TQM and lean strategy deployment in Italian hospitals

Implementation of Wayfinding Signage in Public Hospitals and Its Evaluation Towards Quality Improvement

Background: Signage is important in any public place. It involves information about nomenclature, wayfinding, service timing, emergency preparedness, and regulatory compliance. It plays an important role in helping the patient reach their desired destination with minimum difficulty, thereby enhancing the patient experience. The hospital under study is a vast facility encompassing 130 acres. Outpatient services have a monthly footfall of nearly 1 lakh patients, and there are about 1,800 admissions per month. Patients and visitors are usually unaware of the facility and face difficulties in wayfinding amidst the large number of patients. Due to difficulty in wayfinding, the patients often seek the help of hospital staff to reach the desired locations. Trilingual signage (English, Hindi, and regional language - Odia) was installed in a 960-bed tertiary care public hospital in Eastern India as a Quality Improvement initiative towards the goal of a patient-friendly hospital.

OBJECTIVE

The study aims to evaluate the multi-lingual signage system in the hospital and recommend suggestions.

METHODOLOGY

Wayfinding or the signage work was undertaken as a Total Quality Management (TQM) Project in the study setting, conducted over 36 months. The effectiveness of the signage system was evaluated using a questionnaire-based survey among the patients, attendants, and other visitors.

RESULTS

Color-coded multilingual signage installed in the hospital block and its surrounding areas included the naming of various areas, way-finding, and safety signage. The most difficult areas to find were ICUs (35.6%), OT (31.1%), and laboratories (31.1%). Additionally, 98% of the participants could reach their desired destination but had to double-check with the staff.

CONCLUSION

It was evident from the study that hospital signage plays a crucial role in hospitals by improving wayfinding, enhancing the patient experience, and promoting safety and emergency preparedness. Signage also indirectly contributes to better patient care. In large teaching hospitals, human assistance is also necessary for wayfinding.

Leadership to promote patient safety culture in public hospitals managed by social health organizations

PURPOSE

This paper aims to identify the kind of internal climate leaders should offer health-care professionals to promote a patient safety culture in public hospitals managed by social health organizations in Brazil.

DESIGN/METHODOLOGY/APPROACH

Two surveys were applied to health-care professionals working at three Brazilian public hospitals. The internal climate survey reached 1,013 respondents, and the patient safety culture survey reached 1,302 participants. Both factor and regression analyses were used to analyze the study model and determine how internal climate influences patient safety culture.

FINDINGS

Results indicate that to promote a patient safety culture among health-care professionals, leaders should generate an internal climate based on trust to foster pride in working in the hospital. Possibly, the trust dimension is the most important one and must be developed to achieve job satisfaction and provide better services to patients.

RESEARCH LIMITATIONS/IMPLICATIONS

All the hospitals studied were managed by the same Organização Social de Saúde. Due to the limited responses concerning the respondents' profiles, demographic variables were not analyzed.

PRACTICAL IMPLICATIONS

This research reveals that the trust and pride dimensions can most strongly influence a positive patient safety culture, helping hospital leaders face this huge managerial challenge of consistently delivering high standards of patient safety.

ORIGINALITY/VALUE

This research studies the promotion of a patient safety culture in public hospitals managed by social health organizations, characterized by greater flexibility and autonomy in health-care management and by a greater need for accountability.

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.

The moderating role of Lean Six Sigma practices on quality management practices and quality performance in medical device manufacturing industry

Purpose

The purpose of this paper is to explore the moderating role of Lean Six Sigma (LSS) practices in explaining the relationship between quality management practices (QMPs) and quality performance.

Design/methodology/approach

Partial least square-based structural equation modeling (PLS-SEM) was used to empirically examine the moderating effect of LSS practices on QMPs and quality performance in Malaysian medical device manufacturing companies.

Findings

Findings revealed that both QMPs and LSS practices have a significant and positive effect on quality performance. Furthermore, LSS practices served as a substitute for moderating the positive relationship between QMPs and quality performance in such a way that the relationship becomes weaker as LSS practices increase.

Originality/value

LSS is acknowledged as the most well-known hybrid methodology; however, due to its relative newness, it has not been studied in great detail. Unlike previous studies, this paper argued that Lean and Six Sigma practices are distinct from its predecessor TQM practices; moreover, both Lean and Six Sigma practices do not need to substitute QM/TQM practices instead of complimenting the QMPs. In addition, this study adds to the growing body of QM literature by empirically examine the effect of LSS practices in moderating the relationship between QMPs and quality performance.

An empirical investigation of performance assessment of Indian healthcare industry

Purpose

The purpose of the study is to measure the performance of Indian hospitals, both operationally and financially, by using hospital KPI's. The assessment is predominantly done by linking it to the existing Lean practices in Indian hospitals.

Design/methodology/approach

An empirical study based on cross-sectional survey of hospital managers and specialists in various private healthcare facilities across India was conducted to validate the proposed Lean framework. From an extensive literature survey, the authors identified quality, delivery, efficiency, accessibility and patient centeredness to be the main operational performance (OP) indicators for hospitals. Business or financial performance was measured based on parameters which are average revenue per occupied bed (ARPOB), earnings before interest, tax, depreciation and amortization (EBITDA) and operating revenue. Confirmatory Factor Analysis (CFA) was carried out using a specialized technique, called Structural Equation Modelling(SEM) and an explicit factor structure was hypothesized.

Findings

Management commitment towards Lean in hospitals is statistically proven to have impacted operational and financial performance. However, leanness in technology and business processes showed no statistical significance on either operational or financial performance parameters. Hospital stakeholders showed statistical significance on though it had no impact on the financial performance. Results obtained from the statistical analysis indicate a positive impact of hospital Lean practices on timely delivery of services and improved service quality. Efficiency, accessibility of services and patient centered behavior in hospital operations could not be statistically proven to have impacted the financial performance.

Social implications

Effectiveness of Lean management (LM) principles in improving hospital operations is largely dependent on patient centered behavior. Empowered employees who are trained to add value from a customer view point, make hospital operations safe and improved. Properly trained and communicated employees who are committed to quality improvements can make a positive impact on patients' quality of life and thus positively impact the society. The study lists ways to attain the required outcomes.

Originality/value

This paper is among the very few that has attempted to suggest ways to link implementation of Lean practices more effectively in Indian hospitals to improve hospital performance at operational and financial levels.

Implementation of Lean Management in a Multi-Specialist Hospital in Poland and the Analysis of Waste

At the beginning of the 21st century, Lean Management (LM) tools were introduced into the healthcare sector around the world. In Poland, there are still few LM implementations, and they are not of a comprehensive nature. The aim of this article is to present the application of the LM concept in a hospital in Poland as a tool for the identification and analysis of waste and its impact on the process of organizing the provision of medical services on the example of improvements in the process of patient admission. In the period from 1 July 2019 to 31 December 2019, a project of LM implementation was carried out at the Provincial Specialist Hospital in Wroclaw. The project was based on the method of value-stream mapping and 5Why. Standardized interviews (before and after the project) were conducted with people from the hospital management and middle-level managers. The implementation of LM tools resulted in the identification of a number of wastes, which have been divided into groups. The most important waste was paper medical documentation. Its change to an electronic form allowed for a better use of human capital resources; savings included 2.3 nursing positions and 1.09 medical staff positions.

The influence of soft and hard TQM on quality performance and patient satisfaction in health care: investigating direct and indirect effects

PURPOSE

The present study conceptualizes total quality management (TQM) in terms of soft and hard aspects and examines their effects on quality performance and patient satisfaction. The indirect effects of soft and hard TQM on patient satisfaction through quality performance are also investigated.

DESIGN/METHODOLOGY/APPROACH

A multi-item questionnaire was prepared to gather primary data from a sample of 312 medical employees in private hospitals in Jordan. The measurement model was evaluated for validity and reliability and determined to be acceptable. Structural equation modeling (SEM) was applied to test the research hypotheses.

FINDINGS

The results revealed that soft TQM has a strong positive effect on quality performance and patient satisfaction. Hard TQM was found to positively affect quality performance but to a lesser extent compared to soft TQM. The effect of hard TQM on patient satisfaction, meanwhile, was not significant. Quality performance positively mediated the relationship between TQM - both soft and hard - and patient satisfaction.

ORIGINALITY/VALUE

This study is one of the first to conceptualize TQM in terms of soft and hard aspects in a health care context. It offers valuable insights for managers of private hospitals looking to enhance quality performance and patient satisfaction. The results reveal that soft TQM is the primary driver of quality performance and patient satisfaction in the health care context, which is in stark contrast to the manufacturing sector.

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.

Development of supply chain value stream map for government-supported drug distribution system

Purpose

The requirement of high-quality government-supported healthcare services has necessitated the significance of recognizing new management practices to enhance patient satisfaction. Hence, the purpose of this study is to address the patient's enhanced custom needs through the implementation of supply chain value stream mapping (SCVSM) in government-supported drug distribution system (DDS) for enhanced patient's satisfaction.

Design/methodology/approach

This study elucidates the role of one popular emerging management technique (i.e. SCVSM) in the healthcare sector by an investigative case study. The DDS in Rajasthan (India) was selected for this study. The data for this analysis were gathered in three ways (i.e. direct observation, documentary analysis and semi-structured interviews).

Findings

The outcome of this current study reveals that it is possible to apply the tool (SCVSM) to investigate the wastes in DDS to deliver the medicines at right time, right quantity and right quality. The application of SCVSM concluded that the various Kaizens (areas needed to improve) in lead time; transportation and routing should be adopted. The study further implemented kaizen on the current SCVSM and developed future SCVSM.

Research limitations/implications

Although various stages and functions exist in the healthcare supply chain, the current study is focused on the distribution system of drugs. The proposed approach provides a platform for both researchers and academicians to understand the existing DDS and to implement the SCVSM approach in the healthcare environment. The results show that the proposed SCVSM model is able to identify some operational bottlenecks and wastes which interfere in DDS.

Originality/value

It was observed that limited literature related to lean implementation on DDS and implementation of SCVSM on the healthcare environment in general and government-supported or public in specific are available. The current study on the application of SCVSM in DDS is unique in nature and will definitely add value to the existing literature of the application of value stream mapping (VSM) on the healthcare supply chain management field.

The Influence of Employee Empowerment on Competitive Advantage in Hospitals within Nairobi, Kenya

Background:

The study examined the influence of implementation of employee empowerment on competitive advantage in hospitals within Nairobi. The study looked at the following aspects of employee empowerment; competence, teamwork, motivation, reward and recognition. Employee empowerment is derived from the Total Quality Management (TQM) principles bringing forth competitive advantage that results from high customer satisfaction levels, employee satisfaction and operations efficiency.

Methods:

A descriptive correlational research design that applied positivism philosophy. Data was collected from both private and public hospitals within Nairobi targeting patients who were admitted in these hospitals for more than three days during the study period and senior employees of the respective hospitals. There were 308 participants, 154 hospital employees and 154 patients from 31 hospitals within Nairobi. After institutional and individual consent was obtained, participants filled a self-administered questionnaire. The collected data was coded into SPSS Version 23 software and the analysis was done using descriptive and inferential statistics.

Results:

The findings illustrated that employee empowerment significantly predicted competitive advantage. High responsiveness and good attitude, being reliable, empathy and assuring the patients of their state best enhance patients’ and employee satisfaction.

Conclusion:

This brings out the importance of realigning the staff inputs towards improving patient experiences, as well as considering employees’ performance as individual instead of considering them as teams.

Benchmarking outcomes on multiple contextual levels in lean healthcare: a systematic review, development of a conceptual framework, and a research agenda

BACKGROUND

Reliable benchmarking in Lean healthcare requires widely relevant and applicable domains for outcome metrics and careful attention to contextual levels. These levels have been poorly defined and no framework to facilitate performance benchmarking exists.

METHODS

We systematically searched the Pubmed, Scopus, and Web of Science databases to identify original articles reporting benchmarking on different contextual levels in Lean healthcare and critically appraised the articles. Scarcity and heterogeneity of articles prevented quantitative meta-analyses. We developed a new, widely applicable conceptual framework for benchmarking drawing on the principles of ten commonly used healthcare quality frameworks and four value statements, and suggest an agenda for future research on benchmarking in Lean healthcare.

RESULTS

We identified 22 articles on benchmarking in Lean healthcare on 4 contextual levels: intra-organizational (6 articles), regional (4), national (10), and international (2). We further categorized the articles by the domains in the proposed conceptual framework: patients (6), employed and affiliated staff (2), costs (2), and service provision (16). After critical appraisal, only one fifth of the articles were categorized as high quality.

CONCLUSIONS

When making evidence-informed decisions based on current scarce literature on benchmarking in healthcare, leaders and managers should carefully consider the influence of context. The proposed conceptual framework may facilitate performance benchmarking and spreading best practices in Lean healthcare. Future research on benchmarking in Lean healthcare should include international benchmarking, defining essential factors influencing Lean initiatives on different levels of context; patient-centered benchmarking; and system-level benchmarking with a balanced set of outcomes and quality measures.

The impact of organizational culture archetypes on quality performance and total quality management: the role of employee engagement and individual values

Purpose

The relationship between organizational culture and total quality management (TQM) can be facilitated by the virtue of certain psychological states. Employee engagement refers to a mechanism foreseeable to predict the successful implementation of TQM. Therefore, this study focuses on the attribution theory to propose a model that presents a differential impact of organizational culture archetypes on quality performance and TQM, while underlying role of employee engagement and individual values.

Design/methodology/approach

An empirical study was performed based on the data collected from 153 senior employees working in hotel companies. This study has used partial least squares path modeling (PLS-SEM) to test the relationships and model proposed.

Findings

The findings have confirmed the hypotheses using PLS-SEM and provided a positive significant impact of organizational culture archetypes on employee engagement with quality initiatives; individual values on organizational cultural archetypes and employee engagement with quality initiatives on TQM implementation.

Originality/value

The study concluded that the impact of organizational culture on quality performance and TQM is significant. It is, therefore, suggested that management of hotel companies should work to increase the level of engagement, encourage cultures, while reducing the level of power culture with the emphasis given to individual and organizational quality initiatives.

Line managers and employees use of lean task boards in Norwegian municipal healthcare sector: a tool for action learning?

PURPOSE

This study aims to analyse the line managers and employees' use of lean task boards over time in Norwegian municipalities using action learning theory. The research question was the following: what kind of action learning processes do the line managers and employees' use of the lean task board promote in municipalities' healthcare units?

DESIGN/METHODOLOGY/APPROACH

This qualitative case study data from a Norwegian municipality involved analyses of 750 internal self-recorded logs from task board sessions from 6 different units and 25 semi-structured interviews of managers and employees.

FINDINGS

The task board works for line managers to make employees responsible for forwarding ideas, solutions and implementation of new actions. The use of the task boards contributes to systemising work through establishing new routines and improving orderliness at work. The line managers used the task boards as a project management system to track progress in the purchasing of diverse equipment and initiatives to improve professionalism and their units' facilities. The study explains the learning challenges for managers using the lean task board, as the method promotes finding experience-based solutions that do not involve critical reflection and use of theory.

PRACTICAL IMPLICATIONS

The lean task board is well-suited for managers to promote learning processes that counteract chaos in local healthcare organisations. However, the task board has limitations as a method for improving services amongst healthcare units and for solving difficult problems.

ORIGINALITY/VALUE

The study contributes to understanding how action learning theory can be applied to the analysis of the results of lean task board sessions.

Aligning operational practices to competitive strategies to enhance the performance of Indian manufacturing firms

Purpose

The main purpose of this study is to understand how collective operational practices are adapted or stimulated by a firm's competitive strategy.

Design/methodology/approach

This study employed a data set drawn from 124 plant managers and directors of Indian manufacturing firms. Multiple regression was used to examine the impact of operational practices of lean, total quality management (TQM) and supply chain management (SCM) within competitive clusters of cost leadership, differentiation and focus strategy.

Findings

Results of the study show that the pattern of impact of operational practices on firm's performance varies according to type of the competitive strategy employed. All the three competitive strategy clusters have reported that TQM is the most important trigger for Indian manufacturing firms with relative effect of TQM practices on firm's performance being higher than that of lean and SCM practices.

Research limitations/implications

Cross-sectional data from Indian manufacturing firms were used, and it would be interesting to test the analytical framework of the study for more sectors and countries. Future studies can take a longitudinal research approach to strengthen the findings of the study.

Practical implications

The findings explain how operational practices are aligned with competitive strategies for practitioners so that they can assign limited resources to build diverse operational capabilities based on their strategic choices.

Originality/value

Although very few classical studies are reported in various contexts involving competitive strategy, operational practices and firm's performance, no existing study focuses on how these three domains are linked together in the context of Indian manufacturing sector.

The relationship between quality and governance mechanisms

Purpose

Recent literature has highlighted the importance of quality and governance in supply networks. Usually, the relationships between the actors are complex, comprising both formal and informal interactions. Despite recent advances in quality and governance in supply networks, extant literature highlights the lack of quality in healthcare supply-chain networks in relation to governance mechanisms. This paper aims to investigate the role of governance mechanisms and their influence on the quality of healthcare supply networks, and assumes that governance instruments can support quality performance.

Design/methodology/approach

A multiple-case research approach was employed. Six organisations in the Brazilian healthcare sector were analysed (four operate only with renal replacement therapy, one is a material supplier, and one operates with renal replacement therapy and collective procurement).

Findings

Findings showed that there is no formalised supply network structure in these organisations. A possible consequence of this is that the supply-network governance is dominated by informal relationships. In the quality dimension, managers' awareness is limited, but there are mechanisms in place to control the quality of the materials.

Practical implications

Healthcare managers can actively invest in the social aspects of the relationship between buyer and supplier, such as trust and commitment, thus increasing responsiveness in patient care. However, this informal procedure can lead to problems with tracking and reliability, ultimately leading to quality problems. Therefore, it is recommended that formal and informal governance instruments be used jointly to improve service quality.

Originality/value

This study suggests that the integration of formal and informal mechanisms of governance can improve the quality of supply networks. Additionally, if the administrative process is purely formal, network relationships and their efficiency will be impaired.

Ranking model of total quality management enablers in healthcare establishments using the best-worst method

Purpose

Recent years have witnessed a significant rise in Indian healthcare establishments (HCEs) which indicate that there is a constant need to improve the healthcare quality services through the adoption and implementation of TQM enablers. The purpose of this paper is to identify such enablers and then propose a ranking model for TQM implementation in Indian HCEs for improved performance.

Design/methodology/approach

The study identifies 20 TQM enablers through comprehensive literature survey and expert’s opinion, and classifies them into five main categories. The prominence of these enablers is established using a recently developed novel multi-criteria decision making (MCDM) method, i.e. best-worst method (BWM). The importance of the various main category and sub-category enablers is decided on the basis of their weights which are determined by the BWM. In comparison to other MCDM methods, such as analytical hierarchy process, BWM requires relatively lesser comparison data and also provides consistent comparisons which results in both optimal and reliable weights of the enablers considered in this paper. Further, a sensitivity analysis is also carried out to ensure that the ranking (based on the optimal weights) of the various enablers is reliable and robust.

Findings

The results of this study reveal that out of five main category enablers, the “leadership-based enablers (E1)” and the “continuous improvement based enablers (E5)” are the most and the least important enablers, respectively. Similarly, among the 20 sub-category enablers, “quality leadership and role of physicians (E14)” and “performing regular survey of customer satisfaction and quality audit (E52)” are the most and the least dominating sub-category enablers, respectively.

Research limitations/implications

This study does not explore the interrelationship between the various TQM enablers and also does not evaluate performance of the various HCEs based on the weights of the enablers.

Practical implications

The priority of the TQM enablers determined in this paper enables decision makers to understand their influence on successful implementation of the TQM principles and policies in HCEs leading to an overall improvement in the system’s performance.

Originality/value

This study identifies the various TQM enablers in HCEs and categorizes them into five main categories and ranks them using the BWM. The findings of this research are quite useful for management of the HCEs to properly understand the relative importance of these enablers so that managers can formulate an effective and efficient strategy for their easy and smooth implementation which is necessary for continuous improvement.

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.

Lean management and operational performance in health care

Purpose

The purpose of this paper is to examine the impact of lean management (LM) on operational performance (OP) in the context of health care in Jordanian private hospitals. LM is measured using four bundles: total quality management (TQM), human resource management (HRM), just-in-time system (JIT) and total productive maintenance (TPM). The study also investigates the effects of OP dimensions on hospitals’ business performance (BP).

Design/methodology/approach

The study is based on survey data collected from 260 respondents from 25 private hospitals in Jordan. Validity and reliability analyses were performed using SPSS and Amos, and the study hypotheses were tested using structural equation modeling.

Findings

The study found that the TQM bundle affects quality performance positively, but does not affect efficiency and accessibility performances, while the HRM bundle positively affects all OP dimensions. Furthermore, the JIT bundle positively contributes to both efficiency and accessibility performances, while the TPM bundle positively influences quality and accessibility performances. Moreover, the results have demonstrated that OP dimensions of quality and accessibility significantly and positively affect hospitals’ BP.

Originality/value

This study is one of the first to adapt the four lean bundles popularized in the manufacturing sector and apply them in a health-care context. It examines the effects of the four lean bundles on hospitals’ OP in terms of efficiency, quality and accessibility. In addition, the study demonstrates the role of OP dimensions in improving private hospitals’ BP.

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 bundles in health care: a scoping review

PURPOSE

The purpose of this paper is to review original research on lean management (LM) in health care to identify potential research gaps and present recommendations for future research. The paper also discusses the current state of implementing LM practices in health care. In addition, it presents and highlights "lean bundles" imported from manufacturing, namely, total quality management (TQM), human resource management, just-in-time and total productive maintenance, as a potential implementation strategy of LM in hospitals to optimize overall health care performance.

DESIGN/METHODOLOGY/APPROACH

The scoping review was conducted based on the guidelines specified by Arksey and O'Malley (2005). Relevant included studies were retrieved by searching various electronic databases. The PRISMA guidelines were applied to identify and select eligible studies.

FINDINGS

The majority of previous studies used selected practices to measure LM in health care. In most cases, these practices reflected a narrow and biased view of LM. Lean bundles which comprehensively view LM and reflect all its aspects have rarely been discussed in the health care literature. Evidence about the contribution of lean bundles to hospital performance needs to be addressed in future studies.

PRACTICAL IMPLICATIONS

This paper demonstrates the implementation of the four lean bundles in hospitals. It argues that, instead of adopting one dimension or selected practices of LM, hospitals viewing LM as a comprehensive multi-dimensional approach through the adoption of the four lean bundles are expected to maximize their performances.

ORIGINALITY/VALUE

This is one of the first works to comprehensively review and discuss lean bundles in the context of health care. It argues that the adoption of the four lean bundles by hospitals will enable them to yield the maximum LM performance benefits. In addition, a proposed survey questionnaire based on the literature review is provided to assist researchers in conducting future empirical studies.

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.

Quality Management Systems in the Ambulant Sector: An Analytical Comparison of Different Quality Management Systems

BACKGROUND

Since 1 January 2004, all physicians, psychotherapists, and medical care centers that are under contract to statutory healthcare in Germany are obliged, according to § 135a Section 2 of the Fifth Social Security Statute Book, to introduce an intra-institutional quality management system.

METHODS

A total of 24 medical practices were chosen through random sampling. In total, there were 12 family physicians and specialist practices each and eight practices each per quality management system. The analysis was carried out with the help of three specially developed questionnaires (physician, employee, and patient). A total of 26 quality categories with different questions were available in the three survey groups (physicians, employees, and patients). The Kruskal⁻Wallis test checked the extent to which the different scores between the quality management systems were significant and effective for specialists or family physicians.

RESULTS

"Quality and Development in Practices (QEP)" had the highest average score. Due to a specific family practitioner specialism, "Quality management in Saxony medical practices (QisA)" followed with good average scores. The individual quality categories in the quality management systems, such as the "range of services" or "allocation of appointments", received the highest average scores among the specialists. In contrast, categories such as "telephone enquiries" and "external cooperation and communication" received the highest average scores among the family physicians.

CONCLUSION

Differences in the evaluation of quality management systems and medical groups (specialists/family physicians) were found in the study. The reasons for these differences could be found in the quality categories.

Brazilian nursing professionals: leadership to generate positive attitudes and behaviours

PURPOSE

This paper aims to identify the kind of work environment that should be offered by hospital leaders to their nursing staff in Brazil to generate job satisfaction, organizational commitment and organizational citizenship behaviour within their field of expertise.

DESIGN/METHODOLOGY/APPROACH

A survey was applied to 171 nurses and 274 nursing technicians who work at five private hospitals in Brazil. Both factor analysis and regression analysis were used to analyse the study model.

FINDINGS

The results indicate that to stimulate positive behaviours and attitudes among nursing staff, managers should mainly be concerned about establishing a clear and effective communication with their professionals to ensure role clarity, promote a good working environment and encourage relationships based on trust.

RESEARCH LIMITATIONS/IMPLICATIONS

The limitations of the study are absence of the researcher while the questionnaires were filled out and the fact that the sample comprised respondents who made themselves available to participate in the research.

PRACTICAL IMPLICATIONS

This study contributes to elucidate the factors that can promote a good internal climate for nursing staff, assisting hospital leaders to face the huge managerial challenges of managing, retaining and advancing these professionals.

ORIGINALITY/VALUE

The findings contribute to the body of knowledge in leadership among nursing professionals in developing countries. Hospital leaders in Brazil should encourage trusting relationships with nursing professionals through clear, effective and respectful communications, besides investing in team development and promoting a good working environment.

TQM implementation for the healthcare sector

Purpose

The purpose of this paper is to enlarge the debate on total quality management (TQM) implementation in the healthcare sector and to evaluate how and whether leadership can affect TQM implementation.

Design/methodology/approach

This paper is based on findings from a literature review of TQM and leadership. The authors analysed these findings to categorise causes of a lack of leadership in TQM programme implementations.

Findings

The authors propose three categories of causes of a lack of leadership in TQM programme implementation. The first cause is well-known: a lack of senior managers’ involvement and commitment. The second category is the “combined leadership” that occurs in large healthcare organisations; and the third category is the influence of an external “political leadership” on public healthcare.

Research limitations/implications

This paper presents researchers with three categories of causes of failure of leadership in TQM implementation that can be investigated. It also encourages reflections from practitioners concerning TQM leadership in the healthcare sector.

Practical implications

The authors request that practitioners reflect on ways to create or sustain a “monolithic” leadership, especially in large organisations, to ensure a common vision, values and attitude for unitary TQM governance.

Originality/value

In an original way, this paper analyses and proposes three categories of causes linked to a lack of TQM leadership in the healthcare sector.