International Journal of Quality & Reliability Management

Just in time elements extraction and prioritization for health care unit using
decision making approach
Mahender Singh Kaswan, Rajeev Rathi, Mahipal Singh,
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Mahender Singh Kaswan, Rajeev Rathi, Mahipal Singh, (2019) "Just in time elements extraction and
prioritization for health care unit using decision making approach", International Journal of Quality &
Reliability Management, https://doi.org/10.1108/IJQRM-08-2018-0208
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QUALITY PAPER Just in time

elements
Just in time elements extraction
extraction and prioritization for
health care unit using decision
making approach Received 6 August 2018
Revised 14 December 2018
Mahender Singh Kaswan, Rajeev Rathi and Mahipal Singh Accepted 8 January 2019

Department of Mechanical Engineering,

Lovely Professional University, Phagwara, India
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Abstract
Purpose – The purpose of this paper is to identify and prioritize prime just-in-time ( JIT) elements in Indian
healthcare sector based on the degree of importance and difficulty. This facilitates the implementation of JIT
philosophy in healthcare services without any failure as well as provides quality services to patients at low cost.
Design/methodology/approach – JIT elements related to health care services have been sorted out from
comprehensive literature survey. Moreover, important and difficult JIT elements have been ranked on the
basis of score obtained by the quantitative method using statistical tools. Furthermore, validation and
prioritization of important JIT elements based on the degree of importance have been computed using the
analytical hierarchy process (AHP) and best worst method (BWM).
Findings – The present work provides important, difficult and easy to implement JIT elements in healthcare
services. Besides, this work justifies the application of decision-making tool (AHP, BWM) for the prioritization
of JIT elements in the health care sector.
Practical implications – The present study develops a deep understanding of JIT concepts in health care
services. Furthermore, it motivates professionals for implementing JIT in healthcare services with healthy
situation for both hospital and supplier.
Social implications – The present work is beneficial for all the dimensions of sustainable development
(social, economic and environmental). The implementation of JIT with a proper understanding of its elements
results in an improved patient care, lesser cost of healthcare delivery, time and better management of
associated medical items. This work also facilitates the proper management of inventory items together with
the reduction in various Lean wastes with the proper implementation of JIT in healthcare. The reduction in
various associated wastes leads to cleaner surrounding and lesser environmental degradation.
Originality/value – This paper outlines the need of a robust JIT approach in the healthcare sector for
quality services. The efficacy of JIT, AHP and BWM has been explored to find out critical elements for
successful JIT implementation in health care.
Keywords Analysis of variance, Statistical tools, Analytical hierarchy process, Just in time,
Healthcare services, Best worst method
Paper type Research paper

1. Introduction
Ever-growing market competition has enforced organizations to relook into their business
strategies for achieving excellence in product quality (Fullerton and McWatters, 2001;
Singh and Rathi, 2018). In order to remain competitive in market, organizations provide quality
products and services at low cost. Several improvement strategies, such as TQM, just-in-time
( JIT), kanban, 5’S etc., have been adopted by different organizations to attain said goal
(Spencer, 1995; Kumar et al., 2011; Rathi et al., 2015a, b) Among these approaches, JIT has
appeared as a magnificent driver in the world of manufacturing since 1980s because it makes
every person responsible for quality to incorporate in the process (Meybodi, 2003). It eradicates
waste present in the system by making the process simpler, reduces non-value-added activities International Journal of Quality &
Reliability Management
and makes material handling simpler (Abdallah and Matsui, 2007). Furthermore, JIT © Emerald Publishing Limited
0265-671X
encourages a better supplier and manufacturer relationship through advanced electronic data DOI 10.1108/IJQRM-08-2018-0208
 IJQRM interchange (EDI) tools to track inventories. Moreover, a real-time database of all the partners
in the supply chain is stored in EDI for a better assessment and availability of material across
the entire supply chain (Cook and Rogowski, 1996; Zare Mehrjerdi, 2011). In many aspects of
JIT like quality improvement and waste reduction, people involvement have been applied in
similar fashion in discrete as well as in continuous manufacturing (Ismail Salaheldin, 2005).
A simplified conceptual JIT model is shown in Figure 1.
Service industries can improve their performance by adopting tools and techniques of
manufacturing organizations (Mehra and Inman, 1990). JIT was originally evolved in
manufacturing environment but later on found its ways of success in the service sector.
JIT perception has migrated from the manufacturing environment to services like insurance
firms, retailers, mail order services, hotels, educational institutions, hospitals, etc. ( Jarrett,
2006). It gives ammunition to service functions to reconstruct their pursuits and
progressively impetus to remain the flag holder in the market (Mehra and Inman, 1990;
Yasin et al., 2003; Rathi et al., 2016a, b).
In health care services, medical errors and increasing patient care costs are continuously
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pinpointing the developing nations. Huge medical expenses as compared to income in

developing nations bring immediate attention to reduce numerous non-value-added
activities in health care ( Joosten et al., 2009). The main causes of high health care cost seem
to be new disease patterns and this is tackled through advanced medical knowledge and
extensive use of technology (Kumar et. al., 2005). Hospitals are adopting new technologies
from big technocrats to reduce costs, improve management, increase operational efficacy
and finally to enhance the utmost customer gratification (Chong et al., 2015).
In order to overcome such alarming situations, a comprehensive proactive awareness
with education that encompass all the partners of health care is the need of hour. Hospital
managements are continuously searching for innovative ways to contain costs without
sacrificing their quality level. Many hospitals have focused on cost containment efforts to
reduce the acquisition price of supply instead of lowering their total delivered cost
(Heinbuch, 1995). JIT may be a possible solution for this if it is implemented with due care
because it works on waste elimination in any system. The main motive of the present
research is to identify various useful elements of JIT in the healthcare sector and prioritize

General inpatient curative care

Specialised in patient care
General outpatient curative care
Dental outpatient curative care
Specialised outpatient curative
care
All rehabilitative care
0.388% 2.122%
All long term care
0.010% 0.696% Patient Transportation
1.343% Laboratory and imaging
0.139% services
Prescribed medicines
2.181% 24.001% Over the counter medicines
0.761% Therapy appliances and medical
1.236%
goods
0.876%
IEC programmes
Immunization programmes
32.015%
Early disease detection
0.001% 15.329% programmes
0.073% Health condition monitoring
5.231% 0.053% programmes
0.216%
Epodemilogical surveillance, risk
5.124% and disease control programme
Prepairing for diseaster and
emergency response
programme
Unspecified preventive care
Government and Health system
administration
Figure 1.
Administration of health financing
Simplified JIT model Other health care services not
else were classified
 the important JIT elements using the analytical hierarch process followed by validation Just in time
using the best worst method. The ultimate ranking of JIT elements provides the key elements
elements so that researchers and practitioners can implement the JIT philosophy across extraction
their unit in a smoother way.
The current paper has been organized in eight sections including introduction. Section 2
is devoted to the literature review of JIT in healthcare and analytical hierarchy process
(AHP). Section 3 highlights the exploration of JIT elements in health care. Section 4
represents the tools used in the current study. The proposed research methodology with
data collection and validation has been presented in the fifth section of the manuscript
followed by results and discussion of scatter chart, AHP and best worst method (BWM) in
Section 6. The concluded remarks of study have been highlighted in Section 7 of article,
and Section 8 contains the future research direction and limitations of the study.

2. Literature review
The health care sector is one the most neglected sector in developing countries like India.
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In India total health expenditure in 2014–2015 was INR4,832,590m (3.89 percent of GDP and
INR3,826 per capita). In the same duration, expenditure attributed to inpatient curative
care was INR1,583,340m (35.1 percent), outpatient curative care INR730,590m (16.2 percent),
patient transportation cost INR206,270m (4.5 percent), preventive care INR304,200m
(6.7 percent) of the total expenditure (Government of India, 2017). Figure 2 demonstrates
health care expenditures by health care functions in India for year 2014–2015. In future, these
expenses will increase and it becomes very challenging for developing countries like India to
provide better medical treatment at reasonable cost. In India, there is a huge lack of healthcare
facilities with only 0.9 beds/1,000 people and this is lowest among BRIC nations. India has the
lowest number of physicians per 10,000 populations among BRIC nations and in rural areas
this situation is more alarming. Nearly 60 percent of people do not have access to inpatient
care within the proximity of 5 kms, and more than 60 percent people are in debt due to huge
health care expenditures.
In order to implement JIT in healthcare, thorough understanding of this lean tool is very
essential along with its elements. The JIT concept was used at Toyota Motor Corporation in their
manufacturing, and they were largely benefited by this philosophy (Sakakibara et al., 1993).
It is a production planning approach that replaces material requirement planning for better
materials management because it works on the principle of zero inventories (Spencer, 1995).
It inflicts highly enforced quality control processes to ensure that the product meets quality

XY SCATTER CHART
240
220
18 31 200
DEGREE OF IMPORTANCE

30 11 8
5 180
25 28 4 19 160
24 6 22 16 13
26 32 17 27 140
29
3 33 2 15 120
9 14 12
7 20 100
21 1023 1 80
60
Figure 2.
40 Health care
20 expenditures by
0 health care functions
0 20 40 60 80 100 120 140 160 180 200 220 240 in India 2014–2015
DEGREE OF DIFFICULTIES
 IJQRM specification as per customer requirements. It is a pull system of operation, in which the point of
application of a worker represents the actions of others (Pisuchpen, 2012; Selto et al., 1995).
Furthermore, it requires top management commitment and smooth material flow throughout the
firm to achieve organizational goals in the most effective way. It reduces manufacturing/service
lead time and creates a win-win situation both for the customer and employer (Ismail Salaheldin,
2005; Sim and Killough, 1998).
JIT implementation is a continuous process and requires the involvement of everyone in
organization because quality can only be built into system when there is overall involvement
from every member of the organization (Wakchaure et al., 2006). In order to initiate this
concept, it is essential to identify JIT elements in health care that are important and easy to
implement along with their ranking according to importance. In the past, a number of
attempts have taken to find out elements of JIT in numerous service industries. Table I
indicates some frequently used JIT elements in industry from the point of view of method,
industry case, expert, academics and adopters (Zhu and Weir, 1994). In the literature, JIT
application is found in healthcare sector for logistics management ( Jarrett, 2006), material
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management (Heinbuch, 1995), logistics expenditure minimization (Whitson, 1997), decision-

making improvement in primary care (McGowan et al., 2008), efficiency improvement in
hospital work (Persona et al., 2008). In prior research problems, researchers were more focused
on elements of JIT in manufacturing, financial service, banking, etc., but the literature lacks
much evidence about identification and ranking of JIT elements in health care services.
Moreover, there is no evidence of prioritization of important JIT elements using AHP and
BWM that support novelty to the present study.
The AHP is a theory of measurement to deal with quantifiable and intangible criteria
that has been applied to numerous areas, such as decision theory and conflict resolution.

S. No. Method Industry case View from expert Academics Adopters

1 Quality circle Cross training Quality circle Quality circle Quality circle
2 Cross training Certification of Preparation time Cross training Preparation time
quality from for operation for operation
supplier
3 Mutual Lead time to In house lot size In house lot sizes Certification of
relationship supply product from supplier quality from
with partner supplier
4 Group technology Quality circle Cross training Lead time to Cross training
supply product
5 JIT education Preparation time Certification of Vendor lot size Group technology
for operation quality from
supplier
6 Preparation time Group technology JIT education Preparation time Preventive
for operation for operation maintenance
7 Vendor lot size Mutual Communication JIT education in house lot size
relationship with
partner
8 Certification of Vendor lot size Group technology Certification of Lead time to
quality from quality from supply product
supplier supplier
9 Lead time to Preventive Lead time to supply Group technology Mutual
supply product maintenance product relationship
with partner
Table I. 10 Authority to stop JIT team JIT team Mutual JIT team
Frequently used lines relationship
elements of JIT with partner
 The AHP was devised by Saaty (1989) to provide a framework for solving different types of Just in time
multi-criterion decision problems based on pairwise comparisons of each criterion elements
(Vargas, 1990; Handfield et al., 2002). It is a commanding management science tool that has extraction
been recognized as useful in structuring complex multi-dimensions, multi-criterion decisions
in management science. The peculiarity of AHP is its flexibility to combine with different
techniques like linear programming, quality function deployment, fuzzy logic, BWM, etc.
This results in the achievement of benefits from the combination of approaches and
interpretation of result in better ways (Vaidya and Kumar, 2006).

3. JIT elements exploration in health care

JIT elements are key components responsible for the successful JIT program in both
manufacturing and service sectors. To learn and use a new concept, it is quite essential to
break it into small-small elements or segments. JIT elements can solve a lot of problems like
lengthy set up, poor quality, machine breakdown, bad design and supplier reliability that
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otherwise hide because of an excessive use of available resources. JIT provides an opportunity
to an organization for a better utilization of resources by providing products or services in the
right quantity, quality, at right place and at the lowest possible cost. Moreover, to implement
JIT in any organization, this is very essential to understand its aspects comprehensively, for
this JIT element identification is vital in the concerned field. In previous research problems,
many attempts have made to find out JIT elements in educational institutes, banking sector
and hotel and in other services (Barlow, 2002; Nisar et al., 2014). The literature lacks any
evidence about the exploration of JIT elements in healthcare sector along with their respective
rankings. In the present study, a comprehensive literature survey has been done to identify
JIT elements in the healthcare sector. From comprehensive literature survey, the authors have
identified 33 elements of JIT pertaining to the healthcare sector (refer Table II).

4. Tool used
4.1 Analytic hierarchy process
The AHP was developed by T L Saaty as a decision-making model (Saaty, 1988a, b). It is a
well-known decision-making approach used to solve complex decision problems in research
and technology. Moreover, pair-wise comparisons of similar things are made against a
specified norm, and it also reviews the strength of one thing over another (Saaty, 1989).
It uses nine point scales (1–9) to perform pair-wise comparisons at each level for the
selection of the best alternative (Saaty, 1989). It converts the human preferences between
offered parameters as equal: (1), moderately (3), strongly (5), very strongly (7) or extremely
preferred (9). The values, thus, obtained in the scaling process are converted into priority
values to compare alternatives (Chan et al., 2008).

4.2 Analysis of variance

The analysis of variance (ANOVA) was developed by Professor Ronald A. Fisher in 1921 for
validating the collected data and was also used for comparing the mean of more than two
groups. It is a collection of a slew statistical paradigm and associated methods to analyze the
difference among different groups. It offers computational elegance, and it results in a lesser
error as compared to t-test and z-test (Gopalsamy et al., 2009). ANOVA is a useful technique
to find the effect of input parameters through a lot of experiments by the design of
experiments (Gopalsamy et al., 2009). ANOVA analysis made null and alternate hypothesis
followed by the calculation of mean squares (MS) and degree of freedoms. In last, the F-ratio
is calculated that is the ratio of MS between and within the samples. If the obtained value of
F-ratio is more than the tabled value, then the hypothesis is rejected and, hence, leads to the
conclusion that variable is significant.
 IJQRM S. No. JIT elements in health care References

1 Primary vendor program Kinney (1992), Ramani (2006), Roeber (2011)

2 Relation between supplier
and hospital
3 Flexible workforce
4 Respect for human
resource
5 Life time employment
6 Automation
7 House keeping
8 Just in time purchasing
( JITP)
9 Job satisfaction
10 Bottom round
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Heinbuch (1995), Jarrett (2006), Chunning and Kumar (2000), Clarke
(1998), Yasin et al. (2003), Jacobs and Pelfrey (1995), Ha and Kim (1997)
Kinney (1992), Chunning and Kumar (2000), Clarke (1998), Jacobs and
Pelfrey (1995), Gupta (2012)
Duclos et al. (1995), Chunning and Kumar (2000), Clarke (1998)
Clarke (1998), Jacobs and Pelfrey (1995), Gupta (2012)
Munyisia et al. (2011)
Jacobs and Pelfrey (1995)
Duclos et al. (1995), Jacobs and Pelfrey (1995), Gupta (2012), Ha and
Kim (1997)
Heinbuch (1995), Gupta and Heragu (1991)
Inman et al. (2011)

management
11 Jidoka (To check quality at Kinney (1992)
the source)
12 Quality circles Chunning and Kumar (2000), Clarke (1998)
13 5’S Haque K. et al. (2012)
14 ABC ranking approach Jacobs and Pelfrey (1995), Gupta (2012)
15 Team work Kinney (1992), Chunning and Kumar (2000), Clarke (1998)
16 Radio frequency Zare Mehrjerdi (2011)
identification (RFID)
17 Error prevention (Poka Haque et al. (2012)
Yoke)
18 Top management support Kinney (1992)
19 Education program Chunning and Kumar (2000), Clarke (1998), Munyisia et al. (2011),
Roeber (2011), Gupta (2012), Winch and Henderson (2009)
20 Incremental Kinney (1992)
implementation
21 Customer relationship Kinney (1992)
management
22 Elimination of waste Kinney (1992), Chunning and Kumar (2000), Clarke (1998), Jacobs and
Pelfrey (1995)
23 Case cart system Miller H. (2001)
24 Kanban Kollberg et al. (2006), Kinney (1992), Chunning and Kumar (2000),
Clarke (1998)
25 Total quality Kim C. et al. (2006)
management (TQM)
26 Total productive Chunning and Kumar (2000), Clarke (1998)
maintenance (TPM)
27 Group technology (GT) Kinney (1992), Gupta (2012)
28 Kaizen Jacobs and Pelfrey (1995), Gupta (2012)
29 Faster communication Munyisia et al. (2011), Winch and Henderson (2009)
30 Customer satisfaction Heinbuch (1995), Gupta (2012), Pan and Pokharel (2007),
Winch and Henderson (2009), Aptel et al. (2009)
Table II. 31 Planning Chunning and Kumar (2000), Clarke (1998)
Elements of JIT 32 Group incentive scheme Chunning and Kumar (2000), Clarke (1998)
in health care 33 Standardization Kinney (1992), Jacobs and Pelfrey (1995), Gupta (2012)

4.3 Best worst method

The BWM is a pairwise comparison method developed to solve multi-criterion decision-
making problems (Rezaei, 2015; Ahmadi et al., 2017). It was developed by Rezaei (2015)
and has been efficaciously applied in numerous real-life applications such as the
selection of biomass thermochemical conversion technology (Van de Kaa et al., 2017),
 evaluation of the external forces affecting the sustainability of oil and gas supply chain Just in time
(Ahmad et al., 2017), evaluating service quality of airline industry (Gupta, 2018), ranking elements
of barriers to energy efficiency in building (Gupta et al., 2017), assessment of the extraction
technologies for the treatment of urban sewage sludge (Ren et al., 2017), measuring the
efficiency of university–industry PhD projects (Salimi and Rezaei, 2016), supplier selection
(Rezaei et al., 2016), etc. It is a modified AHP method to find the relative weights of factors/
elements by instituting the vectors of the relative preferences of the most important
criterion over all the other criteria and that of all the other criteria over the least important
criterion (Ren et al., 2017). BWM uses fewer pairwise comparisons, and final weights
derived by this method are highly reliable as it provides more consistent comparisons
compared to AHP.

5. Methodology adopted
The present work methodology was divided into three main phases: phase one
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contained the identification of JIT elements followed by data validation in the second phase
and the ranking of the JIT elements in the healthcare sector in the last phase.
For this, JIT elements were identified by a vast literature review from several reputed
databases, and questionnaires were prepared and circulated to healthcare employees.
The present work covered 20 Indian healthcare services and nine employees from each
service, and a sample size of 180 employees was taken in consideration for the analysis.
A five-point Likert scale questionnaire was designed, and employees were inquired to specify
the significance of 33 enlisted elements on the scale of 0–4. The questionnaire used in the
present study is divided into two phases. In first phase, “0” represents ‘not at all difficult’ and
“4” represents ‘very difficult to implement’ JIT element. In second phase, “0” represents ‘not at
all important’ and “4” represents ‘very important to implement’ JIT element.
The questionnaires were sent to employees through mail or post as per convenience.
Furthermore, the collected data from available sources were validated through the
ANOVA approach to ensure that the data were acquired from distributed population.
The responses of employees were analyzed, and their scores were estimated and plotted
on the scatter chart for finding important and easy to implement JIT elements in the health
care sector. In the next step, prioritization and validation of important elements
were carried out using AHP. Furthermore, the results of AHP were compared with the
BWM method (Figure 3).

5.1 Data collection

In the present study, three different methods were used to collect the data pertaining to JIT
elements in healthcare. First method dealt with sending e-mails to doctors and pharmacist of

Management Worker
Global Market

Organization success Process Supplier

Competitive strategic
advantage JIT Outcomes
Increased Profit
Figure 3.
Fewer Inventories
Proposed research
Better information flow
JIT methodology
 IJQRM reputed hospitals, and second, the questionnaires were sent to the health care employees,
and third, healthcare facilities were visited. Figure 4 shows the nature of respondents i.e.
doctors, pharmacist, nursing staff, pharmacist and other supporting staff.

5.2 Data validation using ANOVA

The validation of the collected data is very important to extract fair inferences from the
targeted population. If the data are not authentic, then result will not be consistent and can
consequently lead to the lack of reality about the results. The ANOVA is a very useful
technique concerning researchers in the field of engineering and statics. It is a useful
technique for testing homogeneity, comparing difference among different groups of data

Formulation of Null and Alternate

Hypothesis
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To find out mean of sample

means

Calculate Sum of Squares (SS) for

variance between the samples

Calculate variance or Mean

Square (MS) between the samples

Calculate Sum of Squares (SS) for

variance within the samples

Calculate variance or Mean

Square (MS) within the samples

Calculation of F ratio

If F ratio Accept H0
>F Data is not significant

Figure 4. Neglect H0
Nature and number The data is driven from different Collect data from other
of respondents resources resources
 and more than two groups of population. The flow chart shows the step-by-step procedure Just in time
of data validation using an ANOVA approach (refer Figure 5). elements
Step 1: formulation of null and alternate hypothesis. In first step, null and alternate extraction
hypotheses are set to check whether there is a significant difference between sample means
or not:
H0. There is no significant difference among sample means.
Ha. There is a significant difference among sample means.
Step 2: estimation of mean of sample means. In order to find out the mean of the sample
means, the sample size and total number of items in the sample are required. In the present
study, a sample size (k) of nine is used, and the total number of items (n) are 180. Table III
presents nine samples and 180 elements of the samples that were used for the validation of
the entire data. In order to find the mean of sample means, the average of each sample is
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Literature review
Phase 1: Identify
JIT elements
Identification of JIT elements

Preparation of questionnaire

Circulation of questionnaire
Phase 2:
validation of
collected data Data collection

Validation of data using ANOVA

Analysis of data

Final Score of elements

Phase 3: Ranking Prioritization and validation of important

JIT element elements using AHP

Conclusions Figure 5.
Procedure for data
validation using
Future research direction ANOVA technique
 IJQRM Relationship
Primary between ABC
Hospital vendor supplier and Flexible Quality ranking Team Incremental
No. program hospital workforce Housekeeping circles approach work planning Standardization

1 11 14 12 12 14 16 18 13 15
2 14 16 17 13 16 11 17 14 14
3 12 11 12 13 12 17 14 13 14
4 15 17 13 11 17 15 13 11 16
5 13 14 14 12 14 14 16 15 13
6 11 14 13 11 11 11 15 16 12
7 13 16 17 12 12 14 11 10 18
8 15 17 12 11 14 13 14 12 11
9 14 19 16 14 13 12 16 14 13
10 11 12 14 11 14 15 18 18 14
11 13 14 19 12 10 16 14 14 15
12 12 16 14 13 14 10 15 11 16
13 11 13 13 14 11 12 12 13 13
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14 11 16 17 14 17 14 17 14 18
15 11 15 11 12 18 11 16 13 16
Table III. 16 14 14 13 13 13 13 17 17 17
Addition of degree of 17 10 16 13 15 13 14 15 16 12
importance and 18 12 14 13 9 14 15 14 10 13
degree of difficulty for 19 12 13 12 16 19 12 12 18 12
calculating mean of 20 14 15 15 11 15 16 16 16 11
each sample Total 249 296 280 249 281 271 300 278 283

summed up and then divide by the sample size:

12:45 þ14:8 þ14 þ 12:45 þ 14:1 þ13:55 þ15 þ 13:9 þ 14:15
Mean of sample means ¼ ¼ 13:8:
9

Step 3: estimate sum of squares (SS) for variance between the samples. In this step, for the
estimation of sum of square, the square of the difference between each sample from the
mean of sample means is taken and multiplied with the number of items in each sample size,
and then all are summed up:

SS between the samples ¼ 20 ð12:4513:82Þ2 þ ð14:8013:82Þ2 þ ð14:0013:82Þ2

þ ð12:4513:82Þ2 þ ð14:1013:82Þ2 þ ð13:5513:82Þ2

þ ð15:0013:82Þ2 þ ð13:9013:82Þ2
þ ð14:1513:82Þ ¼ 128:104:
Step 4: estimation of MS between the samples. In this step, the sum of square between the
samples is divided by the degree of freedom between the samples to obtain MS between them:
128:11 128:11
MS between samples ¼ ¼ ¼¼ 16:013:
k1 91
Step 5: estimate sum of squares (SS) for variance within the samples. In fifth step, deviations
of the values of the sample items for all the samples from corresponding means of the
samples are estimated. Then, with the addition of squares of the deviations, the sum of
squares (SS) for variance within the samples is calculated:

SS within samples ¼ 37:24 þ65:843þ82:00 þ50:947þ109 þ76:95

þ76:00 þ111:8þ 73:885 ¼ 683:665:
 Step 6: estimate MS within the samples. The sixth step pertains to the estimation of MS Just in time
within the samples, and it is obtained by dividing the sum of squares for variance within the elements
samples by the degree of freedom within samples:
extraction
683:665 683:665 683:665
MS within groups ¼ ¼ ¼ ¼ 3:998:
nk 1809 171
Step 7: calculation of F-ratio. The final step of data validation is related to the calculation of
F ratio. It is the ratio between the two variances, i.e., between and within the samples:
MS between samples 16:013
F ratio ¼ ¼ ¼ 4:005:
MS within samples 3:998

From Table IV, it is clear that the calculated F-value is greater than F-critical. We can reject
the null hypothesis that suggested the difference between the sample means is significant.
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Inference from ANOVA analysis shows that the collected samples did not belong to the
same universe, so the data drawn are completely authentic.

6. Results and discussion

6.1 Analysis of data
In the current problem, 33 elements of JIT in health care services are recognized from a
comprehensive literature survey. But due to a lot of uncertainty involved with these
elements, it is not easy to apply all the elements in the conception of JIT in health care
services. Therefore, it is necessary to differentiate between the elements of JIT system based
on their ease and difficulty in implementation in health care services. Hence, for this
purpose, a survey of numerous hospitals was carried out to obtain the insights of the basics
and benefits of listed elements. The questionnaires were circulated in 20 health care
services. All the responses were analyzed, and the mean score for each part was calculated.
According to responses given in Tables V, “4” represents most important and “0” represents
least important, whereas in Tables VI, “4” represents most difficult and “0” represents least
difficult. Tables V and VI represent the score for the degree of importance and the degree of
difficulties, respectively. Table V shows that team work is the most important JIT element in
healthcare with the mean score of 189 followed by the relationship between supplier and
hospital with the mean score of 184 and so on. TPM with the mean score of 85 and lifetime
employment with the mean score of 86 are the least important elements of JIT in healthcare
(refer Table V ). Table VI indicates that planning and top management support (TMS) are
the most difficult to implement JIT elements in healthcare with the mean score of 190 each.
The case cart system and primary vendor program are the least difficult to implement
elements with the mean score of 84 each.

6.2 XY scatter chart

XY scatter chart is drawn between importance as abscissa and difficulty as ordinate.
The axis crosses at their relative value of population mean ( μ) i.e. for x-axis it is 120 and for
y-axis its value is 120.

Source of variation SS DF MS F-ratio 5% F limit

Table IV.
Between groups 128.104 8 16.013 Value of various
Within groups 683.665 171 3.998 4.005 1.94 variables associated
Total 811.769 179 20.011 with ANOVA
 IJQRM
Response
S. No. JIT elements 4 3 2 1 0 Mean score (0–240)

1 Primary vendor program 16 23 13 6 2 165

2 Relation between supplier and hospital 27 17 10 5 1 184
3 Flexible workforce 16 22 15 5 2 165
4 Respect for human resource 16 17 10 10 7 145
5 Life time employment 5 7 11 23 14 86
6 Automation 21 11 8 12 8 145
7 House keeping 19 13 8 18 2 149
8 Just in time purchasing ( JITP) 23 14 10 7 6 161
9 Job satisfaction 8 9 21 16 6 117
10 Bottom round management 9 6 26 10 9 116
11 Jidoka (to check quality at the source) 21 14 10 8 7 154
12 Quality circles 24 21 9 3 3 180
13 5’S 20 25 11 2 2 179
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14 ABC ranking approach 19 12 20 8 1 160

15 Team work 32 14 8 3 3 189
16 Radio frequency identification (RFID) 30 8 5 11 6 165
17 Error prevention (Poka Yoke) 10 13 12 13 12 116
18 Top management support 28 11 15 5 1 180
19 Education program 21 13 20 2 4 165
20 Incremental implementation 28 15 4 5 8 170
21 Customer relationship management 9 10 8 23 10 105
22 Elimination of waste 27 7 9 11 6 157
23 Case cart system 11 14 7 15 13 115
24 Kanban 8 7 11 19 15 94
25 Total quality management (TQM) 8 7 12 22 11 99
26 Total productive maintenance (TPM) 5 3 18 20 14 85
27 Group technology (GT) 17 21 10 4 8 155
28 Kaizen 13 9 10 15 13 114
29 Faster communication 9 8 18 15 10 111
Table V. 30 Customer satisfaction 17 11 15 9 8 140
Degree of importance 31 Planning 27 11 10 9 3 170
of JIT elements in 32 Group incentive scheme 5 10 16 18 11 100
health care services 33 Standardization 18 21 15 5 1 170

In Figure 6, the lower right corner represents JIT most important and comparatively easy
elements from the implementation point of view in healthcare:
• top right part of Figure 6 represents JIT important and difficult elements in
health care;
• the top left part of Figure 6 shows JIT elements that are less important and difficult to
implement in the healthcare sector; and
• bottom left part of Figure 6 depicts JIT elements in healthcare that are comparatively
less important but easy to implement in healthcare.

6.3 Prioritization and validation of important elements of JIT in healthcare using AHP
In order to validate the findings based upon the degree of importance, top five scored
elements, namely, team work (TW), relation between supplier and hospital (RBSH),TMS,
quality circles (QC) and 5’S are selected for further prioritization using AHP. Besides, AHP is
used to validate the rank of important elements (based on degree of importance) obtained by
using statistical score. Steps evolved in AHP are as follows.
 Response
Just in time
S. No. JIT elements 4 3 2 1 0 Mean score (0–240) elements
extraction
1 Primary vendor program 6 8 9 18 19 84
2 Relation between supplier and hospital 8 9 20 13 10 112
3 Flexible workforce 10 13 9 18 10 115
4 Respect for human resource 22 16 10 6 6 162
5 Life time employment 27 14 7 11 1 175
6 Automation 21 14 8 13 4 155
7 House keeping 6 13 8 21 12 100
8 Just in time purchasing ( JITP) 29 10 13 7 1 179
9 Job satisfaction 9 8 16 11 16 103
10 Bottom round management 3 9 19 11 18 88
11 Jidoka (to check quality at the source) 26 15 11 6 2 177
12 Quality circles 4 17 9 16 14 101
13 5’S 11 21 10 12 6 139
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14 ABC ranking approach 9 8 20 11 12 111

15 Team work 8 12 12 19 9 111
16 Radio frequency identification (RFID) 18 9 15 11 7 140
17 Error prevention (Poka Yoke) 18 13 6 12 11 135
18 Top management support 32 12 11 4 1 190
19 Education program 26 10 6 10 8 156
20 Incremental implementation 7 8 21 14 10 108
21 Customer relationship management 2 9 14 14 21 77
22 Elimination of waste 15 13 17 12 3 145
23 Case cart system 7 6 11 16 20 84
24 Kanban 19 17 9 10 5 155
25 Total quality management (TQM) 21 11 17 9 2 160
26 Total productive maintenance (TPM) 13 20 13 7 7 145
27 Group technology (GT) 13 11 22 4 10 133
28 Kaizen 19 19 9 10 3 161
29 Faster communication 15 12 9 16 8 130
30 Customer satisfaction 28 14 10 3 5 177 Table VI.
31 Planning 25 26 5 2 2 190 Degree of difficulties
32 Group incentive scheme 14 18 11 9 8 140 of JIT elements in
33 Standardization 8 11 13 22 6 113 health care services

No. of Persons
18
No. of Persons
16
14
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 IJQRM Step 1: making comparison matrix from pairwise comparison. A comparison matrix, which
is reciprocal matrix, is made from pairwise comparison. Table VII represents a comparison
matrix. In this problem, the number of pairwise comparisons is 10. Here “1” represents the
comparison of two same element with each other. Furthermore, if the judgmental value is on
the left side of “1,” we put the actual judgmental value, whereas if it is on the right side of
“1,” we put the reciprocal value. The viewpoint of hospital employees were considered for
assigning the value to each element against other elements. Here ‘1’ assign for least
important and ‘9’ assign for most important.
Step 2: summing up each column of the reciprocal matrix. In the second step, the
summation of each column of the reciprocal matrix was carried out. The second matrix after
summing each column of the reciprocal matrix is given in Table VIII.
Step 3: by dividing each element of the second matrix with the sum of its column, we obtain
normalized relative weight. In this step, each element of the second matrix is divided by the
sum of its column to obtain normalized relative weight as shown in Table IX.
Step 4: estimation of row wise sum of each row of weighted matrix. In the next step, row
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wise sum of each row is carried out as shown in Table X.

Step 5: estimation of weighted matrix. In this step, the sum of last column of Table X was
carried out as 5.000022. Then, each element of last column is divided by 5.000022 to obtain the
weights. The weighted matrix was Table XI:

w ¼ ½0:108992; 0:271557; 0:032766; 0:483417; 0:103279:

As it is normalized, the sum of all the elements in priority vector is 1. The priority vector
shows the relative weights among the factors considered. Table XI depicts the ranking of

Elements TMS RBSH QC TW 5’S

TMS 1.0000 0.3333 5.0000 0.2000 1.0000

Table VII. RBSH 3.0000 1.0000 7.0000 0.3333 5.0000
Comparison matrix QC 0.2000 0.1429 1.0000 0.1111 0.2000
from pairwise TW 5.0000 3.0000 9.0000 1.0000 5.0000
comparison 5’S 1.0000 0.2000 5.0000 0.2000 1.0000

Elements TMS RBSH QC TW 5’S

TMS 1.0000 0.3333 5.0000 0.2000 1.0000

RBSH 3.0000 1.0000 7.0000 0.3333 5.0000
Table VIII. QC 0.2000 0.1429 1.0000 0.1111 0.2000
Matrix for summing TW 5.0000 3.0000 9.0000 1.0000 5.0000
up of each column of 5’S 1.0000 0.2000 5.0000 0.2000 1.0000
reciprocal matrix ∑ 10.2000 4.6762 27.0000 1.8444 12.2000

Elements TMS RBSH QC TW 5’S

TMS 0.098039 0.071283 0.185185 0.108436 0.081967

RBSH 0.294118 0.213849 0.259259 0.180727 0.409836
Table IX. QC 0.019608 0.03055 0.037037 0.060242 0.016393
Normalized relative TW 0.490196 0.641547 0.333333 0.542182 0.409836
weighted matrix 5’S 0.098039 0.04277 0.185185 0.108436 0.081967
 important elements (based upon degree of importance) of JIT in the healthcare. The results Just in time
of AHP revealed that team work got the highest weightage (0.483417) followed by elements
relationship between suppler and hospital (0.271557). Furthermore, TMS (0.108992) extraction
obtained third rank. The score of important elements (based on degree of importance) is
obtained by using statistical tools, which shows that team work (189), relationship between
supplier and hospital (184) and TMS (180) obtained the first, second and third ranks,
respectively (refer Table V ).The results of AHP are nearly very similar to those obtained by
statistical tools; this shows the robustness of the of the applied tools. Furthermore, AHP
validates the findings made by statistical tools for the selection of important elements for
successful JIT implementation in healthcare services.
Step 6: estimation of eigenvalue. Eigenvalues are a special set of scalars associated with
the linear system of equations. In order to check the consistency of subjective judgment
principle, eigenvalue is found out by the summation of products between each element of
eigenvector and the sum of column of reciprocal matrix (Saaty, 1988):
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lmax ¼ 10:2  0:108992 þ 4:6762  0:271557 þ27  0:032766 þ1:8444  0:483417

þ12:2  0:103279 ¼ 5:417766:
Step 7: estimation of consistency index. In the next step, the consistency index is found using
the formula (CI) ¼ λmax-n/n-1. The consistency index obtained is:

CI ¼ 5:4177665=51 ¼ 0:104442:

Step 8: estimation of consistency ratio (CR). In eighth step, the CR is obtained by dividing the
consistency index by the random consistency index (RCI):
Consistency index
Consistency ratio ¼ ;
Random consistency index
where RCI is the random consistency index, and the value of RCI in random consistency
index Table XII against 5 is 1.12, so RCI ¼ 1.12:
CR ¼ 0:104442=1:12 ¼ 0:093252 ¼ 9:32%:
The CR is less than 10 percent, so subjective judgments are highly consistent and reliable.

Elements TMS RBSH QC TW 5’S ∑

TMS 0.098039 0.071283 0.185185 0.108436 0.081967 0.544911 Table X.

RBSH 0.294118 0.213849 0.259259 0.180727 0.409836 1.357789 Row wise sum
QC 0.019608 0.03055 0.037037 0.060242 0.016393 0.163831 of each row
TW 0.490196 0.641547 0.333333 0.542182 0.409836 2.417094 normalized relative
5’S 0.098039 0.04277 0.185185 0.108436 0.081967 0.516398 weighted matrix

S. No. Elements Rank Weightage

1 Top management support 3 0.108992

2 Relationship between supplier and hospital 2 0.271557
3 Quality circle 5 0.032766 Table XI.
4 Team work 1 0.483417 Ranking of important
5 5’S 4 0.103279 elements of JIT
 IJQRM To validate the ranking obtained using the AHP method, the BWM method is used. The
BWM method uses to 2n – 3 pairwise comparison rather than 2n-1 of AHP. Here n is number
of elements used in pairwise comparison matrix. Moreover, a small number of comparisons
result in more consistency because as the number of comparisons increases, inconsistencies
also increases. The ranking of important JIT elements based on five criteria is carried out using
the BWM. Five criteria included for the analysis and ranking of BWM are: better patient
care, cost of healthcare, healthy and hygienic work environment, fast flow of information in
healthcare supply chain, and timely delivery of items. It has been found from BWM that team
work, relation between supplier and hospital, TMS obtained first, second and third ranks,
respectively. The same elements obtained the same ranks in the ranking of elements using the
AHP approach (refer Table XI). The CR in AHP is found to be 0.0932, and in the BWM method,
the average CR is 0.033. The CR close to zero is a measure of the reliability of a method; hence,
the rank found AHP and BWM methods are more realistic for generalization. Table XIII
represents the ranking of important JIT elements using the BWM method, whereas Table XIV
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represents the comparison of ranking of JIT elements by AHP and BWM methods.
The results obtained by ranking important JIT elements are very important for the
hospital employees and managers to adopt JIT philosophy. Furthermore, it is obvious from
the ranking of both AHP and BWM that team work is the most significant JIT element. The
full cooperation and coordination are essential from all the members from upstream and
downstream of healthcare supply chain for the successful JIT program. Moreover, when all
the employees are whole heartily evolved, it will result in a better and economical patient
care in the hospitals. The relationship between supplier and hospital is the second most
important JIT element; better relationship results in timely delivery of medical items for
hospitals and both parties enjoy the benefits of the resulting relationship. The TMS got
3rd rank by both BWM and AHP ranking; TMS is very essential as it is the main force
behind the implementation and execution of the JIT program in a healthcare unit.

Table XII.
Average n 1 2 3 4 5 6 7 8 9 10
random consistency
index table RCI 0 0 0.58 0.9 1.12 1.24 1.32 1.41 1.45 1.49

JIT important elements BWM index BWM rank

RBSH 0.0239977 0.0356805 0.0287011 0.0180552 0.1461862 0.25262069 2

TMS 0.0918586 0.0218655 0.0111966 0.0287046 0.0417379 0.195363218 3
5’S 0.0159172 0.0047034 0.0107793 0.0041241 0.0334276 0.068951724 5
Table XIII. TW 0.0642172 0.2022862 0.0487414 0.0392586 0.0248069 0.379310345 1
BWM matrix table QC 0.0173276 0.0067552 0.055469 0.0132 0.0110897 0.103841379 4

JIT important elements AHP weightage AHP ranking BWM weightage BWM ranking

RBSH 0.271557 2 0.25262069 2

Table XIV. TMS 0.108992 3 0.195363218 3
Comparison of AHP 5'S 0.103279 4 0.068951724 5
and BWM ranking TW 0.483417 1 0.379310345 1
(questionnaire) QC 0.032766 5 0.103841379 4
 The rankings of important JIT elements are highly valuable for the entire supply chain of Just in time
healthcare: supplier, hospital and patients. The JIT program results in a better relationship elements
between supplier and hospital that consequently results in a proper management of extraction
inventory of the hospitals. Suppliers have access to hospital medical and other associated
items and hospitals relish the large quantity discount. The implementation of JIT program
provides healthy condition at different wards through 5’S, and it provides a good ambience
for the healthcare employees that encourages a better patient care. The patients get better
patient care through improved work environment and more time dedicated by the hospital
employees, which otherwise goes in vain in other non-value-added activities.

7. Conclusions
The Indian healthcare sector is lagging behind its neighbor countries like China in terms of
healthcare spending, life expectancy, infant mortality rate, etc. The main reason behind this
is comparatively lesser governmental initiatives, increased privatization, and limited
insurance coverage together with limited attention on resources of healthcare sector
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(Yip and Mahal, 2008). Despite these reasons, the Indian health care sector can flourish by
adopting quality tools like just in time. So, this paper has focused on extraction and
prioritization of JIT elements in the healthcare services to achieve excellence. A survey of
20 hospitals is carried out to extract the JIT elements, and the collected data are validated by
the ANOVA. Furthermore, to find important and easy to implement JIT elements in the
healthcare, the score of JIT elements for the degree of importance and difficulty is estimated
and plotted on the scatter chart using a scale of 0–120. The JIT elements, vendor program,
relationship between supplier and hospital, flexible workforce, housekeeping, quality circle,
ABC ranking approach, incremental implementation and standardization are found to be
important and easy to implement areas in the healthcare sector.
From the survey results, five important JIT elements are spotted: team work, relationship
between supplier and hospital, TMS, quality circle and 5’S. Furthermore, AHP is used for the
prioritization of these five important JIT elements. AHP results show that team work is the
most essential element with the highest weightage (0.483417) followed by the relationship
between supplier and hospital (0.271557). The results obtained from AHP are completely in
agreement with the results obtained from a statistical tool. This validates the proper selection
of important JIT elements for healthcare services to achieve quality service at low cost.
To validate the findings of AHP, BWM is used so that consistency among ranks of the
important JIT elements can be established. BWM results also highlighted that team work,
relationship between supplier and hospital and TMS are the prime elements for the success
of any JIT program within an organization. It is obvious from the ranking of important
elements by the AHP and BWM method that for successful implementation of JIT plan,
whole heartily cooperation from entire supply chain is of foremost importance. The supplier
at the top of supply chain ensures the timely distribution of medical items, management of
hospital ensures the optimum utilization of resources and hospital employees work in team
to deliver high-quality healthcare at optimum cost.

8. Future scope and limitations

In the present study, the authors mainly focused on the extraction and prioritization of
important JIT elements in the healthcare sector. For future research, the present work can
be integrated with Lean and Green Six Sigma for finding and implementing proper JIT
element in service sectors in a logical way. The prime limitation of the present study is that
it is entirely focused on the Indian healthcare sector. The applications of JIT in healthcare
vary from nation to nation as per the government initiatives and healthcare polices of the
concerned nation. In future, researchers can explore a generalized framework of JIT for a
particular healthcare service with the understanding of JIT elements.
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Corresponding author
Rajeev Rathi can be contacted at: rathi.415@gmail.com

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