Productivity and performance improvement in the medical records department of a hospital

Lean Six Sigma Approach to Improve the Management of Patients Undergoing Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both emergency and elective surgery. The incidence of the disease related to an increasingly elderly population coupled with the efficacy and safety of LC treatment resulted in an increase in the frequency of interventions without an increase in surgical mortality. For these reasons, managers implement strategies by which to standardize the process of patients undergoing LC. Specifically, the goal is to ensure, in accordance with the guidelines of the Italian Ministry of Health, a reduction in post-operative length of stay (LOS). In this study, a Lean Six Sigma (LSS) methodological approach was implemented to identify and subsequently investigate, through statistical analysis, the effect that corrective actions have had on the post-operative hospitalization for LC interventions performed in a University Hospital. The analysis of the process, which involved a sample of 478 patients, with an approach guided by the Define, Measure, Analyze, Improve, and Control (DMAIC) cycle, made it possible to reduce the post-operative LOS from an average of 6.67 to 4.44 days. The most significant reduction was obtained for the 60-69 age group, for whom the probability of using LC is higher than for younger people. The LSS offers a methodological rigor that has allowed us, as already known, to make significant improvements to the process, standardizing the result by limiting the variability and obtaining a total reduction of post-operative LOS of 67%.

Doctor 1847: Software multiplataforma y multidispositivo para facilitar el autodiagnóstico, triaje y seguimiento de pacientes sospechosos y confirmados por SARS-CoV-2

Los servicios de emergencia a nivel mundial se han visto sobrepasados en sus capacidades debido a la pandemia de SARS-CoV-2, situación generalizada en países con sistemas sanitarios robustos y agravados en países rezagados. Como una solución, la aplicación Doctor 1847 se desarrolló entre los meses de abril y mayo de 2020 en Tegucigalpa, Honduras; para hacer auto diagnóstico, triaje, seguimiento de pacientes sospechosos y confirmados por infección de SARS-CoV-2, reduciendo las demoras sanitarias. Con este software se minimizó la congestión de pacientes que acuden a una emergencia hospitalaria por considerar tener esta enfermedad, al hacer uso de manera temprana de esta herramienta se obtiene la identificación de signos y síntomas de peligro que pueden conllevar a estados críticos que requieren acceso a servicios de urgencia y especializados. También se disminuyó el riesgo a pacientes sanos, personal sanitario y de servicio, de exponerse a un verdadero riesgo. De forma complementaria, se entregó una interfaz web con datos útiles para los tomadores de decisiones en cuanto al control de esta pandemia, conociendo el comportamiento sintomático de esta enfermedad en el país. Todo lo anterior ha sido posible debido al paradigma de la computación en la nube, aprovechando su capacidad elástica y ubicua; en conjunto con las capacidades de las redes convergentes de nueva generación y dispositivos móviles inteligentes. Palabras clave: SARS-CoV-2; Telemedicina; Triaje; Salud Pública; Epidemiología; Computación en la Nube

Six Sigma in blood transfusion services: A dream too big in a third world country?

BACKGROUND AND OBJECTIVES

Transfusion errors can occur anywhere from blood donation to final blood transfusion. They are a source of increased cost and patient mortality. Automated workflows can reduce transcription errors, but resource-poor centres still use semi-automated/manual method for testing including manual labelling of column agglutination cards/testing tubes. Missing out any details on these cards can lead to errors in reporting results, wastage and loss of resources and effort. The aim of this study was to implement Six Sigma DMAIC (Define, Measure, Analyse, Improve and Control) methodology to reduce transcription errors while labelling gel card in immunohaematology lab to zero defect.

MATERIALS AND METHODS

In this prospective study, transcription errors while manually performing 200 tests with 1400 opportunities were analysed. Baseline variables like number of errors, defects per million opportunities and sigma level in our current setup were measured. With the application of DMAIC methodology, root cause analysis for each error using Ishikawa diagram and structured Interviews were done to identify causes. A multipronged approach to deal with errors was done to improve critical areas using brainstorming sessions and developing training sheets for practice. After implementing the changes, baseline variables were reanalysed.

RESULTS

Application of DMAIC resulted in an overall reduction in defects from 34.86% to 0.56% with sigma level improvement from 1.89 to 4.08.

CONCLUSION

Six Sigma methodology can be used in a resource-poor setting even with lack of automation to ensure error-free process flow.

Effects of Lean Interventions Supported by Digital Technologies on Healthcare Services: A Systematic Review

Despite the increasing utilization of lean practices and digital technologies (DTs) related to Industry 4.0, the impact of such dual interventions on healthcare services remains unclear. This study aims to assess the effects of those interventions and provide a comprehensive understanding of their dynamics in healthcare settings. The methodology comprised a systematic review following the PRISMA guidelines, searching for lean interventions supported by DTs. Previous studies reporting outcomes related to patient health, patient flow, quality of care, and efficiency were included. Results show that most of the improvement interventions relied on lean methodology followed by lean combined with Six Sigma. The main supporting technologies were simulation and automation, while emergency departments and laboratories were the main settings. Most interventions focus on patient flow outcomes, reporting positive effects on outcomes related to access to service and utilization of services, including reductions in turnaround time, length of stay, waiting time, and turnover time. Notably, we found scarce outcomes regarding patient health, staff wellbeing, resource use, and savings. This paper, the first to investigate the dual intervention of DTs with lean or lean–Six Sigma in healthcare, summarizes the technical and organizational challenges associated with similar interventions, encourages further research, and promotes practical applications.

Lean Six Sigma case studies literature overview: critical success factors and difficulties

Purpose

Recently, several areas are successfully applying the Lean Six Sigma methodology, specifically in healthcare, public services, higher education institutions and manufacturing industries. This study aims to present an extensive literature review involving Lean Six Sigma practical applications in the last five years, described in a case studies format.

Design/methodology/approach

A systematic literature review was conducted, and 39 articles were selected and analyzed.

Findings

An increase in Lean Six Sigma applications in healthcare and higher education institutions was identified. Furthermore, Lean Six Sigma is effectively applied in several areas and is continuously used in traditional industries. The main critical success factor identified was leadership and management involvement, project management and organizational infrastructure, as well as training and education. Also, the main difficulties found are related to the organization's culture and developing communication with leaders and managers.

Research limitations/implications

The main difficulties found in this research are related to the lack of data presented in some articles analyzed, where only information about how the Lean Six Sigma application was conducted is shown, not mentioning difficulties or success factors identified.

Originality/value

Case studies are fundamental to help popularize Lean Six Sigma applications, showing a real-life scenario of how the methodology is implemented, the main difficulties encountered and critical success factors found. Thus, the value of this study is promoting and developing research involving Lean Six Sigma case study applications to guide new researchers and practitioners on the subject.

An Overview of Hospital Capacity Planning and Optimisation

Health care is uncertain, dynamic, and fast growing. With digital technologies set to revolutionise the industry, hospital capacity optimisation and planning have never been more relevant. The purposes of this article are threefold. The first is to identify the current state of the art, to summarise/analyse the key achievements, and to identify gaps in the body of research. The second is to synthesise and evaluate that literature to create a holistic framework for understanding hospital capacity planning and optimisation, in terms of physical elements, process, and governance. Third, avenues for future research are sought to inform researchers and practitioners where they should best concentrate their efforts. In conclusion, we find that prior research has typically focussed on individual parts, but the hospital is one body that is made up of many interdependent parts. It is also evident that past attempts considering entire hospitals fail to incorporate all the detail that is necessary to provide solutions that can be implemented in the real world, across strategic, tactical and operational planning horizons. A holistic approach is needed that includes ancillary services, equipment medicines, utilities, instrument trays, supply chain and inventory considerations.

Lean six sigma in the healthcare sector: A systematic literature review

Healthcare is a very important sector as our lives depend on it. During the novel corona virus pandemic, it was evident that our healthcare organizations still lack in terms of efficiency and productivity. Especially in the developing nations, the problems were much bigger. Lean Six Sigma (LSS) is a methodology which when implemented in an organization, helps to increase the process capability and the efficiency, by reducing the defects and wastes. The present study systematically reviews the research studies conducted on LSS in the healthcare sector. It was found that comparatively less studies are focused on improving the medical processes, most of the studies targeted the management processes. Moreover, lesser number of studies were being conducted for developing nations, but now it seems that the focus of research scholars has shifted towards the developing nations also. But it was observed that the studies in these nations were majorly empirical in nature, very few studies were conceptual or exploratory. There is a need for guiding healthcare professionals on creating a continuous improvement environment, which sustains the improvements achieved after LSS implementation.

How Do Different Health Record Systems Affect Home Health Care? A Cross-Sectional Study of Electronic- versus Manual Documentation System

Objective

To investigate electronic health record (EHR) systems compared to manual systems (MS) in home health care and how documentation and reporting activities are impacted regarding time use, variation, and accuracy.

Methods

This is a cross-sectional study of two municipalities (M1 and M2) that use statistical process control charts and interview with caregivers to discuss the issue. Regarding reporting, 309 observations were used for the control charts in M1 and 572 for those in M2. Concerning documentation, 831 observations were used for M1 and 572 for M2. In addition, interviews were conducted with four caregivers from each municipality.

Results

The municipality with EHR system use 3% of their total time for documentation and 7% for reporting. The municipality with the MS uses 7% of their total time in documentation and 12% for reporting. There is less variation in the charts for the municipality with the EHR system, than for the municipality using an MS.

Conclusion

The municipality using the EHR system uses less time for documentation and reporting than the other municipality. This is probably due to the standardization of information in M1, and that M2 needs to record documentation twice. The standardization arising from EHR use system may cause less variation in the process than the MS, but less variation might also negatively affect information accuracy. Reduced time for oral reporting also affects information accuracy.

Performance and service quality enhancement in a healthcare setting through lean six sigma strategy

Purpose

The article intended to excavate the Lean Six Sigma (LSS) deployment challenges, Critical Success Factors (CSF), tools and techniques, and managerial implications in an Indian healthcare setting.

Design/methodology/approach

The article illustrates a case study established using Action Research (AR) approach. Further, the case study is based on the Define, Measure, Analyze, Improve, Control (DMAIC) phases of LSS. The performance and service quality of the Endodontics department of a dental college attached to a hospital is enhanced and sustained through the LSS strategy.

Findings

The processing time of Root Canal treatment is reduced by determining the root causes for delay and implementing sustainable solutions. The structured deployment of the LSS strategy helped the Endodontics department to reduce the processing time from an average of 116 min–84 min. Thus, the process's sigma level is enhanced from 0.06 to 4.17 and assisted in sustaining the results.

Research limitations/implications

The case study's findings are based on the single AR carried out at an Endodontics department of a dental college hospital based on LSS strategies. Even though this study's results cannot be generalized, the deliverables of the case study can be used to develop the LSS roadmap for the dental colleges to enhance the service quality and safety of the patients.

Originality/value

The article provides step-by-step details for implementing LSS in dental college hospitals with critical analysis based on robust statistical tools and techniques. The case study provides evidence of the adoption of LSS in medical college education and provides the confidence to adopt the same through novice users. The study's findings may persuade the policymakers to add LSS in the medical education curriculum to reinforce safety and reduce errors in the healthcare system.

A qualitative study of the adoption of Value Stream Mapping in breast cancer centers

PURPOSE

In order to design a patient-centered discharge process, the entire process is visualized in Value Stream Mapping. The duration of the process steps and waiting times are measured and presented. As a team, health professionals discuss problems and agree on suitable solutions.

METHODS

After applying Value Stream Mapping, we conducted eight interviews in 2018, four with physicians and four with breast care nurses. We used the Consolidated Framework for Implementation Research to develop the interview guide and to identify categories for content analysis. To identify the differences in attitude and experience between the occupational groups, we conducted a framework analysis.

RESULTS

Each team of health professionals developed action steps to optimize the discharge process. Obstacles became apparent in the implementation of these action steps. The lack of adequate staff and complex structures were identified as the main factors. These hierarchical structures also prevented a patient-centered discharge process independent of patient-centered care by health professionals. Self-efficacy varied more among breast care nurses than physicians. The group of physicians perceives standardization in the discharge process critically and therefore assumes limitations in transferring Value Stream Mapping to hospitals. The breast care nurses were open in their attitude. Financial incentives contribute to the acceptance of the method.

CONCLUSION

Value Stream Mapping is a simple way to uncover waste and develop applicable action steps. Since the implementation of the action steps was hindered by hierarchical problems and a lack of resources, management involvement and a hospital-wide approach could be beneficial.

The Contribution of Variable Control Charts to Quality Improvement in Healthcare: A Literature Review

Objective

To conduct a literature review to determine where and how variable control charts have contributed to quality improvement in healthcare.

Methods

A targeted literature search of the ABI/INFORM Global, Science Direct, Medline and Google Scholar databases was conducted, which yielded 6875 papers. Screening articles on the basis of title and abstract resulted in references to 163 articles, leading to the identification of 29 articles published between 1992 and 2019 that met the inclusion criteria. Common themes, variables and units of analysis were then analyzed.

Results

Variable control charts have been applied in 11 different healthcare contexts, using 17 different variables, at various levels within healthcare organizations. The main reason for applying variable control charts is to demonstrate a process change, usually following a specific change or quality intervention. The study identified various limitations and benefits of applying variable control charts. The charts are visually easy to understand for both management and employees, but they are limited by their requirement for potentially complex and resource-intensive data collection.

Conclusion

Variable control charts contribute to quality improvement in healthcare by enabling visualization and monitoring of variations and changes in healthcare processes. The methodology has been most frequently used to demonstrate process shifts after quality interventions. There still is a great potential for more studies applying variable control charts.

The first evidence about conceptual vs analytical lean healthcare research studies

PURPOSE

Several authors have examined the lean healthcare literature, but besides all efforts made, articles comparing conceptual and analytical studies were not found. Thus, a systematic review is conducted aiming to understand the state of the art of lean healthcare by investigating and comparing how conceptual and analytical articles address tools/methods, application fields, implementation barriers and facilitators and positive and negative impacts.

DESIGN/METHODOLOGY/APPROACH

Articles in English about lean healthcare, published in journals in the last ten years (2009-2018) and indexed in Web of Science (WoS) or Scopus were examined and assessed by following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) protocol. A qualitative content analysis on the eligible articles was conducted, and results from the conceptual and analytical studies were compared.

FINDINGS

There is a literature gap regarding tools/methods in both conceptual and analytical approaches once they prioritize for different items. Barriers, facilitators and negative impacts are perceived differently within both categories and might require more extensive analysis. The same items prevail in both conceptual and analytical categories when analyzing healthcare fields and positive impacts.

ORIGINALITY/VALUE

There is a lack of articles comparing conceptual and analytical studies concerning lean healthcare. So, this study's relevance is in identifying theoretical and applied research gaps to strengthen the lean healthcare state of the art and to integrate theoretical-applied knowledge. For healthcare professionals, it might provide an overview of the key factors that can promote lean implementation.

Application of Lean Six Sigma in conservative dentistry: an action research at an Indian dental college

Purpose

The article evaluates the obstacles, lessons learned and managerial implications of deploying Lean Six Sigma (LSS) in a dental college hospital in India.

Design/methodology/approach

The work adopts the action research (AR) methodology to establish a case study, which is carried out using the LSS define–measure–analyze–improve–control (DAMIC) approach in a dental college. It uses LSS tools to enhance the productivity and performance of the Conservative Dentistry Department of a dental college and to unravel the obstacles and success factors in applying it to the education and healthcare sector together.

Findings

The root cause for high turn-around time (TAT) is ascertained using LSS tools and techniques. The effective deployment of the solutions to the root causes of variation assists the dental college to reduce the TAT of the Conservative Dentistry process from an average of 63.9 min–36.5 min (i.e. 42.9% improvement), and the process Standard Deviation (SD) was reduced from 2.63 to 2 min. This, in turn, raises the sigma level from 0.48 to 3.23, a noteworthy successful story for this dental college.

Research limitations/implications

While the results and recommendations of this research are focused on a single case study, it is to be noted that the case study is carried out with new users of LSS tools and techniques, especially with the assistance of interns. This indicates the applicability of LSS in dental colleges; thus, the adopted modality can be further refined to fit India's education and hospital sector together.

Originality/value

This article explains the implementation of LSS from an aspiring user viewpoint to assist dental colleges and policymakers in improving competitiveness. In addition, the medical education sector can introduce an LSS course in the existing programme to leverage the potential of this methodology to bring synergy and collaborative research between data-based thinking and the medical field based on the findings of this study. The most important contribution of this article is the illustration of the design of experiments (DOE) in the dental college process.

Improving ward level efficiency using a modified treatment room layout according to Lean methodologies

INTRODUCTION

Standardised ward treatment rooms have the potential to improve efficiency in performing routine tasks. Our aim was to produce a standardised layout for commonly used equipment using a Lean approach.

METHODS

A standardised layout was devised for equipment used for venepuncture, intravenous cannulation (IVC), arterial blood gas sampling, urinary catheter insertion and nasogastric tube insertion. Stakeholder engagement was sought from house officers (HO), nursing staff, store staff and care attendants. HO were timed gathering equipment pre- and post-intervention, and a questionnaire was distributed. Feedback from all potential stakeholders contributed to the final design using repeat Plan, Do, Study, Act (PDSA) cycles.

RESULTS

The intervention was implemented across 20 inpatient wards, in 3 tertiary university teaching hospitals. The mean time taken to gather equipment for IVC significantly reduced, from 94.9 to 33.9 s (n = 166; p < 0.0001). Self-reported frustration among HO with the treatment room significantly decreased from 54.9 to 4.5% (p < 0.0001). There was a 62.3% reduction in the need for HO to ask other ward staff for help to locate equipment.

CONCLUSION

This study demonstrates improved efficiency with a time saving of over 1 min for a very commonly performed ward-based task. Ward-based staff reported reduced frustration and less interruptions following the standardisation and optimisation of treatment room layouts.

Simulation-based lean six sigma for Industry 4.0: an action research in the process industry

Purpose

The primary aim of this article is to ascertain the modalities of leveraging Lean Six Sigma (LSS) for Industry 4.0 (I4.0) with special reference to the process industries. Moreover, it intends to determine the applicability of simulation-based LSS in the automation of the mineral water industry, with special emphasis on the robust design of the control system to improve productivity and performance.

Design/methodology/approach

This study adopts the action research methodology, which is exploratory in nature along with the DMAIC (define-measure-analyze-improve-control) approach to systematically unearth the root causes and to develop robust solutions. The MATLAB simulation software and Minitab statistical software are effectively utilized to draw the inferences.

Findings

The root causes of critical to quality characteristic (CTQ) and variation in purity level of water are addressed through the simulation-based LSS approach. All the process parameters and noise parameters of the reverse osmosis (RO) process are optimized to reduce the errors and to improve the purity of the water. The project shows substantial improvement in the sigma rating from 1.14 to 3.88 due to data-based analysis and actions in the process. Eventually, this assists the management to realize an annual saving of 20% of its production and overhead costs. This study indicates that LSS can be applicable even in the advent of I4.0 by reinforcing the existing approach and embracing data analysis through simulation.

Research limitations/implications

The limitation of this research is that the inference is drawn based on a single case study confined to process industry automation. Having said that, the methodology deployed, scientific information related to optimization, and technical base established can be generalized.

Originality/value

This article is the first of its kind in establishing the integration of simulation, LSS, and I4.0 with special reference to automation in the process industry. It also delineates the case study in a phase-wise manner to explore the applicability and relevance of LSS with I4.0. The study is archetype in enabling LSS to a new era, and can act as a benchmark document for academicians, researchers, and practitioners for further research and development.

Lean Six Sigma competitiveness for micro, small and medium enterprises (MSME): an action research in the Indian context

Purpose

The aim of the article is to ascertain the challenges, lessons learned and managerial implications in the deployment of Lean Six Sigma (LSS) competitiveness to micro, small and medium Enterprises (MSME) in India and to establish doctrines to strengthen the initiatives of the government.

Design/methodology/approach

The research adopts the Action Research methodology to develop a case study, which is carried out in the printing industry in a Tier III city using the LSS DMAIC (Define-Measure-Analyze-Improve-Control) approach. It utilizes LSS tools to deploy the strategy and to unearth the challenges and success factors in improving the printing process of a specific batch of a product.

Findings

The root cause for the critical to quality (CTQ) characteristic, turn-around-time (TAT) is determined and the solutions are deployed through the scientifically proven data-based approach. As a result of this study, the TAT reduced from an average of 1541.2–1303.36 min, which in turn, improved the sigma level from 0.55 to 2.96, a noteworthy triumph for this MSME. The company realizes an annual savings of USD 12,000 per year due to the success of this project. Top Management Leadership, Data-Based Validation, Technical Know-how and Industrial Engineering Knowledge Base are identified as critical success factors (CSFs), while profitability and on-time delivery are the key performance indicators (KPIs) for the MSME. Eventually, the lessons learned and implications indicate that LSS competitiveness can be treated as quality management standards (QMS) and quality tools and techniques (QTT) to ensure competitive advantage, sustainable green practices and growth.

Research limitations/implications

Even though the findings and recommendations of this research are based on a single case study, it is worth noting that the case study is executed in a Tier III city along with novice users of LSS tools and techniques. This indicates the applicability of LSS in MSME and thus, the modality adopted can be further refined to suit the socio-cultural aspects of India.

Originality/value

This article illustrates the deployment of LSS from the perspective of novice users, to assist MSME and policymakers to reinforce competitiveness through LSS. Moreover, the government can initiate a scheme in line with LSS competitiveness to complement the existing schemes based on the findings of the case study.

Green service production in healthcare and role of value chain flexibility

Purpose

This paper aims to understand the specific role of value chain flexibility (VCF) in the strategies of green service production (GSP) in healthcare. The study explores the key dimensions of VCF and their linkages with the current GSP strategies in healthcare firms.

Design/methodology/approach

The study uses an exploratory case study with three representative national-level healthcare firms in India. A multiple case study methodology was utilized to explore the relationships between GSP and VCF.

Findings

The findings of the study suggest that several strategies for GSP require the support of multiple dimensions of VCF. More importantly, the role of each dimension of VCF depends upon the innovativeness of green service design, green procurement and green service practices.

Research limitations/implications

The study was conducted in the emerging healthcare market of India. Thus, the generalizability of the framework needs to be tested in another context. The study reports the employee's perception, and the patients’ (customers) views were not included.

Originality/value

The study is a first step to understand the theoretical perspectives of the relationships between GSP and VCF by exploring the underlying concepts. Furthermore, the study explicates the dynamics of their interplay in a systematic way and contributes to a framework of GSP and VCF in the healthcare context.

Lean Six Sigma implementation and sustainability roadmap for reducing medication errors in hospitals

Purpose

The purpose of this study is to propose a Lean Six Sigma (LSS) roadmap to guide healthcare practitioners in the implementation of LSS along with a customized LSS tool kit for reducing medication errors.

Design/methodology/approach

The authors initially critically reviewed several frameworks/roadmaps of Lean, Six Sigma and LSS which have been proposed in healthcare sector from the existing literature. This review has led to an understanding of key characteristics, limitations and reasons behind the development of such frameworks/roadmaps. A conceptual roadmap was developed and then validated by a number of LSS experts and a healthcare practitioner. Based on the previous studies and taking LSS experts’ opinions into account, a revised roadmap for reducing medication is presented.

Findings

The roadmap for LSS in reducing medication errors is developed. This roadmap includes three phases: Phase 1 cultural readiness for LSS employment in reducing medication errors; Phase 2 preparation, initialization and implementation; and Phase 3 sustainability.

Research limitations/implications

The roadmap has been tested with only a handful of practitioners of LSS. Moreover, only two case studies have been carried out in a Thai hospital setting which followed the roadmap. In order to improve the validity of research, more case studies need to be executed and more people should be used for testing the roadmap with varied cultures.

Originality/value

This is the first attempt in the development of a LSS roadmap that healthcare practitioners can follow to reduce medication errors using LSS methodology and sustaining LSS in their organizations.

Analyzing the Lean Six Sigma enabled organizational performance to enhance operational efficiency

Purpose

The aim of this analysis is to review the Indian manufacturing organizations practicing Lean Six Sigma (LSS) tools/techniques with an objective of monitoring the performance of an organization and to develop recommendation for strategies to benchmark organizational operational efficiency.

Design/methodology/approach

This study offers insights of the LSS performance measurement aspects of the Indian manufacturing organizations based on Data envelopment analysis (DEA) approach. The five inputs and two outputs are considered on the basis of literature review and discussed with the practitioners.

Findings

In this analysis, the relative efficiency score of 18 Indian manufacturing organizations has been determined in order to assist evaluation of the impact of monetary investment on the outputs. The present analysis not only investigates the optimum level of input variables but also lays down a significant observation that an organization having higher profit and inventory turnover ratio is not necessarily an efficient organization.

Practical implications

The results assist to determine the best practice units, potential source of inefficiency and deliver beneficial data for the consistent enhancement of the operational efficiency. The DEA results assist managers and decision makers to derive appropriate strategies to enhance their performance with reference to the efficient organization and to regard it as their role model.

Originality/value

This analysis renders a DEA based framework of LSS practicing Indian manufacturing organizations. The framework is unique in terms of its input-outputs variable selection and measurement procedure.

Reducing medication errors using lean six sigma methodology in a Thai hospital: an action research study

Purpose

The purpose of this paper is to illustrate the use of Lean Six Sigma (LSS) and its associated tools to reduce dispensing errors in an inpatient pharmacy of a teaching hospital in Thailand.

Design/methodology/approach

The action research methodology was used to illustrate the implementation of Lean Six Sigma through the collaboration between the researcher and participants. The project team followed the Lean Six Sigma Define, Measure, Analyze, Improve, Control (DMAIC) methodology and applied its tools in various phases of the methodology.

Findings

The number of dispensing errors decreased from 6 to 2 incidents per 20,000 inpatient days per month between April 2018 and August 2019 representing a 66.66% reduction. The project has improved the dispensing process performance resulting in dispensing error reduction and improved patient safety. The communication channels between the hospital pharmacy and the pharmacy technicians have also been improved.

Research limitations/implications

This study was conducted in an inpatient pharmacy of a teaching hospital in Thailand. Therefore, the findings from this study cannot be generalized beyond the specific setting. However, the findings are applicable in the case of similar contexts and/or situations.

Originality/value

This is the first study that employs a continuous improvement methodology for the purpose of improving the dispensing process and the quality of care in a hospital. This study contributes to an understanding of how the application of action research can save patients' lives, improve patient safety and increase work satisfaction in the pharmacy service.

Application of Six Sigma methodology in an Indian chemical company

Purpose

The aim of this paper is to deploy Six Sigma (SS) methodology for addressing the customer complaints pertaining to Chemical-X in an Indian chemical company.

Design/methodology/approach

The study followed a structured Define, Measure, Analyze, Improve, Control (DMAIC) approach to address the customer complaints. The complaints have been classified into different categories along with a project charter in the define phase. In the measure phase, measurement system analysis (MSA) and supplier, input, process, output and control (SIPOC) have been applied. In the analyze and improve phase, why–why analysis, process capability study, how–how analysis, Gage repeatability and reproducibility and Taguchi design have been applied to optimize the manufacturing process parameters for Chemical-X. Lastly, in the control phase, validation of 20 batches has been piloted to validate the optimized parameters.

Findings

The findings of this study highlight the optimization and prioritization of the process parameters. It shows that humidity has the least impact on the manufacturing of Chemical-X, whereas shift type has the maximum impact. The experimental output indicates that the 1st Shift, the holding time after grinding should be twenty-four hours, and the temperature after grinding should be 40 °C to reduce the customer complaints concerning lumps formation in Chemical-X.

Research limitations/implications

The study is performed for a single product (Chemical-X). It has focused only from the manufacturing process view and not from the transportation, suppliers and downstream supply chain view.

Originality/value

A systematic and data-driven approach of the SS methodology ensured that the customer complaints due to lumps formation reduced from 5% (approx.) to 1% (approx.) which resulted in the cost saving of INR 4 million (approx.) annually.

A review on the use of operational research techniques in the medical records department

Introduction:

Various operational research (OR) techniques have been used in different areas of healthcare. One of the areas in which OR techniques can be effective is the medical records department (MRD). The aim of this study is to review the applications of OR in the management of MRD and its related processes.

Methods:

This is a review article. In order to collect data, English-language studies published between 2000 and 2018, related to the use of OR techniques in MRD, in the Medline, Science Direct, ProQuest and Web of science databases were investigated. From 1165 retrieved studies, 19 articles met the inclusion criteria and were included in the final review.

Results:

The results showed that different OR techniques such as linear programming, integer programming, simulation, hierarchical analysis process, etc. have been used in various aspects of the MRD and its ongoing processes such as improving efficiency, workload management, resource allocation, optimal scheduling of staff work hours, patient scheduling, patient admission and discharge.

Conclusion:

It can be concluded that if the managers and experts of MRD and health information management become familiar with the principles and techniques of OR and become aware of the importance of these techniques in improving efficiency of MRD, there is a hope that in the future these techniques will find their true place in MRD and ultimately enhance the quality of services provided to patients.

Adaptation of the balanced scorecard model to measure performance of the departments at Dr Zainoel Abidin Regional General Hospital, Banda Aceh

Purpose

This paper aims to determine the performance of the departments at Dr Zainoel Abidin Regional General Hospital, Banda Aceh, Indonesia, in 2016, based on the targets and realization of their work programs using balanced scorecard.

Design/methodology/approach

This study adopted qualitative and quantitative approaches.

Findings

The overall results of the performance appraisal using the balanced scorecard approach seen from the financial, internal business, customer and training and learning perspectives are good. Dr Zainoel Abidin Regional General Hospital has provided good services, and performance of its departments have generated the expected outcome, realized by the Hospital.

Originality/value

The novelty of the present study lies in its research model, where human resources (transformational leadership, organizational commitment and resource uniqueness) and financial management (business plans, budget and performance).

An exploratory study into the use of Lean Six Sigma to reduce medication errors in the Norwegian public healthcare context

PURPOSE

Medication errors are a significant cause of injury in Norwegian hospitals. The purpose of this study is to explore how Lean Six Sigma (LSS) has been used in the Norwegian public health-care context to reduce medication errors.

DESIGN/METHODOLOGY/APPROACH

A mixed method approach was used to gather data from participants working in the four regions served by the Norway health authorities. A survey questionnaire was distributed to 38 health-care practitioners and semi-structured interviews were conducted with 12 health-care practitioners.

FINDINGS

The study finds that the implementation of LSS in the Norwegian public health-care context is still in its infancy. This is amidst several challenges faced by Norwegian hospitals such as the lack of top-management support, lack of LSS training and coaching and a lack of awareness around the benefits of LSS in health care.

RESEARCH LIMITATIONS/IMPLICATIONS

Because of the large geographical area, it was difficult to reach participants from all health regions in Norway. However, the study managed to assess the current status of LSS implementation through the participants' perspectives. This is a fruitful area for future research whereby an action research methodology could be used.

ORIGINALITY/VALUE

To the best of the authors' knowledge, this is the first empirical study into the use of LSS methodology in reducing medication errors. In addition, this study is valuable for health-care practitioners and professionals as a guideline to achieve the optimal benefit of LSS implementation to reduce medication errors.

Lean healthcare: scale, scope and sustainability

Purpose

Lean healthcare is highlighted in the literature as an approach to quality improvement and operational efficiency. The purpose of this paper is to study how Lean healthcare has been implemented by analyzing empirical outcomes.

Design/methodology/approach

The authors used a literature review as the primary research method, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses process. Peer-reviewed journals were analyzed – searching for Lean healthcare implementation, tools used, wastes addressed, outcomes and sustainability.

Findings

Evidence suggests that Lean can improve healthcare operational effectiveness. However, empirical studies show implementation is still highly localized with small successes. Most transformations are focused on implementing one or two Lean tools that primarily target patient waiting times and there is minimal evidence about sustainability. Establishing clear definitions for healthcare-related Lean terminology may improve practice, especially episodic care and service quality.

Originality/value

This work provides a Lean healthcare case review. The research makes a significant contribution to Lean healthcare by increasing understanding (scale, scope and sustainability). From a theory building perspective, the authors suggest that barriers to adoption include a common healthcare-specific Lean terminology, and a need to expand implementation beyond small successes. This understanding will help identify key areas for further research in Lean healthcare management.

Reducing the risk of healthcare-associated infections through Lean Six Sigma: The case of the medicine areas at the Federico II University Hospital in Naples (Italy)

RATIONALE, AIMS, AND OBJECTIVES

Lean Six Sigma (LSS) has been recognized as an effective management tool for improving healthcare performance. Here, LSS was adopted to reduce the risk of healthcare-associated infections (HAIs), a critical quality parameter in the healthcare sector.

METHODS

Lean Six Sigma was applied to the areas of clinical medicine (including general medicine, pulmonology, oncology, nephrology, cardiology, neurology, gastroenterology, rheumatology, and diabetology), and data regarding HAIs were collected for 28,000 patients hospitalized between January 2011 and December 2016. Following the LSS define, measure, analyse, improve, and control cycle, the factors influencing the risk of HAI were identified by using typical LSS tools (statistical analyses, brainstorming sessions, and cause-effect diagrams). Finally, corrective measures to prevent HAIs were implemented and monitored for 1 year after implementation.

RESULTS

Lean Six Sigma proved to be a useful tool for identifying variables affecting the risk of HAIs and implementing corrective actions to improve the performance of the care process. A reduction in the number of patients colonized by sentinel bacteria was achieved after the improvement phase.

CONCLUSIONS

The implementation of an LSS approach could significantly decrease the percentage of patients with HAIs.

Hospital capacity management based on the queueing theory

Purpose

The purpose of this paper is to focus on the contributions of queueing theory to hospital capacity management to improve organizational performance and deal with increased demand in the healthcare sector.

Design/methodology/approach

Models were applied to six months of inpatient records from a university hospital to determine operation measures such as utilization rate, waiting probability, estimated bed capacity, capacity simulations and demand behavior assessment.

Findings

Irrespective of the findings of the queueing model, the results showed that there is room for improvement in capacity management. Balancing admissions and the type of patient over the week represent a possible solution to optimize bed and nurse utilization. Patient mixing results in a highly sensitive delay rate due to length of stay (LOS) variability, with variations in both the utilization rate and the number of beds.

Practical implications

The outcomes suggest that operational managers should improve patient admission management, as well as reducing variability in LOS and in admissions during the week.

Originality/value

The queueing theory revealed a quantitative portrait of the day-by-day reality in a fast and flexible manner which is very convenient to the task of management.

Strategic lean actions for sustainable competitive advantage

Purpose

The purpose of this paper is to add to the quality management body of knowledge by solidifying the connection between operational and strategic aspects of lean transformation. Previous research has examined these issues in isolation, demonstrating mixed results in financial and operational efficiencies. The authors show that when operational and strategic changes are jointly considered the likelihood of success for lean transformation increases.

Design/methodology/approach

The authors provide a literature review of 109 peer-reviewed papers on lean manufacturing and qualitative analysis of 23 Baldrige award winners (2000-2014) that implemented lean to assess the importance of strategic actions in achieving a sustainable competitive advantage through lean transformation.

Findings

The authors find that lean transformation yields mixed results unless strategic actions are taken by senior management. These strategic actions include but are not limited to knowledge management, human resources, and business growth and can result in performance heterogeneity by improving the output/input ratio of the firm. This performance can then manifest as either doing the same level of business with fewer resources (a profit play) or doing more business with the same resources (a growth play). As specific examples, the authors analyzed Baldrige award winners for evidence of lean strategic action to drive performance gains. The authors suggest further model validation through directed interview and/or survey research.

Originality/value

This paper clarifies the need for jointly implementing lean tools with strategic actions. The findings provide more deliberate strategic actions for organizations wishing to increase the likelihood of success of lean transformation and ultimately improve quality.

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.

The application of Lean Six Sigma methodology to reduce the risk of healthcare-associated infections in surgery departments

RATIONALE

Nowadays, the monitoring and prevention of healthcare-associated infections (HAIs) is a priority for the healthcare sector.

AIMS AND OBJECTIVES

In this article, we report on the application of the Lean Six Sigma (LSS) methodology to reduce the number of patients affected by sentinel bacterial infections who are at risk of HAI.

METHODS

The LSS methodology was applied in the general surgery department by using a multidisciplinary team of both physicians and academics. Data on more than 20 000 patients who underwent a wide range of surgical procedures between January 2011 and December 2014 were collected to conduct the study using the departmental information system. The most prevalent sentinel bacteria were determined among the infected patients. The preintervention (January 2011 to December 2012) and postintervention (January 2013 to December 2014) phases were compared to analyze the effects of the methodology implemented. The methodology allowed the identification of variables that influenced the risk of HAIs and the implementation of corrective actions to improve the care process, thereby reducing the percentage of infected patients.

RESULTS

The improved process resulted in a 20% reduction in the average number of hospitalization days between preintervention and control phases, and a decrease in the mean (SD) number of days of hospitalization amounted to 36 (15.68), with a data distribution around 3 σ. The LSS is a helpful strategy that ensures a significant decrease in the number of HAIs in patients undergoing surgical interventions. The implementation of this intervention in the general surgery departments resulted in a significant reduction in both the number of hospitalization days and the number of patients affected by HAIs.

CONCLUSIONS

This approach, together with other tools for reducing the risk of infection (surveillance, epidemiological guidelines, and training of healthcare personnel), could be applied to redesign and improve a wide range of healthcare processes.

Application of Lean Six Sigma to Improve Service in Healthcare Facilities Management: A Case Study

The purpose of this paper is to present a case study on the application of the Lean Six Sigma (LSS) quality improvement methodology to facilities management (FM) services at a healthcare organization. Research literature was reviewed concerning whether or not LSS has been applied in healthcare-based FM, but no such studies have been published. This paper aims to address the lack of an applicable methodology for LSS intervention within the context of healthcare-based FM. The Define, Measure, Analyze, Improve, and Control (DMAIC) framework was followed to test the hypothesis that LSS can improve the service provided by an FM department responsible for the maintenance and repair of furniture and finishes at a large healthcare organization in the southwest United States of America. Quality improvement curricula and resources offered by the case study organization equipped the FM department to apply LSS over the course of a five-month period. Qualitative data were gathered from pre- and post-intervention surveys while quantitative data were gathered with the Organization's computerized maintenance management system (CMMS) software. Overall, LSS application proved to be useful for the intended purpose. The authors proposes that application of LSS by other FM departments to improve their services could also be successful, which is noteworthy and deserving of continued research.

Use of Six Sigma Methodology to Reduce Appointment Lead-Time in Obstetrics Outpatient Department

This paper focuses on the issue of longer appointment lead-time in the obstetrics outpatient department of a maternal-child hospital in Colombia. Because of extended appointment lead-time, women with high-risk pregnancy could develop severe complications in their health status and put their babies at risk. This problem was detected through a project selection process explained in this article and to solve it, Six Sigma methodology has been used. First, the process was defined through a SIPOC diagram to identify its input and output variables. Second, six sigma performance indicators were calculated to establish the process baseline. Then, a fishbone diagram was used to determine the possible causes of the problem. These causes were validated with the aid of correlation analysis and other statistical tools. Later, improvement strategies were designed to reduce appointment lead-time in this department. Project results evidenced that average appointment lead-time reduced from 6,89 days to 4,08 days and the deviation standard dropped from 1,57 days to 1,24 days. In this way, the hospital will serve pregnant women faster, which represents a risk reduction of perinatal and maternal mortality.