Applications of Lean Six Sigma in an Irish hospital

Development of an improvement framework for warehouse processes using lean six sigma (DMAIC) approach. A case of third party logistics (3PL) services

This study aims at developing an improvement framework of warehouse processes by improving process cycle efficiency using lean six sigma (DMAIC) approach. A case study method was used to illustrate the evaluation of the existing processes in the warehouse of a third party logistics company with a focus on productivity using warehouse lean tools. Data were collected based on warehouse operational areas of suppliers, customers and internally related with a focus on warehouse core processes. The optimization of the warehouse processes was based on established lean tools. Based on the warehouse evaluation, high non-value added activities were observed leading to a low process cycle efficiency of 40%. After the implementation of the lean six sigma approach, the process cycle efficiency improved of up to 70%. An improvement framework was also established for productivity across the warehouse processes to minimise waste. Lean warehousing has been used to illustrate solutions to a real-time problem of productivity which has negatively impacted on management and customer satisfaction. The study has added to lean warehousing focusing on all the warehouse processes using six sigma DMAIC approach, unlike most literature which concentrates on a specific process. Also develop a framework for the improvement of the processes.

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.

Fuzzy AHP approach for barriers to implement LSS in the context of Industry 4.0

Purpose

The purpose of the present work is identification and prioritization of barriers to Lean Six Sigma (LSS) implementation in Indian manufacturing industries in the context of Industry 4.0 (I4.0) to surmount the impediments in the path of successful implementation.

Design/methodology/approach

In total, 27 barriers identified through critical review of literature and expert's opinion are evaluated with Cronbach's alpha values including item-total correlations or corrected item-total correlations (CITC) using statistical tool. Finally, 20 barriers were analyzed and ranked employing Fuzzy Analytical Hierarchy Process (FAHP).

Findings

The study depicts that “Lack of leadership, advisory and monitoring,” “Lack of clarity about economic benefits” and “Lack of integration of LSS with smart tools/I4.0” are potential barriers to drive the path for proper implementation of LSS in Industry 4.0 with due consideration of its technologies in Indian manufacturing industries.

Practical implications

The study provides better knowledge platform for academicians and researchers about hidden aspects of LSS implementation barriers in view of advanced manufacturing technologies. This research will help the practitioners to design their business plans in implementing new quality improvement tools to get advantage in current competitive environment.

Originality/value

The barriers are selected based on literature and opinion from industry and academic experts. Five major criteria are decided after incorporating inputs. The ranking of the barriers is attained by well standard mathematical technique. This will enable the practitioners to design strategies to eliminate the hindrances in order to shape the right path for effective implementation of LSS approach in view of advanced manufacturing technologies.

Success factors for lean six sigma projects in healthcare

Identifying critical success factors (CSFs) of continuous improvement projects is crucial for management control and operations management domains. Despite the availability of manufacturing-related literature, studies on CSFs in more dynamic and complex healthcare-related operations are scarce. This study, based at a large public tertiary healthcare organization, identifies CSFs in implementing Lean Six Sigma (LSS). 62 LSS projects completed by Green Belts in consultation with Black Belts were analyzed for project success by a review team of practitioners (Black Belters) and academics. Using a grounded theory approach, numerous success factors were initially identified. A series of brainstorming sessions and workshops helped to narrow down and revise all the CSFs present in each of the 62 LSS projects to eight CSFs. The success of the 62 completed projects was assessed against each of the eight CSFs on a five-point Likert scale. Success was measured against whether the project met its stated aim and achieved the Key Performance Indicators that had initially been identified. Finally, the correlations of each factor rating against project success were analyzed to validate the relationship between each success factor and project success. The findings confirm that all eight CSFs identified are significantly correlated to project success. This study contributes to the management control, operations management, and healthcare literature by identifying CSFs of continuous improvement projects and introducing a relatively unique, rigorous, and practically proven evaluation method applied via an industry and academic partnership. Specified CSFs and the method used to identify these will benefit managers of continuous improvement projects.

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.

Strategies for successful deployment and sustainment of Lean Six Sigma in healthcare sector in India: a multi-level perspective

Purpose

This study aims to present Lean Six Sigma (LSS) deployment and sustainment strategies for the healthcare sector from a multi-level perspective. The objective is to present LSS implementation insights to enable policymakers, practitioners and academicians to test and develop an LSS framework for healthcare sectors.

Design/methodology/approach

The strategies identified are the result of a multi-method research design involving literature review, action research (AR) and Delphi study. Further, the AR portion of the study involved more than 10 years of projects focused on the deployment of LSS in the healthcare sector.

Findings

The strategies include a holistic view from the multi-level perspective, considering the Top Management Level, Middle Management Level and Operational Level. The authors ascertained 27 strategies across the three levels of organizational structure for the effective deployment of LSS. Further, the authors present a customized LSS “pocket guide” from the healthcare perspective for quick reference.

Research limitations/implications

The strategies delineated in this study are based on the Indian healthcare section only; thus, further research in additional geographic contexts is needed. Also, further research is necessary to provide additional empirical validation of the effects of the identified strategies on LSS program outcomes and to verify that the strategies operate at the proposed organizational levels. Future research should also focus on identifying the interrelationships between strategies within and across levels, developing a “road map” for LSS implementation in hospitals and designing the LSS curriculum for medical schools and other medical training programs.

Practical implications

Observations of this study can contribute to developing a holistic framework for successful LSS implementation in the healthcare sector for academicians, practitioners and policymakers. This, in turn, ensures an enhanced value proposition, improved quality of life and reduced healthcare operational costs. Thus, it ensures a win-win situation among all the stakeholders of the healthcare sector.

Originality/value

The strategies put forth will enable the LSS researchers, academicians and, more particularly, practitioners to delve deeper into specific enablers and safeguard the LSS deployment from backlash. The research has two significant benefits. Firstly, it enhances the understanding of LSS from the healthcare perspective. Secondly, it provides direction for future studies with specific components for hospitals’ LSS framework, which can be further tested, refined and improved.

The Use of Lean Six Sigma Methodology in the Reduction of Patient Length of Stay Following Anterior Cruciate Ligament Reconstruction Surgery

Background: The purpose of this study was to reduce the length of stay of anterior cruciate ligament reconstruction patients within a private hospital in Ireland, reducing any non-value-added activity in the patient pathway, with the goal of increasing patient flow, bed capacity, and revenue generation within the hospital system, while maintaining patient satisfaction. Methods: We used a pre-/post-intervention design and Lean Six Sigma methods and tools to assess and improve the current process. Results: A reduction in inpatient length of stay by 57%, and a reduction in identified non-value-added activity by 88%, resulted in a new day-case surgery pathway for anterior cruciate ligament reconstruction patients. The pathway evidenced no re-admissions and demonstrated patient satisfaction. Conclusion: Six months post-project commencement, we had successfully achieved our goals of reducing our anterior cruciate ligament reconstruction patient's length of stay. This study contributes to the growing body of published evidence which shows that adopting a Lean Six Sigma approach can be successfully employed to optimise care and surgical pathways in healthcare.

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.

Critical success factors and challenges for Lean Startup: a systematic literature review

Purpose

The term Lean Startup (LS) was coined by Eric Ries, and his 2011 book has popularized the concept with organizations, both startups and established organizations, implementing LS. However the empirical grounding is thin and for a long time this subject has been neglected by academia. The purpose of this paper is to present a systematic literature review (SLR) on LS, while highlighting core knowledge and identify gaps.

Design/methodology/approach

A SLR was carried out based on the Preferred Reporting for Systematic Reviews and Meta-Analyses (PRISMA) protocol of Scopus and Web of Science databases. In total, 45 articles published in journals and conferences over 10 years were collected which revealed a number of LS research gaps.

Findings

The SLR revealed the tools and methods associated with LS, most cited pros and cons, reasons that cause LS failure, the challenges that companies face in the implementation of LS, and critical success factors (CSFs) that can support these challenges and minimize the reasons for failure.

Practical implications

The findings of the study can be beneficial to practitioners and senior managers in organizations who wish to delve into the journey of LS. The study also discloses challenges and barriers that can hinder the implementation of LS.

Originality/value

Academic publications regarding LS are sparse and this SLR is one of the first SLRs to explore both the critical failure factors (CFFs) and the CSFs based on peer-reviewed journal and conference proceedings.

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.

Application of Lean Six Sigma framework for improving manufacturing efficiency: a case study in Indian context

Purpose

This study aims to utilize DMAIC methodology along with value stream mapping and other Lean Six Sigma tools in a major automobile light manufacturing industry to reduce defect rates and increase production capacity in their manufacturing line. The study also proposes a modified framework based on lean principles and FlexSim to identify and reduce waste in the selected industry.

Design/methodology/approach

A Lean Six Sigma modified framework has been deployed with DMAIC to reduce the defect rate and increase the production rate. Various tools like value stream mapping, brainstorming, Pareto charts, 5S, kanban, etc. have been used at different phases of DMAIC targeting wastes and inventory in the production line. Also, a simulation model has been utilized for the automobile light manufacturing industry to improve the machine utilization time with varying batch sizes.

Findings

The results of the study indicated a 53% reduction in defect rates. Thus, there would be an expected improvement in sigma value from 3.78 to 3.89 and a reduction in defects per million opportunities (DPMO) from 11,244 to 8,493. Additionally, simulation model using FlexSim was developed, and the optimum ordering batch size of raw material was obtained. It was also analyzed that idle time for various stations could be reduced by up to 30%.

Practical implications

The utilized framework helps identify defects for managers to increase production efficiency. The workers, operators and supervisors on the production line also need to be trained regularly for identifying the areas of improvement.

Originality/value

The modified Lean Six Sigma framework used in this study includes FlexSim simulation to make the framework robust, which has not been used with LSS tools in the literature studied. Also, the LSS finds very less application in the manufacturing domain, considering which this study tends to add value in existing literature taking a case of an automobile light manufacturing industry.

Assessing the Impact of Lean Healthcare on Inpatient Care: A Systematic Review

Healthcare services are facing challenges in increasing their efficiency, quality of care, and coping with surges in demand. To this end, some hospitals have implemented lean healthcare. The aim of this systematic review is to evaluate the effects of lean healthcare (LH) interventions on inpatient care and determine whether patient flow and efficiency outcomes improve. The review was performed according to PRISMA. We used six databases to search for studies published from 2002 to 2019. Out of 5732 studies, 39 measuring one or more defined outcomes were included. Hospital length of stay (LOS) was measured in 23 studies, 16 of which reported a reduction, turnover time (TOT) decreased in six out of eight studies, while the turnaround time (TAT) and on-time starts (OTS) improved in all five and seven studies, respectively. Moreover, eight out of nine studies reported an earlier discharge time, and the boarding time decreased in all four cases. Meanwhile, the readmission rate did not increase in all nine studies. Lastly, staff and patient satisfaction improved in all eight studies. Our findings show that by focusing on reducing non-value-added activities, LH contributed to improving patient flow and efficiency within inpatient care.

Development of an integrated framework of LGSS strategies for Indian manufacturing firms to improve business performance: an empirical study

Purpose

This article aims to explore synergies between Lean, Green and Six Sigma practices in order to propose an integrated LGSS framework for continuous and incremental improvement in the Indian manufacturing industries. The three-dimensional LGSS framework seeks to provide various combinations and support operational, financial, environmental and social needs.

Design/methodology/approach

In the research method, first, the current problems faced by Indian manufacturing industries are considered and proposition of a conceptual framework that qualitatively integrates synergistic aspects of Lean, Green and Six Sigma practices, and second, the framework is checked by a survey taken from 203 Indian firms by using SPSS-AMOS.

Findings

The hypothesized result suggests that the positive impact of integrated practices on firm performance in terms of operational, financial, social and environmental outcomes. It also provides a systemic and holistic approach to problem-solving through constant and incremental enhancement in the manufacturing sector.

Research limitations/implications

In this research, only Indian manufacturing industries have been studied but can be extending into different geographical areas and sectors. Future research is also possible for different behavior and characteristics of companies that can lead to recommending strategies on how companies can improve performance. Most importantly, future research can try to understand which specific practice can contribute to competitive advantage and business success.

Practical implications

Manufacturing firms that want to improve environmental sustainability should implement integrated LGSS practices into their supply chain. The set of combined practices improves operational, social, economical and environmental benefits.

Social implications

The research presents an integrated approach of LSS for the manufacturing industry which leads their business processes to achieve economic sustainability through continuous growth and improved operational efficiency. Manufacturing industries result in outcomes like reduced cost, lead time, improved quality, sustainable market position, profitability, customer satisfaction, etc.

Originality/value

This research is different from previous studies because it integrates Lean, Green and Six Sigma practices into a unique framework that fulfills a specific need of the Indian manufacturing sector that guides operational, social, environmental and financial issues in Indian industries.

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 risk of development or exacerbation of nutritional deficits by optimizing patient access to mealtime assistance

Objective

Optimize patient access to mealtime assistance, decrease missed meal incidence, risk of malnutrition, reduce food waste and staff rework.

Design

Lean Six Sigma methodology informed a pre/post intervention design.

Setting

31 bed ward including Specialist Geriatric services and Acute Stroke Unit within an Irish University teaching hospital.

Participants

Clinical and non-clinical staff including catering, nursing, speech and language therapy, dietetics and nutrition; patients, relatives.

Interventions

An interdisciplinary team used the structured Define/Measure/Analyse/Improve/Control (DMAIC) framework to introduce visual aids and materials to improve the access of patients to assistance at mealtimes.

Main outcome measures

Pre and post outcomes measures were taken for the number and cost of uneaten meals, rework for staff, staff and patient satisfaction, patient outcomes.

Results

Following a 1-month pilot of a co-designed process for ensuring access to assistance at mealtimes, average wasted meals due to staff not being available to assist patients requiring mealtime assistance went from 3 per day to 0 corresponding to an average reduction of 0.43 kg per participating patient in food waste per day. Patients receiving assistance did not require additional oral therapeutic nutritional supplements, evidenced no new incidences of aspiration pneumonia or swallowing difficulties and were discharged without requirement for ongoing Dietetics and Nutrition support. Following a 6 month Control period comprising repeated PDCA cycles, the initiative was incrementally introduced to a further 10 wards/units, with positive feedback from patients and staff alike.

Conclusion

The co-designed new process highlights the importance of staff and patient collaboration, inclusion and participation in designing quality improvement projects.

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.

Analysis and Evaluation of Reviews on Lean and Six Sigma in Health Care

BACKGROUND AND OBJECTIVES

Health care is a complex industry in which professionals are facing the challenge of balancing lower costs with better health and quality of care. To remain competitive, health care organizations have promoted the use of Lean and Six Sigma in various settings. More than 300 refereed English-language articles about Lean and/or Six Sigma in health care are found in the literature, and many reviews have been published on this subject.

METHODS

This article characterizes the literature by evaluating and classifying 22 reviews, based on year of publication, country, taxonomy, health care setting, outcome, tools, and enabling factors, in order to identify gaps in the literature and set new directions for research.

RESULTS

Findings indicate that 90% of reviews are characterized by restrictive inclusion criteria that result in the inclusion of only 3% to 66% of the literature at the corresponding time. Furthermore, there is no full comprehensive literature review available on Lean and Six Sigma in health care. Other gaps in the literature include more studies with better research design, broader applications in various health care settings and various countries, sustainability assessment and long-term effects, and evidence of failed Lean and Six Sigma implementations.

CONCLUSION

This study provides an updated starting point for future research to researchers and practitioners in the field.

Investigating the relationship between Lean Six Sigma's intangible impacts and organisational innovation climate factors

Purpose

This paper aims to investigate the relationship between the intangible impacts of Lean Six Sigma (LSS) and organisational innovation climate factors and proposes a conceptual model to link them. This paper ultimately aims to extend the range of LSS application by proposing LSS as a tool for fostering organisational innovation.

Design/methodology/approach

The paper followed a qualitative research approach to identify, analyse and categorize the intangible impacts of LSS by reviewing previous literature on its application and conducting in-depth interviews with its experts. Then, a detailed description of organisational innovation climate was provided to highlight its main factors. Finally, a conceptual model was developed to illustrate the relationships among the collected information.

Findings

LSS was found to have many intangible impacts categorized as organisational or individual related. Organisational innovation climate is determined by a number of factors that were found to be positively influenced by many of LSS's intangible impacts. Thus, a number of propositions between LSS's intangible impacts and organisational innovation climate factors were proposed, as illustrated by a conceptual model.

Originality/value

Studying the relationship between LSS and innovation by considering LSS's intangible impacts and linking them to organisational innovation climate factors is a relatively new approach that makes the contribution of this research valuable and significant to academics and professionals.

Improvement project in higher education institutions: A BPEP-based model

Improvement projects (IPs) are a fundamental element in any quality management system from any organization. In Higher Education Institutions (HEIs), IPs are constantly implemented to maintain excellence in academic and administrative processes. In this study, we propose a model for IP implementation that is based on the Baldrige Performance Excellence Program (BPEP). As a part of the model, we propose a series of research hypotheses to be tested. The data used to test the hypotheses were gathered from a questionnaire that was developed after an extensive literature review. The survey was administered to Mexican public HEIs, and more than 700 responses were collected. The data were assessed in terms of convergent and discriminant validity, obtaining satisfactory results. To test the proposed relationships between the model constructs, we utilized Structural Equation Modeling (SEM) using the software IBM SPSS Amos. The analysis confirmed the statistical validity of both the model and the hypotheses. In conclusion, our model for IP implementation is a useful tool for HEIs that seek to attain excellence in their processes through IPs.

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

Purpose

The purpose of this paper is to explore the voice of the customer, key performance indicators, critical to quality characteristics, critical success factors, and commonly used tools and techniques for deploying the Lean Six Sigma (LSS) strategy in Indian private hospitals, with special attention to the medical records.

Design/methodology/approach

The study utilizes the action research methodology to obtain a greater understanding of the use of LSS in the Indian healthcare sector. Multiple case studies were designed and successfully deployed to understand and ascertain challenges in LSS implementation. Five case studies were carried out in the Medical Records Departments (MRD) of four private hospitals in India.

Findings

Patients perceive that waiting in queue harms their health, which can be rectified by addressing the cycle time of the system. The research also found that effective leadership, availability of data, involvement of cross-functional team and effective communication are critical to the success of LSS projects. In addition, control charts, cause and effect diagram, 5S, gemba, two-sample t-test, standardization, waste analysis and value stream mapping are some of the common tools used to improve healthcare systems.

Research limitations/implications

The research was restricted to studying the impact of LSS on the workflow and resource consumption of the MRD in Indian allopathic hospitals only. The validity of the results can be improved by including more hospitals and more case studies from the healthcare sector in different countries.

Originality/value

The findings will enable researchers, academicians and practitioners to incorporate the results of the study in LSS implementation within the healthcare system to increase the likelihood of successful deployment. This will provide greater stimulus across other departments in the hospital sector for wider and broader application of LSS for creating and sustaining process improvements.

Assessing the state of lean and six sigma practices in healthcare in Mexico

PURPOSE

The purpose of this study is to assess the state at which lean and six sigma (LSS) are used as a management system to improve the national health system national health system of Mexico.

DESIGN/METHODOLOGY/APPROACH

Cross-sectional survey-research. The survey was administered at 30 different hospitals across six states in Mexico. These were selected using convenience sampling and participants (N = 258) were selected through random/snowball sampling procedures, including from top managers down to front-line staff.

FINDINGS

Only 16 per cent of respondents reported participation in LSS projects. Still, these implementations are limited to using isolated tools, mainly 5s, failure mode and effects analysis (FMEA) and Fishbone diagram, with the lack of training/knowledge and financial resources as the top disabling factors. Overall, LSS has not become systematic in daily management and operations.

RESEARCH LIMITATIONS/IMPLICATIONS

The sampling procedure was by convenience; however, every attempt was made to ensure a lack of bias in the individual responses. If still there was a bias, it is conjectured that this would likely be in overestimating the penetration of LSS.

PRACTICAL IMPLICATIONS

The penetration of LSS management practices into the Mexican health system is in its infancy, and the sustainability of current projects is jeopardized given the lack of systematic integration. Hence, LSS should be better spread and communicated across healthcare organizations in Mexico.

ORIGINALITY/VALUE

This is the first research work that evaluates the use of LSS management practices in a Latin American country, and the first journal paper that focuses on LSS in healthcare in Mexico.

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 implementation in healthcare supply chain: a scoping review

Purpose

The purpose of this paper is to identify the lean production (LP) practices applied in healthcare supply chain and the existing barriers related to their implementation.

Design/methodology/approach

To achieve that, a scoping review was carried out in order to consolidate the main practices and barriers, and also to evidence research gaps and directions according to different theoretical lenses.

Findings

The findings show that there is a consensus on the potential of LP practices implementation in healthcare supply chain, but most studies still report such implementation restricted to specific unit or value stream within a hospital.

Originality/value

Healthcare organizations are under constant pressure to reduce costs and wastes, while improving services and patient safety. Further, its supply chain usually presents great opportunities for improvement, both in terms of cost reduction and quality of care increase. In this sense, the adaptation of LP practices and principles has been widely accepted in healthcare. However, studies show that most implementations fall far short from their goals because they are done in a fragmented way, and not from a system-wide perspective.

An integrative approach to improving patient care pathways

PURPOSE

Globally, healthcare managers continue to struggle with increasing demands for their services being delivered with limited or shrinking resources. It is, therefore, clear that systems, processes and practices need to change to meet these challenges. The purpose of this paper is to assess how integrating two improvement technologies, Lean and integrated care pathways (ICP) might help.

DESIGN/METHODOLOGY/APPROACH

Lean and ICP in healthcare provide a platform to develop conceptual frameworks for integrating two approaches.

FINDINGS

A conceptual integrated framework is provided to assist care pathway designers and implementers to consider the synergistic benefits of combining approaches to improvement.

RESEARCH LIMITATIONS/IMPLICATIONS

The authors provide a conceptual framework that requires empirically testing.

PRACTICAL IMPLICATIONS

This research provides a conceptual framework to aid practitioners to improve healthcare design and delivery.

ORIGINALITY/VALUE

For the first time, the authors bring together two approaches to improving patient care pathway design and consider how these are linked in relation to improving healthcare delivery.

Measuring Lean Six Sigma and quality performance for healthcare organizations

Purpose

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

Design/methodology/approach

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

Findings

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

Research limitation/implications

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

Originality/value

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

Lean leadership attributes: a systematic review of the literature

Purpose

Emphasis on quality and reducing costs has led many health-care organizations to reconfigure their management, process, and quality control infrastructures. Many are lean, a management philosophy with roots in manufacturing industries that emphasizes elimination of waste. Successful lean implementation requires systemic change and strong leadership. Despite the importance of leadership to successful lean implementation, few researchers have probed the question of ideal leadership attributes to achieve lean thinking in health care. The purpose of this paper is to provide insight into applicable attributes for lean leaders in health care.

Design/methodology/approach

The authors systematically reviewed the literature on principles of leadership and, using Dombrowski and Mielke’s (2013) conceptual model of lean leadership, developed a parallel theoretical model for lean leadership in health care.

Findings

This work contributes to the development of a new framework for describing leadership attributes within lean management of health care.

Originality/value

The summary of attributes can provide a model for health-care leaders to apply lean in their organizations.

Using Six Sigma DMAIC Methodology and Discrete Event Simulation to Reduce Patient Discharge Time in King Hussein Cancer Center

Short discharge time from hospitals increases both bed availability and patients' and families' satisfaction. In this study, the Six Sigma process improvement methodology was applied to reduce patients' discharge time in a cancer treatment hospital. Data on the duration of all activities, from the physician signing the discharge form to the patient leaving the treatment room, were collected through patient shadowing. These data were analyzed using detailed process maps and cause-and-effect diagrams. Fragmented and unstandardized processes and procedures and a lack of communication among the stakeholders were among the leading causes of long discharge times. Categorizing patients by their needs enabled better design of the discharge processes. Discrete event simulation was utilized as a decision support tool to test the effect of the improvements under different scenarios. Simplified and standardized processes, improved communications, and system-wide management are among the proposed improvements, which reduced patient discharge time by 54% from 216 minutes. Cultivating the necessary ownership through stakeholder analysis is an essential ingredient of sustainable improvement efforts.

Six Sigma in healthcare: a systematic review of the literature

Purpose

The purpose of this paper is to illustrate the systematic role played by Six Sigma methodology in improving the quality of healthcare. The literature review identifies the relevant opportunities for successful introduction and development of Six Sigma approach in healthcare sector.

Design/methodology/approach

A systematic methodology to identifying literature on Six Sigma in healthcare is presented. Web of Science, Medline, Emerald Insight, ASQ and ProQuest databases (1998-2016) were searched, and 68 papers of fair methodological quality were identified.

Findings

The findings of the systematic review reveal a growing interest in research on Six Sigma adoption in healthcare. The findings indicate that Six Sigma applications in healthcare have been focused on the entire hospital with no real focus on a particular department or function. The key findings on benefits, success factors, challenges and common tools of Six Sigma from the existing literature are also presented in the paper.

Research limitations/implications

The papers included in the systematic review were peer-reviewed papers available in English. Due to these limitations, relevant papers may have been excluded. Moreover, the authors have excluded all conference and white papers for their inclusion in this study.

Originality/value

This paper can serve as a guide on how Six Sigma approach can be applied to improve the quality of healthcare. The authors also believe that this is possibly the most comprehensive systematic literature review on the topic and will set the foundation for various research avenues based on the key findings of this study.

The social benefits of kaizen initiatives in healthcare: an empirical study

Purpose

The purpose of this paper is to identify the most influential determinants of healthcare employees’ problem-solving capabilities and attitudes towards kaizen initiatives, and clarify how these determinants are related to social outcomes.

Design/methodology/approach

Drawing on the input-process-outcome framework, applied to kaizen initiatives, the determinants of the input and process factors are embodied in hypotheses concerning the direct effects of input and process factors on social outcomes and the indirect effects of input factors on social outcomes resulting from process factors. The hypotheses are tested through multiple regressions using data from 105 kaizen initiatives drawn from two hospitals.

Findings

Of the 14 determinants investigated, goal clarity, team autonomy, management support, goal difficulty and affective commitment to change (ACC) are the most influential determinants of kaizen capabilities and/or employees’ attitude. Goal clarity, goal difficulty, team autonomy and management support are also found to influence social outcomes directly and/or indirectly through ACC, internal processes and/or an action orientation.

Practical implications

The results support healthcare practitioners to understand how to establish “focused kaizen” actions to leverage specific determinants that positively influence social outcomes.

Originality/value

This study provides an original contribution to the literature concerning effective kaizen initiatives in healthcare operations by empirically testing a comprehensive model of the relationship between kaizen initiative determinants and social outcomes. Unlike previous studies, which are mostly anecdotal or focused on one or few determinants, this research adopts a holistic view, and investigates a pluralist set of determinants on social outcomes through a systematic and quantitative approach.

How much of Toyota's philosophy is embedded in health care at the organisational level? A review

AIMS

Identify which of Toyota's principles are reported in health care institutions at the organisational level and to identify the type of reported outcomes related to the effectiveness of lean production reported in these studies.

BACKGROUND

No scientific research has been conducted to determine which of Toyota's principles are embedded in health care systems. This knowledge is needed to perform targeted adjustments in health care.

EVALUATION

Sixty studies were identified for the final analysis.

KEY ISSUE(S)

Some Toyota Way principles appear more deeply embedded in health care institutions than others are.

CONCLUSION

Not all principles of Toyota's philosophy and production system were embedded in the studies in this review. The type of reported outcomes at the organisational level was diverse.

IMPLICATIONS FOR NURSING MANAGEMENT

This literature review increases our knowledge about how many (and which) of the Toyota Way principles are embedded in health care. This knowledge may support reflection by nursing managers about how the full range of lean management principles could be embedded at the managerial and/or operational level.

A morphological analysis of research literature on Lean Six Sigma for services

Purpose

The purpose of this paper is to review the existing literature on Lean Six Sigma (LSS) for services, construct a morphological analysis (MA) framework and identify research gaps to point to future research possibilities and priorities.

Design/methodology/approach

The MA framework is based on literature review of 175 papers published from 2003 to 2015, across 67 journals recognised by Scopus or ABS Academic Journal Quality Guide 2015. A three-phased methodology is used by the authors, with Phase1 featuring a five-stage systematic review protocol to identify relevant journal papers for review; Phase2 presenting a framework for classifying the reviewed papers in terms of their fundamental, methodological, chronological and sector-wise orientations; and Phase3 constructing an MA framework on the classified papers and identifying the research gaps.

Findings

The MA framework constructed based on six dimensions, namely, organizational context of applications, desired outcomes, implementation systems, LSS tools and techniques, integration with other management philosophies and evaluation methods, involving 40 focused themes, has revealed 355 distinct research gaps as opportunities for future research.

Practical implications

This paper confirms the existence of substantial scope and points to specific topics for further research in the area of LSS for services. The findings demonstrate the gaps in academic research on the subject. In addition, the study also helps organisational leaders and practitioners to look at LSS from a holistic perspective in the services context.

Originality/value

The MA framework of the existing literature on LSS for services presents a unique, systematic effort to identify research opportunities. In addition, a five-stage systematic review protocol is proposed in this paper. This could be valuable to researchers and practitioners in enabling them to systematically review the literature on research subjects of interest to them.

The Development of a Six Sigma–Based Ulcus Decubitus Prevention Model to Respond to Adverse Events

Introduction: Based on the number of incidences of Ulcus Decubitus in 2015 which was 2.4 ‰ and 1.59 ‰ in 2016, the incidences of Ulcus Decubitus is an indicator of patient safety. In one of the public hospitals in Surabaya, it showed that the achievement of a Ulcus Decubitus indicator had not been reached yet (the standard is 1.5 ‰ per year). One of the efforts that can be done to prevent the occurrence of ulcus decubitus is by way of Six Sigma-based ulcus decubitus prevention.Methods: The design of this research was an explanatory research study using a cross-sectional approach. The research respondents were nurses at Inpatient Wards (4 Rooms); 57 nurses via the Purposive Sampling technique. The research data was analysed with Partial Least Square (PLS)Results: Individual factors (Path Coefficient 0,200 t: 6,580), organisational factors (Path Coefficient 0,373 t: 9,278) and management factors (Path Coefficient 0.099 t: 2.184) are all significantly correlated with the Six Sigma-based Ulcus decubitus prevention.Conclusions: Individual, Organisational and Management factors are important factors in the Six Sigma-based Ulcus Decubitus prevention model. It needs advanced research to find out how much the influence of Six Sigma-based Ulcus Decubitus prevention implementation will decrease the incidences of Ulcus Decubitus.

Analyzing Lean Six Sigma enablers: a hybrid ISM-fuzzy MICMAC approach

Purpose

The purpose of this paper is to identify Lean Six Sigma enablers (LSSEs) and analyse the interaction among the enablers via a hierarchical model developed by employing interpretive structural modelling (ISM) and determine the driving and dependence power of enablers through fuzzy MICMAC (Matriced’ Impacts Croise´s Multiplication Applique´ea´un Classement) analysis.

Design/methodology/approach

An expert group of industry professionals and academicians is consulted at the initial stage as an input for ISM methodology to explore the paired relationship among LSSEs for each parameter of Lean Six Sigma (LSS) implementation. The outcome of ISM is further utilized by fuzzy MICMAC analysis to discover the enablers that are strong drivers and highly dependent. Fuzzy set is included in MICMAC analysis in order to obtain more precise output and effective model.

Findings

In total, 20 key enablers are identified through a literature review and expert opinion that emerged as the most significant factors towards LSS implementation. The identified enablers are portrayed into a structural form representing as input and output variables. Later, the driving and the dependence power of each enabler is presented in cluster form.

Research limitations/implications

The paired relationships among LSSEs are obtained through the interpretation made by the experts. The judgments of experts are subjective and may be biased; as difference in expert opinion may influence the final outcome. Conducting a large-scale survey may provide a better catch for interactions of LSSEs.

Practical implications

This study provides strong practical implications for researchers as well as industry practitioners. The industry professionals must deliberately focus on the identified LSSEs more conservatively during LSS implementation and the top management should plan strategically to avoid any implementation failure.

Originality/value

The present study identifies 20 crucial enablers of integrated LSS and presents them in a hierarchical form which will be beneficial for researchers and practitioners. The interactions among the enablers shown in cluster form will help in better execution of LSS.

Lean Thinking in Global Health Care

This chapter explains the overview of Lean production; the overview of value stream mapping (VSM); the applications of Lean production in global health care; the implementation of Lean production in global health care; and the challenges and implications of Lean production in global health care. Lean production can be used to identify and eliminate the wastes in any health care activity performed within a health care facility. Lean production can be applied to hospitals and health care organizations to redesign health care processes toward improving the quality of care and reducing costs and wastes. Successful Lean health care efforts result in the measurable improvements in patient outcomes, such as improved quality, less harm due to preventable errors, better access, shorter waiting times, and better service. Implementing Lean production has the potential to enhance health care performance and gain sustainable competitive advantage in global health care.

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

Purpose

– The purpose of this paper is to illustrate how Lean Six Sigma (LSS) methodology was applied to a medical records department (MRD) of a hospital in India to reduce the Turn-Around-Time (TAT) of medical records preparation process and thus to improve the productivity and performance of the department.

Design/methodology/approach

– The research reported in this paper is based on a case study carried out using LSS approach and in improving the medical records preparation process.

Findings

– The root causes for the problem were identified and validated through data-based analysis from LSS tool box, at different stages in the project. As a result of this project, the TAT was reduced from average 19 minutes to eight minutes and the standard deviation was reduced by one-tenth, which was a remarkable achievement for department under study. This was resulted in the reduction in the work-in-process inventory of medical records from 40 units to 0 at the end of the day. Project in-turn reduced the staffing level from the earlier level of six to a current level of four.

Research limitations/implications

– The paper is based on a single case study executed in IP-MRD of a single hospital and hence there is limitation in generalizing the specific results from the study. But the approach adopted and the learning from this study can be generalized.

Originality/value

– This paper will be helpful for those professionals who are interested in implementing LSS to healthcare organization to improve the productivity and performance.