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

Shreeranga Bhat; Jiju Antony; E. V. Gijo; Elizabeth A. Cudney

doi:10.1108/IJQRM-07-2018-0193

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

Shreeranga Bhat, Jiju Antony, E. V. Gijo, Elizabeth A. Cudney

Management Science & Engineering

Research output: Contribution to journal › Article › peer-review

69 Scopus citations

Abstract

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.

Original language	British English
Pages (from-to)	90-111
Number of pages	22
Journal	International Journal of Quality and Reliability Management
Volume	37
Issue number	1
DOIs	https://doi.org/10.1108/IJQRM-07-2018-0193
State	Published - 6 Jan 2020

Keywords

Healthcare
India
Lean
Lean Six Sigma
Medical records
Six Sigma

Access to Document

10.1108/IJQRM-07-2018-0193

Cite this

@article{396e6230b4ca445985389d5bac99397b,

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

abstract = "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.",

keywords = "Healthcare, India, Lean, Lean Six Sigma, Medical records, Six Sigma",

author = "Shreeranga Bhat and Jiju Antony and Gijo, {E. V.} and Cudney, {Elizabeth A.}",

note = "Funding Information: Montgomery , D.C. and Runger , G.C. ( 2007 ), Applied Statistics and Probability for Engineers , John Wiley & Sons , New York, NY . Table I Summary of LSS applications in hospitals S. No. Author Objective Methodology/Tools Findings Conclusions/Challenges 1 Bahensky et al. (2005) To eliminate non-value adding activities in radiology CT scanning Faxing patient information, early contrast administration, transfer of patient information, insertion coverage, CT room escorts and exam procedure scheduling Command centre experienced 30% reduction in calls Patient throughput increased by 31% Total takt time reduced by 30% Patient experience time decreased by 33% Travel time for technicians declined by 91% LSS can be combined with the kaizen approach for better results Team dynamics enable the project to draw solutions through free exchange of ideas The cross-functional team, cultural change and top management support are crucial for the success of an LSS project 2 Fairbanks (2007) To improve operating room throughput Process measurement, process mapping, education and staging area for first cases of the day Increase in on-time start from 12% to 89% Decrease in mean TAT from 23.8 to 17.9 min Increase in perception of employee teamwork and overall facility rating The project has improved patient flow, and teamwork and pride among perioperative staff members Research culminated that LSS has a positive implication for both staff members and facility 3 Yu and Yang (2008) To improve the OP-MRD average waiting time Simulation, regression, time series plot and gemba Decrease in average waiting time from 42.3 to 6.55 min LSS has the potential to tackle high healthcare cost and low efficiency, which are of major concern for consumers, business leaders, insurance industry and governments The research concluded that developing an effective approach to reduce healthcare cost and increase healthcare efficiency without compromising healthcare quality is the need of the hour 4 Wijma et al. (2009) To improve the efficiency of the nursing department Pie chart, Pareto chart and waste elimination Substantial decrease in the annual cost of the nursing department after deployment LSS is a structured methodology to solve complex operational problems LSS stimulates organizational innovations To be effective, LSS demands an organizational framework, with specific roles and responsibilities for MBBs, BBs, GBs, and methods from project management to monitor progress and schedules LSS works better through the DMAIC roadmap LSS draws effective solutions based on data, and not just hypothesis and deliberate analysis 5 Bisgaard and Does (2009) To reduce the length of stay at the hospital Dot plot, Pareto chart, scatter plot, control charts, ANOVA and box plot Decrease in average length of stay by 2.4 days for a patient volume of approximately 30 patients per year with annual savings of $36,000 LSS is a results-oriented approach, which ensures improved quality, while reducing costs on both the clinical and operational side of healthcare The strategy not only aids the patients, but also healthcare providers and the bottom line 6 Yamamoto et al. (2010) To improve profit by increasing insulin medication safety and delivery Flow charts, failure mode and effects analysis, ANOVA, and cause and effect diagram Overall cost savings estimated to be $75,000 The LSS methodology demonstrates positive, validated outcomes in improving patient safety and patient care Commitment of the hospital administration and staff are critical to the success of the project 7 Schoonhoven et al. (2011) To improve the allocation of resources VSM and statistical tools About 95% of patients had an appointment for first consultation within 10 days Throughput times within 14 days resulting in increased revenue amounting to $70,000 LSS together with the conceptual framework developed by de Mast et al. (2011) can help to diagnose and resolve workflow and efficiency problems 8 Mozammel and Mapa (2012) To improve the process of nursing shift directors Cause and effect diagram, process flow chart and statistical charts Free time of nursing shift directors increased to 17 from 2.8%, which is used for patient care Reduction in overall documentation from 39 to 26% The DMAIC approach is a consistent and standardized way of problem solving for the LSS methodology 9 Lokkerbol et al. (2012) To reduce work-related injuries in the hospital Control charts and frequency table Average number of incidents dropped from 12 to 7.2 The challenge of LSS project deployment is in changing the behaviour of the organization and its employees Focussing on implementation and developing a creative and recognizable system are critical elements for a LSS project 10 Sanders and Karr (2015) To reduce the TAT for the emergency department (ED) specimens Statistical tools and waste reduction Vials used for testing and in extra specimens decreased by 50% ED specimens without orders declined by 90% Complete blood count analysis TAT reduced by 30% Troponin TAT variation cut by 10% ED registered nurses rainbow draw time decreased from 5 to 2 min The LSS methodology, which extracts a project-focussed approach from Six Sigma and relies less on the speed of Lean, can also give rapid improvement results in the hospitals 11 Nayar et al. (2016) To remove wasteful processes and implement a more robust process Value stream mapping and process redesign The barrier to smooth process flow was identified as the receipt of the non-Veterans Health Administration medical record, which resulted in delays in filling prescriptions. The crucial factors determined during the work were veteran education, process redesign and outreach to community providers LSS can be applicable even to simple processes, where Lean dominates under the DMAIC umbrella of the SS Table II Summary of LSS projects deliverables in the MRD of Indian hospitals 0,000 5,000 Project VOC KPIs CTQ CSFs STTs Outcomes A Quick service Waiting time, queue length Cycle Time Leadership, data through information technology (IT), training on LSS tools, involvement of staff, and motivation of the employees I-chart, simulation, cause and effect diagram, 5S, kanban, gemba, two-sample t -test and waste analysis 65% reduction in average cycle time 97% decrease in average waiting time 97% reduction in queue length Annual Savings of $7,000 B Reduced operational costs Inventory reduction, improved productivity Turnaround time Visionary leadership, top management commitment and involvement, employee involvement, involvement of scientific (doctors and nurses) staff, availability of data, effective communication, and knowledge about tools and techniques for problem solving I-chart, cause and effect diagram, 5S, kanban, check sheets, run chart, standardization, poka-yoke, visual management, waste analysis, two-sample t -test and gemba 25% decrease in the TAT of the process Zero inventory of the medical records and other work-in-progress (WIP) files at the end of the day Annual Savings of Annual Savings of $10,000 C and D Quick and quality service, reduced operational costs Waiting time, queue length, percentage scheduled utilization of staff, and inventory Cycle time and TAT Top management involvement and commitment; empirical validation in every phase; organizational belief, vision and culture; LSS projects{\textquoteright} success celebration; regular and clear communication; visionary leadership; involvement of cross-functional team; availability of data; project selection, prioritization and tracking; and training on LSS methodology and its associated tools and techniques Xbar-R chart, cause and effect diagram, 5S, standardization, poka-yoke, visual management, analysis of variance (ANOVA), two-sample t -test, multi-vari chart, gemba, group technology, cell layout, takt time, value stream mapping (VSM), simulation, spaghetti diagram, box plot, and Pareto diagram Case C 50% reduction in service time 94% reduction in queue length 48% decline in scheduled staff utilization Case D 58% reduction in the TAT of the process Zero inventory at the end of the day 34% decrease is staff requirement Annual savings of $20,000 annual savings E Quick and quality service Productivity, absenteeism of employees Waiting time Top management involvement and commitment; regular and clear communication; involvement of cross-functional team; availability of data; project selection; and training Kruskal–Wallis test, cause and effect diagram, Box–Cox transformation, control charts, gemba, box plot and normality test 57% decline in average waiting time Annual Savings of Annual Savings of $15,000 Publisher Copyright: {\textcopyright} 2019, Emerald Publishing Limited.",

year = "2020",

month = jan,

day = "6",

doi = "10.1108/IJQRM-07-2018-0193",

language = "British English",

volume = "37",

pages = "90--111",

journal = "International Journal of Quality and Reliability Management",

issn = "0265-671X",

publisher = "Emerald Group Publishing Ltd.",

number = "1",

}

TY - JOUR

T1 - Lean Six Sigma for the healthcare sector

T2 - a multiple case study analysis from the Indian context

AU - Bhat, Shreeranga

AU - Antony, Jiju

AU - Gijo, E. V.

AU - Cudney, Elizabeth A.

N1 - Funding Information: Montgomery , D.C. and Runger , G.C. ( 2007 ), Applied Statistics and Probability for Engineers , John Wiley & Sons , New York, NY . Table I Summary of LSS applications in hospitals S. No. Author Objective Methodology/Tools Findings Conclusions/Challenges 1 Bahensky et al. (2005) To eliminate non-value adding activities in radiology CT scanning Faxing patient information, early contrast administration, transfer of patient information, insertion coverage, CT room escorts and exam procedure scheduling Command centre experienced 30% reduction in calls Patient throughput increased by 31% Total takt time reduced by 30% Patient experience time decreased by 33% Travel time for technicians declined by 91% LSS can be combined with the kaizen approach for better results Team dynamics enable the project to draw solutions through free exchange of ideas The cross-functional team, cultural change and top management support are crucial for the success of an LSS project 2 Fairbanks (2007) To improve operating room throughput Process measurement, process mapping, education and staging area for first cases of the day Increase in on-time start from 12% to 89% Decrease in mean TAT from 23.8 to 17.9 min Increase in perception of employee teamwork and overall facility rating The project has improved patient flow, and teamwork and pride among perioperative staff members Research culminated that LSS has a positive implication for both staff members and facility 3 Yu and Yang (2008) To improve the OP-MRD average waiting time Simulation, regression, time series plot and gemba Decrease in average waiting time from 42.3 to 6.55 min LSS has the potential to tackle high healthcare cost and low efficiency, which are of major concern for consumers, business leaders, insurance industry and governments The research concluded that developing an effective approach to reduce healthcare cost and increase healthcare efficiency without compromising healthcare quality is the need of the hour 4 Wijma et al. (2009) To improve the efficiency of the nursing department Pie chart, Pareto chart and waste elimination Substantial decrease in the annual cost of the nursing department after deployment LSS is a structured methodology to solve complex operational problems LSS stimulates organizational innovations To be effective, LSS demands an organizational framework, with specific roles and responsibilities for MBBs, BBs, GBs, and methods from project management to monitor progress and schedules LSS works better through the DMAIC roadmap LSS draws effective solutions based on data, and not just hypothesis and deliberate analysis 5 Bisgaard and Does (2009) To reduce the length of stay at the hospital Dot plot, Pareto chart, scatter plot, control charts, ANOVA and box plot Decrease in average length of stay by 2.4 days for a patient volume of approximately 30 patients per year with annual savings of $36,000 LSS is a results-oriented approach, which ensures improved quality, while reducing costs on both the clinical and operational side of healthcare The strategy not only aids the patients, but also healthcare providers and the bottom line 6 Yamamoto et al. (2010) To improve profit by increasing insulin medication safety and delivery Flow charts, failure mode and effects analysis, ANOVA, and cause and effect diagram Overall cost savings estimated to be $75,000 The LSS methodology demonstrates positive, validated outcomes in improving patient safety and patient care Commitment of the hospital administration and staff are critical to the success of the project 7 Schoonhoven et al. (2011) To improve the allocation of resources VSM and statistical tools About 95% of patients had an appointment for first consultation within 10 days Throughput times within 14 days resulting in increased revenue amounting to $70,000 LSS together with the conceptual framework developed by de Mast et al. (2011) can help to diagnose and resolve workflow and efficiency problems 8 Mozammel and Mapa (2012) To improve the process of nursing shift directors Cause and effect diagram, process flow chart and statistical charts Free time of nursing shift directors increased to 17 from 2.8%, which is used for patient care Reduction in overall documentation from 39 to 26% The DMAIC approach is a consistent and standardized way of problem solving for the LSS methodology 9 Lokkerbol et al. (2012) To reduce work-related injuries in the hospital Control charts and frequency table Average number of incidents dropped from 12 to 7.2 The challenge of LSS project deployment is in changing the behaviour of the organization and its employees Focussing on implementation and developing a creative and recognizable system are critical elements for a LSS project 10 Sanders and Karr (2015) To reduce the TAT for the emergency department (ED) specimens Statistical tools and waste reduction Vials used for testing and in extra specimens decreased by 50% ED specimens without orders declined by 90% Complete blood count analysis TAT reduced by 30% Troponin TAT variation cut by 10% ED registered nurses rainbow draw time decreased from 5 to 2 min The LSS methodology, which extracts a project-focussed approach from Six Sigma and relies less on the speed of Lean, can also give rapid improvement results in the hospitals 11 Nayar et al. (2016) To remove wasteful processes and implement a more robust process Value stream mapping and process redesign The barrier to smooth process flow was identified as the receipt of the non-Veterans Health Administration medical record, which resulted in delays in filling prescriptions. The crucial factors determined during the work were veteran education, process redesign and outreach to community providers LSS can be applicable even to simple processes, where Lean dominates under the DMAIC umbrella of the SS Table II Summary of LSS projects deliverables in the MRD of Indian hospitals 0,000 5,000 Project VOC KPIs CTQ CSFs STTs Outcomes A Quick service Waiting time, queue length Cycle Time Leadership, data through information technology (IT), training on LSS tools, involvement of staff, and motivation of the employees I-chart, simulation, cause and effect diagram, 5S, kanban, gemba, two-sample t -test and waste analysis 65% reduction in average cycle time 97% decrease in average waiting time 97% reduction in queue length Annual Savings of $7,000 B Reduced operational costs Inventory reduction, improved productivity Turnaround time Visionary leadership, top management commitment and involvement, employee involvement, involvement of scientific (doctors and nurses) staff, availability of data, effective communication, and knowledge about tools and techniques for problem solving I-chart, cause and effect diagram, 5S, kanban, check sheets, run chart, standardization, poka-yoke, visual management, waste analysis, two-sample t -test and gemba 25% decrease in the TAT of the process Zero inventory of the medical records and other work-in-progress (WIP) files at the end of the day Annual Savings of Annual Savings of $10,000 C and D Quick and quality service, reduced operational costs Waiting time, queue length, percentage scheduled utilization of staff, and inventory Cycle time and TAT Top management involvement and commitment; empirical validation in every phase; organizational belief, vision and culture; LSS projects’ success celebration; regular and clear communication; visionary leadership; involvement of cross-functional team; availability of data; project selection, prioritization and tracking; and training on LSS methodology and its associated tools and techniques Xbar-R chart, cause and effect diagram, 5S, standardization, poka-yoke, visual management, analysis of variance (ANOVA), two-sample t -test, multi-vari chart, gemba, group technology, cell layout, takt time, value stream mapping (VSM), simulation, spaghetti diagram, box plot, and Pareto diagram Case C 50% reduction in service time 94% reduction in queue length 48% decline in scheduled staff utilization Case D 58% reduction in the TAT of the process Zero inventory at the end of the day 34% decrease is staff requirement Annual savings of $20,000 annual savings E Quick and quality service Productivity, absenteeism of employees Waiting time Top management involvement and commitment; regular and clear communication; involvement of cross-functional team; availability of data; project selection; and training Kruskal–Wallis test, cause and effect diagram, Box–Cox transformation, control charts, gemba, box plot and normality test 57% decline in average waiting time Annual Savings of Annual Savings of $15,000 Publisher Copyright: © 2019, Emerald Publishing Limited.

PY - 2020/1/6

Y1 - 2020/1/6

N2 - 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.

AB - 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.

KW - Healthcare

KW - India

KW - Lean

KW - Lean Six Sigma

KW - Medical records

KW - Six Sigma

UR - http://www.scopus.com/inward/record.url?scp=85074013985&partnerID=8YFLogxK

U2 - 10.1108/IJQRM-07-2018-0193

DO - 10.1108/IJQRM-07-2018-0193

M3 - Article

AN - SCOPUS:85074013985

SN - 0265-671X

VL - 37

SP - 90

EP - 111

JO - International Journal of Quality and Reliability Management

JF - International Journal of Quality and Reliability Management

IS - 1

ER -

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

Abstract

Keywords

Access to Document

Other files and links

Fingerprint

Cite this