Lean Six Sigma solutions for quality improvement
in healthcare sector: a systematic review
Akshay Prasad, Akshay Kurup, Jishnu K, G Abhisek, Alok Kumar Samanta and G Varaprasad
Mechanical Engineering Department
National Institute of Technology, Calicut
Kerala, India
Abstract
The level of service quality offered to the patients is drastically
declining over the years. The main purpose of this paper is to
show a systematic analysis of the literature review based on lean
six sigma in the healthcare process. This review aims at to
improve service quality by identifying problems faced in the
healthcare process and providing reliable solutions. A descriptive
review focusing on lean six sigma in the healthcare process,
followed by bibliometric analysis aligned with consistent
literature review. The literature review related to healthcare
process identifies the problems faced in hospitals. Reliable
solutions for the problems are identified from literature and
summarized. Primary problems are identified through literature
review, while the results might not be accurate due to lack of
diversity of papers reviewed. Hospital management can utilize
the literature classification and the notable references provided
in this review for in-process quality improvement. The procedure
adopted in this paper is an integrated bibliometric and systematic
literature review. The main contribution of this paper includes
providing reliable solutions for problems faced in the healthcare
sector as derived from the review.
Keywords—Lean Six Sigma; Healthcare; Medical; Patient; quality
improvement
I. INTRODUCTION
Lean Six Sigma is a quality improvement methodology
that integrates two methods namely Lean and Six Sigma. Lean
methodology only considers the activities which add value to
the product or service remaining all is considered as waste.
The lean tools that were employed in the healthcare sector to
reduce the Non Value added (NVA) activities are: Value
Stream Mapping (VSM), 5S, Poka-yoke, etc. Similarly Six
Sigma uses a systematic problem-solving approach known as
DMAIC (Define, Measure, Analyze, Improve and Control) to
reduce variation in the process. The various Six Sigma tools
proved their utility in the healthcare sector are: Failure Mode
Effect Analysis (FMEA), Statistical Process Control (SPC),
Pareto analysis, why analysis, affinity diagram, etc. The
shortcomings of Lean that it can’t reduce the variation and of
Six Sigma is that it can’t get process speed. Hence LSS
integrates both these methods to overcome their individual
limitations. The need for process improvement in the
healthcare sector compelled the healthcare management to
adopt LSS to obtain similar benefits as achieved by the
manufacturing sector.


 

II. METHODOLOGY
Researchers in several domains have adopted a
methodology by combining bibliometric analysis and a
systematic literature review to portray the development of the
concept in their fields. This investigation has been helpful in
indicating perceptive structure in the research domain. This
investigation helps in distinguishing the important in the
particular field. Selection of material was carried out in the
most comprehensive databases i.e. Web of Science (WoS).
WoS is regarded as the most dependable interdisciplinary
database that has no coverage bias between management and
engineering topics. As only articles published in the SSCI,
ESCI, and SCIE are covered in WoS, thus guaranteeing the
quality of material. A literature search was first carried out
with a generic keyword “Lean Six Sigma” followed by
Boolean operator “AND” then within brackets the other
keywords (“health”, “healthcare”, “hospital”, “medical”,
“laboratory”, “clinic”, “nursing home”, “patient”) separated by
Boolean operator ‘OR”. In WoS the search criteria was
“Topic” (Title, Author Keywords, Abstract and Keyword
Plus).
The literature search resulted in 167 journal articles
published in English language. We considered all the articles
which were published between the years 2005 and 2019. The
data collected from the journal papers and their specifications
were tabulated using MS Excel. This tabulated data was then
further used for an analysis of the various studies done in the
health care sector. The entire journals were categorized and a
bar graph was plotted on the basis of their year of publication.
Also the journal papers were analyzed on the basis of their
research areas and country/region the publication was done in.
Bar graphs were plotted based on these factors as well.
The articles between the years 2014 and 2019 where LSS
was implemented to get a tangible result were only considered
for analyzing the recent healthcare problems and
corresponding solutions (Table 4).
III. RESULTS AND DISCUSSION
The analysis of the journal papers based on their year of
publications indicates that the most number of studies were
done in the year 2018, with 27 publications, contributing to a
16.77% of the total journal papers analyzed. This is followed
closely by the year 2017, with 26 publications, and the year
2016, with 20 publications. The bar graph depicting the
analysis is shown in Fig. 1.


 

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 TABLE II. RESULTS ANALYSIS TABLE FOR RESEARCH AREAS FIELD
Record
Field: Research Areas % of 161
Count
26.708
HEALTH CARE SCIENCES SERVICES 43
%
12.422
ENGINEERING 20
%
10.559
GENERAL INTERNAL MEDICINE 17
%
BUSINESS ECONOMICS 16 9.938 %

Fig. 1. Bar graph depicting number of publications made against year of SURGERY 16 9.938 %
publication. RADIOLOGY NUCLEAR MEDICINE
11 6.832 %
MEDICAL IMAGING
Table I shows the evolution of publications with time. MEDICAL INFORMATICS 8 4.969 %

TABLE I. RESULTS ANALYSIS TABLE FOR PUBLICATION YEARS FIELD NURSING 8 4.969 %

Field: Publication Years Record Count % of 161 MEDICAL LABORATORY TECHNOLOGY 7 4.348 %

2019 14 8.696 % OPERATIONS RESEARCH MANAGEMENT

6 3.727 %
SCIENCE
2018 27 16.770 %

2017 26 16.149 %
The analysis of the journal papers based on their
2016 20 12.422 % country/region of publication indicates that the most number
of studies were done in the USA, with 98 publications,
2015 16 9.938 %
contributing to a 60.87% of the total journal papers analyzed.
2014 12 7.453 % This is followed by Netherlands, with 13 publications. This is
2013 13 8.075 % followed by England, India and Italy, with 9 publications
each. The bar graph depicting the analysis is shown in Fig. 3.
2012 8 4.969 %

2011 7 4.348 %

2010 7 4.348 %

The analysis of the journal papers based on their research

areas indicates that the most number of studies were done in
the area of “Health Care Sciences Services”, with 43
publications, contributing to a 26.71% of the total journal
papers analyzed. This is followed closely by research areas
like “Engineering”, with 20 publications, and “General Fig. 3. Bar graph depicting number of publications made against
Internal Medicine”, with 17 publications. The bar graph countries/regions they were published in.
depicting the analysis is shown in Fig. 2.
The publications with respect to the countries/regions
were analyzed (Table III).

TABLE III. RESULTS ANALYSIS TABLE FOR COUNTRIES/REGIONS FIELD

Field: Countries/Regions Record Count % of 161

USA 98 60.870 %

NETHERLANDS 13 8.075 %

ENGLAND 9 5.590 %

INDIA 9 5.590 %

Fig. 2. Bar graph depicting number of publications made against research ITALY 9 5.590 %
areas the studies focused on.
AUSTRALIA 5 3.106 %
Table II depicts the results of the aforementioned GERMANY 4 2.484 %
analysis done on number of publications made with respect to
SCOTLAND 3 1.863 %
the research areas.
SWITZERLAND 3 1.863 %


 

   

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 Field: Countries/Regions Record Count % of 161 USA. This indicates that there is a high scope for research
BRAZIL 2 1.242 % work in this domain in India. Researchers must focus more on
health care issues and try to find a synergy between LSS and
healthcare practioners.
It is clear from the analyses that the numbers of studies
done in India are substantially less compared to that of the

TABLE IV. RESULTS ANALYSIS TABLE FOR COUNTRIES/REGIONS FIELD

Reference Problem Solution

Usage of Lean Six-Sigma(LSS) framework and increase in communication to
[1] Increased waiting time
patients and families regarding expected and unexpected waits
[2] Timeliness of discharge from the hospital Earlier posting of discharge orders
[3] Lengthy breakdown time of biomedical equipments The proper maintenance of equipment and preventive maintenance schedule
[4] Lack of a process owner and lack of tracking capability The electronic approval system allows for longitudinal tracking
Patient flow was redesigned, staffing was adjusted to address high demand
[5] Lack of efficiency of clinics
tasks, and scheduling was optimized
redesign the breast repositioning matching procedure using Lean Six-Sigma
[6] Difficulty in providing near perfect services to large processes
Methodology (LSSM)
Early identification of colonized patients through careful collection of data
[7] The risk of healthcare‐associated infections
related to patients' clinical pathways
Need to improve quality and reliability of Accident and
[8] Introduction of LSS model into the existing NHS model in England
Emergency(A&E) arm of the National Health Service
Conducting continuous quality improvement process with Poka-yoke
[9] Increased medication errors
implementation
Shifting those works to senior hospital staff (more than 10 years working
[10] Poor scheduling of appointments between patients and doctors
experience)
Long intensive care unit length of stay and high costs in
[11] Clinical redesign in the ICU using Lean Six-Sigma
ventilation
To improve clinical laboratory efficiency and reduce turnaround
[12] Removal of non value added steps
times
[13] Increased drug round time Planning with involvement of all stakeholders
[14] Improve Pain Management Introduction of backup system for pain management
[15] Improve access to health care services Optimizing the service and the inventory
Standard operating procedure was introduced, use of optimised cart and
[16] Optimizing turnover time
proper introduction before operation
Standardization of procedure, development of protocols and proper
[17] Healthcare associated infections
management
[18] Increased rate of cesarean instead of vaginal delivery Provision of proper knowledge, better staffing and care
[19] Operational efficiency of hospitals Reduce length of stay, proper scheduling and management
Need to reduce distance walked by nurses during anesthesia
[20] Redesign anesthesia cart
process
[21] Maintain a high reliability Provide training sessions with teachings on Lean and Six-Sigma
[22] Lengthy dispatch time of medical reports Introducing digitalization and following systematic procedure
Visual management, education and Introduction of standard operating
[23] Need to optimize service time
procedure
Optimize cart contents, follow standard operating procedure and proper
[24] Increased preoperative time
introductions to be given before operation
[25] Need to reduce pediatric head CTs Optimizing workflow, technology improvement and process improvement.
Optimized process layout, standardized material usage and proper allocation
[26] Need to reduce turnaround time
of staff
Optimized workflow and increased communication between patient and
[27] To reduce turnaround time and improve patient satisfaction
physician
Improve process to manage medications for dual care veteran Formalized system for documenting, proper education on policies and process
[28]
patients. redesign
The implementation of corrective actions and the standardization of some
procedures performed using optical LSS
[29] Increase in health care spending

Reference
Problem Solution
No
Items in the bedside carts were standardized and supplies and medications
[30] Need to renovate patient care facilities
were centralized in a designated area to streamline workflow.
[31] High percentage of hemolytic cases Better practices, better facilities and proper education about hemolysis.


 

   

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[32] High turnaround time
[33] Increasing costs
[34] Long waiting time
[35] Lack of proper framework
[36] Diagnosis accuracy and time for diagnosis
From the data provided in table IV, we can infer that about
50% of these papers discuss on improving the delivery of the
healthcare sector by minimizing the turnaround time, cycle
time and pre-operating time. Around 20% of the literature
deals with quality and another 20% with growth of the
hospitals. Only 10% of the total 36 journals is dealt with both
productivity and cost related dimensions of the healthcare
industry. Even though Lean methodology helps in identifying
the non-value added activities, only 2 authors took LSS to
tackle the high cost factor. Each solution is case specific to
understand the inherent process deficiency and come out with
valid solution with the help of LSS knowledge base.
IV. CONCLUSION
The healthcare industry has been struggling to provide
adequate service in low cost. Any non-value activity in health
care service would affect the quality of care. High-quality
care involves thorough assessment, detection of asymptomatic
and co-existing conditions, accurate diagnosis, appropriate
and timely treatment, referral when needed for hospital care
and surgery, and the ability to follow the patient and adjust
the treatment course as needed. Lean six sigma can be
adopted as a very powerful methodology for tackling the
problems faced in healthcare process. The healthcare
organization management must spend time to understand the
Lean Six Sigma applications and use this methodology for
continuous quality improvements.
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