from general team composition theory. The new theory suggests that Six Sigma belt trainers should focus more on soft skill development.

Design/methodology/approach

A literature review of the two bodies of literature previously mentioned.

Findings

Eight new propositions related to the success of Six Sigma projects are developed. Further, two new constructs, “project leader simultaneity of thought” and “prioritization ability” are suggested for further investigation.

Originality/value

The authors suggest a few practical implications: first a greater emphasis on soft skill training would be beneficial in Six Sigma belt training. A second new point of emphasis in belt training is developing greater internal locus of control in belt candidates. Third, the authors suggest that during the team member selection process a diversity of backgrounds would be beneficial to Six Sigma project success.

Simulation-based Six Sigma value function for system-level performance assessment and improvement

Purpose

The purpose of this paper is to develop a simulation-based value function (VF) that combines multiple key performance indicators (KPIs) into a unified Sigma rating (SR) for system-level performance assessment and improvement.

Design/methodology/approach

Simulation is used as a platform for assessing the multiple KPIs at the system level. A simple additive VF is formed to combine the KPIs into a unified SR using the analytical hierarchy process and the entropy method. Value mapping is utilized to resolve the conflict among KPIs and generate a unified value. These methods are integrated into the standard Six Sigma define-measure-analyze-improve-control (DMAIC) process.

Findings

Simulation results provided the Six Sigma DMAIC process with system-level performance measurement and analysis based on multiple KPIs. The developed VF successfully generated unified SRs that were used to assess various performance improvement plans.

Research limitations/implications

The accuracy and credibility of the results obtained from using the proposed VF are highly dependent on the availability of pertinent data and the accuracy of the developed simulation model.

Practical implications

The proposed approach provides Six Sigma practitioners and performance mangers with a mechanism to assess and improve the performance of production and service system based on multiple KPIs when conducting Six Sigma studies.

Originality/value

This paper contributes to the previous research by handling multiple KPIs in Six Sigma studies conducted at the system level using simulation and VF. The research also provides guidelines for using the different methods of weights assessment to form the VF within the DMAIC process.