Lean Six Sigma for the healthcare sector: a multiple case study analysis from the Indian context

A cross-organizational Lean deployment in an Italian regional healthcare system

PURPOSE

This study explores how Lean was deployed in several hospitals in the Apulia region in Italy over 3.5 years.

DESIGN/METHODOLOGY/APPROACH

An exploratory qualitative design was drawn up based on semi-structured interviews.

FINDINGS

The drivers of Lean in hospitals were to increase patient satisfaction and improve workplace well-being by eliminating non-value-add waste. The participants highlighted three key elements of the pivotal implementation stages of Lean: introduction, spontaneous and informal dissemination and strategic level implementation and highlighted critical success and failure factors that emerged for each of these stages. During the introduction, training and coaching from an external consultant were among the most impactful factors in the success of pilot projects, while time constraints and the adoption of process analysis tools were the main barriers to implementation. The experiences of the Lean teams strongly influence the process of spontaneous dissemination aided by the celebration of project results and the commitment of the departmental hospital heads.

PRACTICAL IMPLICATIONS

Lean culture can spread to allow many projects be conducted spontaneously, but the Lean paradigm can struggle to be adopted strategically. Lean in healthcare can fail because of the lack of alignment of Lean with leadership in healthcare and with their strategic vision, a lack of employees' project management skills and crucially the absence of a Lean steering committee.

ORIGINALITY/VALUE

The absence of managerial expertise and a will to support Lean implementation do not allow for systemic adoption of Lean. This is one of the first and largest long-term case studies on a Lean cross-regional multi-hospital application in healthcare.

Lean Six Sigma to reduce the acute myocardial infarction mortality rate: a single center study

Purpose

Cardiovascular diseases are the leading cause of death worldwide. In Italy, acute myocardial infarction (AMI) is a major cause of hospitalization and healthcare costs. AMI is a myocardial necrosis event caused by an unstable ischemic syndrome. The Italian government has defined an indicator called “AMI: 30-day mortality” to assess the quality of the overall care pathway of the heart attacked patient. In order to guarantee high standards, all hospitals had to implement techniques to increase the quality of care pathway. The aim of the paper is to identify the root cause and understand the mortality rate for AMI and redesign the patient management process in order to improve it.

Design/methodology/approach

A Lean Six Sigma (LSS) approach was used in this study to analyze the patient flow in order to reduce 30-days mortality rate from AMI registered by Complex Operative Unit (COU) of Cardiology of an Italian hospital. Value stream mapping (VSM) and Ishikawa diagrams were implemented as tools of analysis.

Findings

Process improvement using LSS methodology made it possible to reduce the overall times from 115 minutes to 75 minutes, with a reduction of 35%. In addition, the corrective actions such as the activation of a post-discharge outpatient clinic and telephone contacts allowed the 30-day mortality rate to be lowered from 16% before the project to 8% after the project. In this way, the limit value set by the Italian government was reached.

Research limitations/implications

The limitation of the study is that it is single-centered and was applied to a facility with a limited number of cases.

Practical implications

The LSS approach has brought significant benefits to the process of managing patients with AMI. Corrective actions such as the activation of an effective shared protocol or telephone interview with checklist can become the gold standard in reducing mortality. The limitation of the study is that it is single-centered and was applied to a facility with a limited number of cases.

Originality/value

LSS, applied for the first time to the management of cardiovascular diseases in Italy, is a methodology which has proved to be strategic for the improvement of healthcare process. The simple solutions implemented could serve as a guide for other hospitals to pursue the national AMI mortality target.

Application of six sigma and the system thinking approach in COVID-19 operation management: a case study of the victorian aged care response centre (VACRC) in Australia

COVID-19 has posed many unique and critical challenges in various contexts and circumstances. This often led the stakeholders and decision-makers to depart from traditional thinking and the business-as-usual processes and to come up with innovative approaches to tackle various mission-critical situations within a short time frame. In this paper, a real-life case study of COVID-19 operation management following a multi-disciplinary, multi-stakeholder novel integrated approach in aged care facilities in Victoria, Australia, is presented which yielded significant and positive outcomes. The purpose of the intervention was to develop an integrated system performance approach through the application of various quality management tools and techniques to achieve organizational excellence at the aged care centers. The case involved the use of mathematical models along with statistical tools and techniques to address the specific problem scenario. A system-wide management plan was proposed, involving various agencies across several residential aged care facilities during the pandemic. A three-step methodological framework was developed, where Six Sigma, a system thinking approach, and a holistic metric were proposed to manage the value chain of the pandemic management system. The experimental result analyses showed significant improvement in the management process, suggesting the validity and potential of this holistic approach to stabilize the situation and subsequently set the conditions for operations excellence within the sectors. The model offers new insight into the existing body of knowledge and offers an efficient approach to achieving operational excellence in any organization or business regardless of its type, shape and complexity, which can help practitioners in managing complex, mission-critical situations like a pandemic.

Critical analysis of Lean Six Sigma black belt certification courses offered in Brazil

Purpose

This study aims to present an overview and analyze the Lean Six Sigma Black Belt (LSSBB) certifications offered by institutions operating in Brazil.

Design/methodology/approach

This research analyzed LSSBB certification courses offered by 48 institutions in Brazil by comparing the syllabi of the classes to the reference model proposed by the American Society for Quality (ASQ) in the Six Sigma Black Belt Body of Knowledge. This study employed the content analysis technique and hierarchical cluster analysis to analyze the data.

Findings

The results revealed a lack of standardization in the content of Lean Six Sigma (LSS) training in Brazil. 100% of the LSSBB courses analyzed covered four of the 108 techniques recommended by the ASQ Body of Knowledge (i.e. data types, measurement scales, sampling, and data collection plans and methods). In contrast, more than 75% of the courses covered all techniques related to the macro areas of organization-wide planning and deployment, organizational process management and measures, measure, and improve. The major shortcoming of LSS training is related to the macro area Design for Six Sigma framework and methodologies. LSS training is offered in a highly concentrated area in Brazil, the wealthiest region, where universities play a crucial role in disseminating LSS.

Originality/value

The literature lacks studies that critically examine LSS certification courses. There is little research on LSS in Brazil and there are no studies on LSS training in this country.

Lean Six Sigma in Healthcare: A Systematic Literature Review on Challenges, Organisational Readiness and Critical Success Factors

Lean Six Sigma (LSS) has been applied in many healthcare organisations, but there has been limited research on the evolution of LSS application in healthcare. This paper aims to present the challenges, critical success factors (CSFs), readiness factors and most common tools and techniques used for LSS deployment in healthcare. A systematic literature review (SLR) was utilised to research the study objectives. Peer-reviewed literature over a 16-year period was studied to understand the deliverables of LSS. The SLR process identified relevant articles and screened a final selection for those under study. The systematic literature review helped the authors to identify the challenges and tools/techniques used for LSS in healthcare. Several CSFs and readiness factors for LSS deployment in healthcare are also presented. This work informs healthcare managers and professionals on the important factors for successful LSS deployment before embarking on the LSS journey. In addition, this work is a valuable resource for healthcare LSS practitioners and academic researchers to learn about, investigate and deploy LSS in the healthcare sector. This study is one of the most comprehensive SLRs covering the importance and specificity of understanding challenges, CSFs and organisational readiness for LSS in healthcare. This study provides knowledge of the successful deployment of LSS in healthcare.

Lean Six Sigma in Healthcare: A Systematic Literature Review on Motivations and Benefits

While Lean Six Sigma (LSS) has been applied extensively in healthcare organisations, there has been limited research on the trends of LSS application in healthcare in recent years. This paper aims to present the key motivations and benefits of LSS in healthcare with a view to highlighting the types of problems that LSS in healthcare can aid in solving. The authors used a systematic literature review (SLR) approach to achieving the article’s purpose. Peer-reviewed journal articles published between 2011 and 2021 are considered to achieve the study objectives. The systematic review helped the authors to identify the evolution, benefits, and motivations for LSS in healthcare. This work includes directions for managers and healthcare professionals in healthcare organisations to embark on a focused LSS journey aligned with the strategic objectives. This study is perhaps one of the most comprehensive SLRs covering a vital agenda of LSS in healthcare. This study provides all the deliverables of LSS for its successful deployment in healthcare.

G, Koul R, Cudney EA, Chakraborty A. A study on critical failure factors of Design for Six Sigma in Indian companies: results from a pilot survey

Purpose

While Six Sigma (SS) has been deployed effectively in Indian manufacturing and service sectors as a process improvement methodology, the implementation of Design for Six Sigma (DFSS) for robust product and service development has not shown noticeable results. Therefore, this article aims to determine the critical failure factors (CFFs) of DFSS in the Indian context.

Design/methodology/approach

The paper presents the results of a pilot survey on the CFFs of DFSS in Indian companies. The survey participants were specialists in DFSS who have been involved in DFSS projects in their past and present companies. Moreover, the pilot study participants were DFSS Champions, Master Black Belts, Black Belts and Green Belts from the manufacturing and service sectors.

Findings

Company-wide applications of DFSS are very limited in India. Most of the DFSS project failures are reported in the Analyse phase of the project. The results indicated that all 18 CFFs used in the survey have a significant impact on project failures. Also, it was determined that all CFFs are positively correlated with each other. Further, a strong correlation was observed between the voice of the customer (VOC) and project selection and prioritisation. In addition, effective training showed a strong correlation with the right selection of tools.

Research limitations/implications

The pilot survey was based on a limited sample size. Moreover, the study is confined to only the Indian context and data were collected through the authors' networks. However, respondents were proficient, certified and involved in DFSS project deployment in the manufacturing and service sectors. Therefore, the study's findings are useful and meaningful to draw robust inferences.

Originality/value

To the best of the authors' knowledge, this is the first empirical study conducted in the Indian context to identify the reasons for DFSS project failures. The study's findings can aid academicians and practitioners in comprehending and critically examining the CFFs of DFSS before executing a project. Moreover, the research outcome motivates policymakers to create an ecosystem to effectively adopt DFSS for start-ups and micro, small and medium enterprises (MSME) to ensure a circular economy and support the “Atmanirbhar Bharat” initiative.

Prioritization of critical success factors for sustainable Lean Six Sigma implementation in Indian healthcare organizations using best-worst-method

Purpose

Recent years have seen an increased demand for healthcare services, presenting a need to improve service quality through the deployment of sustainable Lean Six Sigma (LSS). This study aims to identify critical success factors (CSFs) of sustainable LSS and prioritize them based on their intensity of importance for the effective implementation of sustainable LSS in the healthcare environment.

Design/methodology/approach

The present study identified 33 leading CSFs through a comprehensive literature review and expert experience and classified them into six major categories based on organizational functions. The primacy of these CSFs is established using the best-worst-method (BWM) approach. The significant advantage of this approach is that the decision-maker identifies both the best and worst criteria among alternatives prior to pairwise comparisons, leading to fewer pairwise comparisons and saving time, energy and resources. It also provides more reliable and consistent rankings.

Findings

The findings of the present study highlight the economic and managerial (E&M) CSFs as the most significant CSFs among the major category criteria of sustainable LSS-CSFs, followed by organizational (O), knowledge and learning (K&L), technological (T), social and environmental (S&E), and external factors (EF). Similarly, management involvement and leadership to implement sustainable LSS (E&M1), structured LSS deployment training and education (K&L2), and availability of required resources and their efficient utilization (O2) are ranked as the topmost CSFs among sub-category criteria of sustainable LSS-CSFs.

Practical implications

The prioritization of sustainable LSS-CSFs determined in this study can provide healthcare managers, researchers and decision-makers with a better understanding of the influence on effective deployment of sustainable LSS, resulting in improved service quality in hospitals.

Originality/value

This paper is an original contribution to the analysis of CSFs in an Indian healthcare institute, utilizing the BMW method for ranking the sustainable LSS-CSFs. The advantage of utilizing and distinguishing the performance of this approach compared to other MCDA approaches in terms of (1) least pairwise comparison and violation, (2) consistency (3) slightest deviation and (4) conformity.

The implementation of Lean Six Sigma framework in the Indian context: a review and suggestions for future research

Purpose

The purpose of this work is to gain insights about Lean Six Sigma (LSS) in the Indian context by reviewing the related literature for one decade based on various perspectives, such as author profile, year of publication, type of firm, type of methodology used, type of industry for which the research work is carried out and the key findings from the research.

Design/methodology/approach

This study reviews the research related to LSS from the articles published in the reputed journals. The literature used for reviewing is derived from the sources, including Science direct, Google scholar, IEEE, Taylor and Francis Group, Emerald Insight, Springer, Inderscience and Elsevier during the period between 2010 and 2021. Totally, the authors have included 141 LSS-related research articles that are published in the Indian context. The keywords used are Lean Six Sigma, Lean Six Sigma in the Indian context, Lean Sigma and LSS to identify and consolidate the research papers published during this timeframe.

Findings

The research papers collected from various reputed journals, including Scopus and non- Scopus enlisted, are classified and grouped under various categories to identify the class of author who publishes more in this field, research trend over the years, the type of firm which implements LSS, the research methodology which is commonly used in LSS and related research and also the key takeaway from these articles are highlighted. Further, the authors have also identified the major contributions of researchers in various sectors during this period in India.

Originality/value

This classification framework and the systematic review help in identifying the research gap and in giving directions for future researchers. It will be useful for researchers and practitioners working on the area of LSS, rural and urban entrepreneurs, start-up managers, professionals working in micro, small and medium enterprises (MSMEs) and executives of the Make in India Project to make India as Aatmanirbhar Bharat Abhiyan. Further, the clear direction of progress over the current decade in manufacturing industries, service sectors and processing industries can help the professionals working in these sectors.

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.

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.

Operation Note Transformation: The Application of Lean Six Sigma to Improve the Process of Documenting the Operation Note in a Private Hospital Setting

Clinical documentation is a key safety and quality risk, particularly at transitions of care where there is a higher risk of information being miscommunicated or lost. A surgical operation note (ON) is an essential medicolegal document to ensure continuity of patient care between the surgical operating team and other colleagues, which should be completed immediately following surgery. Incomplete operating surgeon documentation of the ON, in a legible and timely manner, impacts the quality of information available to nurses to deliver post-operative care. In the project site, a private hospital in Dublin, Ireland, the accuracy of completion of the ON across all surgical specialties was 20%. This project sought to improve the accuracy, legibility, and completeness of the ON in the Operating Room. A multidisciplinary team of staff utilised the Lean Six Sigma (LSS) methodology, specifically the Define/Measure/Analyse/Design/Verify (DMADV) framework, to design a new digital process application for documenting the ON. Post-introduction of the new design, 100% of the ONs were completed digitally with a corresponding cost saving of EUR 10,000 annually. The time to complete the ON was reduced by 30% due to the designed digital platform and mandatory fields, ensuring 100% of the document is legible. As a result, this project significantly improved the quality and timely production of the ON within a digital solution. The success of the newly designed ON process demonstrates the effectiveness of the DMADV in establishing a co-designed, value-adding process for post-operative surgical notes.

Managing the resource allocation for the COVID-19 pandemic in healthcare institutions: a pluralistic perspective

Purpose

As COVID-19 outbreak has created a global crisis, treating patients with minimum resources and traditional methods has become a hectic task. In this technological era, the rapid growth of coronavirus has affected the countries in lightspeed manner. Therefore, the present study proposes a model to analyse the resource allocation for the COVID-19 pandemic from a pluralistic perspective.

Design/methodology/approach

The present study has combined data analytics with the K-mean clustering and probability queueing theory (PQT) and analysed the evolution of COVID-19 all over the world from the data obtained from public repositories. By using K-mean clustering, partitioning of patients’ records along with their status of hospitalization can be mapped and clustered. After K-mean analysis, cluster functions are trained and modelled along with eigen vectors and eigen functions.

Findings

After successful iterative training, the model is programmed using R functions and given as input to Bayesian filter for predictive model analysis. Through the proposed model, disposal rate; PPE (personal protective equipment) utilization and recycle rate for different countries were calculated.

Research limitations/implications

Using probabilistic queueing theory and clustering, the study was able to predict the resource allocation for patients. Also, the study has tried to model the failure quotient ratio upon unsuccessful delivery rate in crisis condition.

Practical implications

The study has gathered epidemiological and clinical data from various government websites and research laboratories. Using these data, the study has identified the COVID-19 impact in various countries. Further, effective decision-making for resource allocation in pluralistic setting has being evaluated for the practitioner's reference.

Originality/value

Further, the proposed model is a two-stage approach for vulnerability mapping in a pandemic situation in a healthcare setting for resource allocation and utilization.

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.

Exploring the use of operational excellence methodologies in the era of COVID-19: perspectives from leading academics and practitioners

Purpose

This paper aims to present the results of a study carried out by the authors in the form of research interviews on the topic: “Exploring the use of operational excellence methodologies in the era of COVID-19.”

Design/methodology/approach

A qualitative interview approach was utilized by interviewing a panel of leading academics and practitioners who are familiar with operation excellence methodologies.

Findings

Operational excellence methodologies are proven and can be utilized in pandemic situations to improve efficiency in the healthcare system and preparedness for pandemics.

Research limitations/implications

One limitation of this research was that most of the interviewees who participated in this study came from Europe, North America, South America and Asia, representing four continents. It would have been better to have different views from other continents such as Australia and Africa. Also, the interviews were short and at a high level. There is an opportunity for further study and analysis.

Practical implications

Operational excellence methodologies are proven and can be utilized in pandemic situations to improve efficiency in the healthcare system and preparedness for pandemics.

Originality/value

The paper provides an excellent resource for those people to get an insight into the value of the application of operations excellence methodologies in pandemic situations to aid healthcare process improvement and aid public and patient safety.

The Role of Value Stream Mapping in Healthcare Services: A Scoping Review

Lean healthcare aims to manage and improve the processes in the healthcare sector by eliminating everything that adds no value by improving quality of services, ensuring patient safety and facilitating health professionals’ work to achieve a flexible and reliable organization. Value Stream Mapping (VSM) is considered the starting point of any lean implementation. Some papers report applications of VSM in healthcare services, but there has been less attention paid to their contribution on sustainability indicators. The purpose of this work is to analyze the role of VSM in this context. To do so, a scoping review of works from recent years (2015 to 2019) was done. The results show that most applications of VSM reported are in the tertiary level of care, and the United States of America (USA) is the country which leads most of the applications published. In relation with the development of VSM, a heterogeneity in the maps and the sustainability indicators is remarkable. Moreover, only operational and social sustainability indicators are commonly included. We can conclude that more standardization is required in the development of the VSM in the healthcare sector, also including the environmental indicators.

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.

Evaluating the effect of critical failure factors associated with sustainable Lean Six Sigma framework implementation in healthcare organization

Purpose

The purpose of this study is to develop a structured hierarchical interrelationship-based model to evaluate the critical failure factors (CFFs) that affect the sustainable Lean Six Sigma (SLSS) framework implementation in a healthcare organization. Further, solution approaches have been provided that guide to eliminate them.

Design/methodology/approach

The CFFs has been identified through empirical study and clustered into six major categories for their better understanding. The interrelation among CFFs has been developed through total interpretive structural modeling (TISM) and classifies the nature using MICMAC technique. Further, prioritized the CFFs based on its driving and dependents power. The methodology enabled the decision-makers, practitioners to systematically analyze the CFFs and develop a structural model for implementing SLSS in the healthcare environment.

Findings

A total of 14 leading CFFs have been identified, and 7-level structured interrelationship-based model has been formed. The experts have provided the solution approach after careful analysis of the developed model. Based on the analysis, it was observed that the significant CFFs affect the deployment of the SLSS framework in healthcare organizations.

Research limitations/implications

The structured model and methodological approach have been tested in a healthcare organization. In the future, the approach can be applied in the different service sectors.

Practical implications

The present study has been conducted in a real-time industrial problem. The practitioners, decision-makers and academicians expressed the usefulness of methodology for understanding the CFFs interrelation and their effect on SLSS implementation. This study also guides decision-makers to systematically tackle related problems.

Originality/value

The development of a structured CFFs based model for SLSS framework implementation using the integrated TISM-MICMAC with a detailed solution approach is a unique effort in a healthcare environment.

The impact of non-urgent patients in emergency departments' operations

Purpose

Globally, the presence of non-urgent patients in emergency departments (EDs) is considered one of the main reasons for creating excessive waiting times and overcrowding in units. This paper aims to understand the impact of non-urgent patients in EDs' operations.

Design/methodology/approach

This study is based on qualitative case studies conducted within two Brazilian EDs, and uses interviews and observations to access the data.

Findings

From a thematic analysis, three key themes emerged: characteristics of non-urgent demands in EDs, negative aspects of non-urgent patients in EDs, and the impact of the healthcare system model on EDs. These themes bring to light the impact that non-urgent patients have in EDs' operations, and provide theoretical and practical implications.

Research limitations/implications

The limitation of this work is bound by the understanding of the non-urgent demands in EDs. Therefore, a benchmarking approach (investigating state-of-the-art practices to avoid such impact) was not applied but was suggested for future research instead.

Practical implications

The research provides significant contributions to practitioners and policymakers, aiding future discussions to improve healthcare coverage and performance.

Social implications

The research provides significant contributions for managers and policymakers, aiding future discussions to improve healthcare. For instance, the use of well-known techniques (e.g. lean, six sigma) are discussed and suggested to enhance healthcare capacity and performance. Furthermore, the policymakers are called upon to evaluate the healthcare access and provide regulations that involve innovative approaches to widen healthcare access.

Originality/value

Based upon empirical data, this research extends the discussions related to non-urgent patient in EDs and is not limited merely to descriptive analysis, but by providing practical propositions and discussions related to the impact of these patients' presence in EDs' operations. Finally, the research provides a range of suggestions for future research related to the EDs' operational performance.

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.