Lean Six Sigma and healthcare

Andres Garcia-Arce

EIN 6935.004 Lean Six Sigma Summer 2015

Contents

Abstract ....................................................................................................... 2
Lean and Six Sigma ...................................................................................... 4
Review of Literature ..................................................................................... 5
Selected Articles .......................................................................................... 7
Conclusions .................................................................................................. 8
References: ................................................................................................ 10

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Abstract
The United States healthcare systems is the most expensive in the world. This
fact aligns with the lack of qualit y and the large amount of waste recognized.
Due to this situation, and to the fact that good results have been reported in the
manufacturing sector, is that qual it y improvement approaches such as Lean and
Six Sigma started to be implemented in the healthcare sector. In this work, we
will provide an overview of the scientific literature published regarding this
topic, anal yzing the three most important articles found. Finally, we conclude
that while there is the common knowledge that Lean and Six Sigma approaches
improves the qualit y of care, also there is a gap of scientific work providing
strong statistical arguments supporting that idea.

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Andres Garcia-Arce
Instructor: Christos A. Nicolau
Lean Six Sigma - EIN 6935-004
27 June 2015

Lean Six Sigma and Healthcare

The healthcare in The United States (U.S.) is the most expensive in the
world, assigning a budget that exceeds the double of the average expenditure in
healthcare for other high-income countries [ 1 3 ] . Furthermore, the U.S. healthcare
is widel y criticized for the lack of qualit y [ 8 ] and the highl y inefficient use of
resources [ 1 ;

7]

. The government has addressed this situation by issuing a bill

called Patient Protection and Affordable Care Act (PPACA), focusing mainl y on
the improvement in coverage, qualit y, and affordabilit y while reducing waste. In
this context is that q ualit y improvement techniques such as Lean and Six S igma
appear as a beacon of light and hope for our sick health care system, promising
to reduce the underl ying waste and improve their processes. This article aims to
provide an overview of the scientific work published on these topics.
The present article is divided into four sections: First, we briefl y describe
the main endpoints of the Lean and S ix Sigma approaches. Secondl y, we
describe the method and results of a preliminary literature review , looking for
published evidence on Lean and Six Sigma implementations in healthcare . Then,
we choose three of the most important articles and provide a critical

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examination of them. Finall y, some conclusions are drawn in the base of this
work, and future directions are also foreseen.
Lean and Six Sigma
Lean is an approach to qualit y improv ement that finds its origins in
Toyota in the middle 1980 s. It states that the waste in all processes is caused
by activities that do not add value to the customer, and must be reduced or
eliminated as much as possible. The main endpoint of Lean is that it sets value
added activities through the customers eye (not the administration), providing a
strong customer-oriented view. Lean also accounts for the waste due to the
overburden and unevenness of workloads. In other hand, Six Sigma is a concept
that is developed by Motorola around the same time by Bill Smith. It focuses
mainl y on the acceleration of the qualit y improvement efforts , providing a
common certification (belts) , caring about the average process and the defects
and defective processes withing t he organization. It also consists of decreasing
the tolerance for errors up to six Sigma (Sigma is a Greek letter usuall y used to
represent the standard deviation and variance of a statistical distribution).
Projects following Lean or S ix Sigma principles usuall y present a certain level
of correlation in terms of the tools that they use. Some of these tools are value
stream maps, root cause anal ysis (RCA), failure mode and effect anal ysis
(FMEA), among others. As a product, Lean Six S igma has born based in both
approaches, providing a robust way to reduce waste, improve processes and
change the culture of the organization.

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Review of Literature
Because of the situation of the U.S. healthcare system, the Lean and Six Sigma
techniques started to be implemented in the healthcare setting . In the hospital
setting, Lean and Six Sigma approaches look to reduce waste and improve the
efficiency of the care provided to patients. In this spirit, we conducted a
preliminary review of the literature aiming for articles and books related to
Lean and Six Sigma, with respect to the healthcare sector. The databases queried
were: Cumulative Index of Nursing and Allied
Health Literature (C INAHL), Library of the
Congress, Library Information Sciences
Technology Abstracts (LISTA), Medical
Literature Anal ysis and Retrieval S ystem
(MEDLINE), Public Medline (PUBMED),
World of Science and World Cat. We searched
these databases for references with titles that
included Lean and hospital, Lean and
healthcare, Six Sigma and hospital,
Figure 1: Exclusion criteria for
the review

Six Sigma and healthcare. The total

amount of references found was 797. The preliminary exclusion criteria

considered duplicates, other than The English language, and subject unrelated to
healthcare, Six Sigma or Lean. Figure 1 summarize the process, also describing
the results of the application of the exclusion criterion . The first author found to
publish work related to Lean and/or Six Sigma is Steven P. Gray in 1995 [ 6 ] . He

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published an article in the Health Care Strategic Management Journal titled

Leaner management structures prepare hospitals for change . In this work, Mr.
Gray describe the realit y of the hospitals management , and found that 75% of
the time, managers were working on paperwork, while onl y the remaining 25%
remained for planning tasks.
The last five years, the published work focuses mainl y on Lean techniques
applied to healthcare problems (opposed to Six Sigma approaches) . Figure 2
shows the distribution of the publications over the years , grouped by the t ype of
work (books and jou rnal articles) and by the subject they cover (Lean, Six
Sigma, and Lean Six Sigma). There are some widel y known applications of L ean
used to reduce the treatment time of a patient, or the waiting time for a surgery
or exam (lead time). Also, the 5S technique (from lean manufacturing) is used
mainl y in operating rooms and nursing stations. Finall y, from 2010 the
published scientific literature about Lean and Six Sigma have grown almost to
the double (please note that 2015 is still current and not all the literature from
2014 and 2015 is reflected in the databases).

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Publications on Lean and Six sigma

Publications by subject

70

30

60

25

50

20

40

15

30

10

20

10
0

0
2010

2011
Books

2012

2013

2014

Journal Articles

2015

2010

2011

Lean

(a)

2012

2013

Six sigma

2014

2015

Lean Six sigma

(b)

Figure 2: references f rom the last five years by (a) type of reference, and (b) by
subject.

Selected Articles
From the articles foun d in the review, three articles were selected and will be
discussed in the following paragraphs. The first article is developed by
Andreamatteo et al. in 2015 [ 3 ] , and consist of a review of the literature covering
Lean principles in healthcare. In this work, 243 articles met the inclusion
criteria. The findings are that the use of Lean approaches improves the qualit y
of care. Specificall y, we highlight two major findings: 1) work is majorl y
documented in the U.S. hospital setting; 2) m ost of the scientific work is related
to challenges and key characteristics for the success. The author ends the article
with a call to the Scientific world to address the strengths and weaknesses of
Lean approaches in the healthcare in a more extensive wa y.
The second article is written by Vest et al. in 2009 [ 1 2 ] and consists of a
review of literature assessing Lean, Six Sigma and Studergroups hardwiring
excellence (a different qualit y improvement method) approaches improving the
U.S. healthcare system. The main thesis of these authors is that a sustainable
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transformation of the hospital requires a transformation in the practices and a

transformation in the culture of the organization . Nine studies met the inclusion
criteria, where examples of qualit y improvements are described in surgery
turnaround time, operating room throughput , scheduling radiology procedures,
among others.
The last article is presented by DelliFraine et al. in 2010 [ 5 ] , and it
considers a review of 177 articles dealing with the evidence on Lean and Six
Sigma based initiatives developed in healthcare. They concluded that in t he last
ten years, onl y 33 of these articles were reporting outcomes, and from those less
than one third presented enough statistical rigor to be considered as evidence.
Naturall y, DelliFraine highlights the importance of more literature providing
good qualit y of science and reports of outcomes that can validate the thesis that
Lean and Six Sigma approaches improve the qualit y of care.
Conclusions
The characteristics of high-qualit y healthcare might be recognized to be safe,
effective, patient-centered, timel y, efficient and equitable [ 9 ] . To achieve the
previousl y mentioned features, different qualit y improvement techniques can be
utilized. While in the mid 1980s the notion of Lean and Six S igma appeared in
Motorola and GE, is not until 15 years later that we found the first articles
published suggesting imple mentation of Lean manufacturing techniques into the
healthcare domain. We conducted a preliminary literature review in which we
found a high proportion of works appl ying Lean principles, as opposed to Six
Sigma. The number of publications has been rising steadil y since 2010. We
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reviewed the best three articles , mainl y anal yzing published work on Lean, S ix
Sigma, and Lean Six Sigma. From them, we learned that the literature suggest s
that these approaches always show a positive impact, although sometimes thos e
efforts get lost. Chakrabort y in 2010 [ 2 ] suggests that to avoid l osing projects we
need: 1) an expert to run the projects; 2) the performance measures require to be
strongl y tied from the beginning; 3) small teams work s; and 4) the participation
of all the organization (including executive s). There are some gaps in the
literature includes that appear after this work. Firstl y, there is a need for an
anal ysis of the strengths and weaknesses of Lean and Six Sigma approaches that
can inform hospital managers about the triggers and consequences.
Additionall y, stronger scientific works providing solid statistical arguments
validating the positive impacts of the Lean and Six Sigma might be beneficial
for the steady improvement of our healthcare system. Future work will incl ude a
deeper anal ysis of the literature found, looking for eviden ce on the relationship
that these qualit y improvement methods might have in preventable hospital
readmissions (m y current area of research).

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References:

Berwick, D. M., & Hackbarth, A. D. (2012a). Eliminating waste in US health care. Journal of
American Medical Association, 307(14), 15136. http://doi.org/10.1001/jama.2012.362

Chakravorty, S. S. (2010b, January 25). Where Process-improvement projects go wrong. The

Wall Street Journal. Retrieved from
http://www.wsj.com/articles/SB10001424052748703298004574457471313938130
DAndreamatteo, A., Ianni, L., Lega, F., & Sargiacomo, M. (2015c). Lean in Healthcare: a
comprehensive review. Health Policy. http://doi.org/10.1016/j.healthpol.2015.02.002

De Koning, H., Verver, J. P. S., van den Heuvel, J., Bisgaard, S., & Does, R. J. M. M. (2006d).
Lean six sigma in healthcare. Journal for Healthcare Quality, 28(2), 411. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/16749293

DelliFraine, J. L., Langabeer, J. R., & Nembhard, I. M. (2010e). Assessing the evidence of Six
Sigma and Lean in the health care industry. Quality Management in Health Care, 19(3),
21125. http://doi.org/10.1097/QMH.0b013e3181eb140e

Gray, S. P. (1995f). Leaner management structures prepare hospitals for change. Health Care
Strategic Management, 13(3), 145.

Institute of Medicine. (2013g). Best care at the lower cost: The Path to Continuously Learning
Health Care in America. (M. Smith, R. Saunders, L. Stuckhardt, & J. M. Mcginnis, Eds.).
Washington, DC: The National Academies Press.

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Most Efficient Health Care 2014: Countries - Bloomberg Best (and Worst). (n.d.-h). Retrieved
June 1, 2015, from http://www.bloomberg.com/visual-data/best-and-worst/most-efficienthealth-care-2014-countries

Taner, M. T., Sezen, B., & Antony, J. (2007i). An overview of six sigma applications in
healthcare industry. International Journal of Health Care Quality Assurance, 20(4), 329
340. http://doi.org/10.1108/09526860710754398

Van den Heuvel, J., Does, R. J. M. M., & de Koning, H. (2006j). Lean Six Sigma in a hospital.
International Journal Six Sigma and Competitive Advantage, 2(4), 377388.
Van den Heuvel, J., Does, R. J. M. M., & Verver, J. P. S. (2005k). Six Sigma in healthcare:
lessons learned from a hospital. International Journal Six Sigma and Competitive
Advantage, 1(4), 380388.

Vest, J. R., & Gamm, L. D. (2009l). A critical review of the research literature on Six Sigma,
Lean and StuderGroups Hardwiring Excellence in the United States: the need to
demonstrate and communicate the effectiveness of transformation strategies in healthcare.
Implementation Science, 4(35). http://doi.org/10.1186/1748-5908-4-35

World health organization. (2014m). WHO | Global health expenditure database. World Health
Organization. Retrieved from http://www.who.int/nha/expenditure_database/en/

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