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Application of Lean Six Sigma methodology to reduce the cycle time of out-
patient department service in a rural hospital

Article  in  International Journal of Healthcare Technology and Management · January 2014

DOI: 10.1504/IJHTM.2014.064257

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222 Int. J. Healthcare Technology and Management, Vol. 14, No. 3, 2014

Application of Lean Six Sigma methodology to reduce

the cycle time of out-patient department service in a
rural hospital

Shreeranga Bhat*
Department of Mechanical Engineering,
ST Joseph Engineering College,
Vamajoor, Mangalore – 575 028, Karnataka, India
E-mail: shreeranga1981@gmail.com
*Corresponding author

N.A. Jnanesh
KVG College of Engineering,
Sullia – 574 327, Karnataka, India
E-mail: jnanesh_na@yahoo.com

Abstract: This article discusses the implementation of Lean Six Sigma (LSS)
methodology in decreasing cycle time of out-patient department service of a
rural hospital. The lean principles and Six Sigma define, measure, analyse,
improve, and control process (DMAIC) approaches have been used to
achieve this result. This article explains the step-by-step approach of LSS
implementation in a rural Indian hospital for quality improvement and timely
service to the community. This resulted in decreased cycle time of the process
from 4.27 minutes to 1.5 minutes. Owing to the project a 97% reduction in
average waiting time in the system and 91% decreases in queue length were
reported. During this study, data was collected on all possible causes. Statistical
techniques and GEMBA were used to analyse the data. Based on analysis
conclusions were made. Lean tools such as kanban, 5S, ergonomic design of
work place, etc., were effectively used to improve process and sustain the
process.

Keywords: lean; Six Sigma; out-patient department; OPD; rural hospital.

Reference to this paper should be made as follows: Bhat, S. and Jnanesh, N.A.
(2014) ‘Application of Lean Six Sigma methodology to reduce the cycle time
of out-patient department service in a rural hospital’, Int. J. Healthcare
Technology and Management, Vol. 14, No. 3, pp.222–237.

Biographical notes: Shreeranga Bhat is a faculty at the Department of

Mechanical Engineering of ST Joseph Engineering College, Mangalore, India.
He holds a Bachelor in Mechanical Engineering and Master in Engineering
Management from Manipal Institute of Technology, Manipal. He is a Certified
Black Belt in Six Sigma from Indian Statistical Institute, Bangalore. His area of
interest includes lean manufacturing, Six Sigma and design of experiments.

N.A. Jnanesh is currently working as Principal of K.V.G. College of

Engineering, Sullia, Karnataka, India. He completed his BE degree from
Mysore University, ME degree from Karnataka University Dharwad and PhD
degree from Mangalore University. His research topic was application of total

Copyright © 2014 Inderscience Enterprises Ltd.

 Application of LSS methodology to reduce the cycle time of OPD service 223

quality management in technical education with special reference to curriculum

development. His areas of interests are TQM, Six Sigma, SQC, production
management and operation management. He is having more than 24 years of
experience in teaching and administration domain. He was the member of
several bodies of universities and visited different countries and presented
several papers in national and international conferences and seminars.
Currently, he is an executive council member of Visvesvaraya Technological
University, Belgaum.

1 Introduction

Lean Six Sigma (LSS) is one of the most modern strategies and well-established
methodologies for improving the speed, quality and cost of manufacturing and service
industries (Johnstone et al., 2011). Lean is a strategy or philosophy that accelerates the
speed of all processes across the enterprise to minimise ‘waste’ in order to improve
firm performance (Womack et al., 1990). Earlier research reported seven types of wastes,
whereas recent publications describe eight types, namely defects, overproduction,
waiting, non-utilisation of talents, transportation, inventory, motion, extra-processing
(DOWNTIME) (Graban, 2009; Liker, 2004). Even though it was basically developed and
applied extensively in manufacturing organisations, service sectors heavily need lean
thinking. This is because most of the service processes are slow, they contain far
too much of work-in-process (WIP) inventory and thus often result in unnecessary
complexity in the service/product offering (George, 2003). Literature survey shows that
lean principles were also successfully applied in healthcare (LaGanga, 2011; Riley et al.,
2010). Six Sigma is a philosophy that employs a well-structured continuous improvement
methodology to reduce process variability and drive out waste within the business
processes using statistical tools and techniques (Banuelas and Antony, 2003). It is based
on principles set up by quality experts, such as Deming, Juran, Shewart and Ishakawa.
Six Sigma has additional data analysis tools and more financial focus than are
found in total quality management (TQM) (Salah et al., 2009). It has proven to be a
customer-focused, data driven and robust methodology with a goal of reducing the
number of mistakes/defects – to as low as 3.4 occasions per million opportunities (Parker
et al., 2007). These benefits of Six Sigma are achieved through the utilisation of a
systematic approach, the define, measure, analyse, improve, and control process
(DMAIC) (Feng and Manuel, 2008). Six Sigma has shown incredible results for the past
30 years, by producing significant savings to the bottom line of many manufacturing
organisations (Aboelmaged, 2010). Six Sigma also showed fruitful results both in
operational and clinical performance improvement of healthcare industry in the last
decade (Adams et al., 2004; Chan et al., 2005). Fusion of lean and Six Sigma is essential
due to the fact that, lean cannot bring a process under statistical control and Six Sigma
alone cannot dramatically improve process speed or reduce invested capital (George,
2002). Lean and Six Sigma share common goals and grounds in terms of striving to
achieve customer satisfaction. Integration of these two powerful methodologies under the
DMAIC umbrella leads to grater quality improvement results (Salah et al., 2010b). LSS
principle focuses on adding value to customers, reducing defectives and wastes,
streamlining value flow, and improving on time delivery (Salah et al., 2011). After
224 S. Bhat and N.A. Jnanesh

starting a LSS project, it may evolve to use more Six Sigma or lean tools or a mix of both
as suitable to the nature of the project where all tools are LSS tools. The suitability of
these tools and methods in general depends on understanding the methods and the
application environment (Salah et al., 2010a). Thus, combined efforts of LSS
methodology are gaining significance both in manufacturing and in service organisation.
Similar to other sectors, LSS tools can be applied to several aspects of health care,
including finance, inventory management, information processing, out-patient clinics,
and inpatient settings, etc. (Cima et al., 2011). The healthcare organisation is the place
where defects and mistakes cannot be tolerated, because it is directly related to human
life. LSS approach is the best option in a healthcare environment to tackle this issue and
to provide quality care at an affordable cost (Ahmed et al., 2013). However, reports of the
effectiveness of using LSS methodology in the out-patient department (OPD)
environment are quite limited (Gijo and Antony, 2013; Yu and Yang, 2008). But
literature survey showed that no case study has been carried out till date on the
application of LSS methodology in OPD of rural hospitals. Therefore, we report the use
of a combined LSS methodology to improve OPD of a rural hospital in India.

2 Research methodology

Research methodology is a structure and plan to discover answers to the research

questions through the application of scientific procedures (Cooper and Schindler, 2006).
The researcher worked with the hospital to provide support for the project in the LSS
techniques, whilst recording data about the exercise from which to develop a case study.
The case study is based on a single case of a single hospital, a single location or a single
event. The research methodology that the project group designed for the case study is as
follows: formulating the research problem, literature survey, collecting the data, analysis
of data, hypothesis testing, interpretation and implementation of results (Yin, 1994). An
initial study was carried out to identify the business case, which in turn helped to define
the problem more specifically. To identify the past history of various improvement
initiatives carried out to address process-related issue, a literature review was undertaken.
A detailed data collection plan was prepared and data was subjected to detailed analysis
using normality testing, I-chart and capability analysis to make meaningful conclusions.
The hypothesis generated was validated by tools such as two sample T-test and GEMBA
and inferences were made (Pyzdek, 2003). Also lean thinking was initiated to support the
conclusion drawn by identifying the ‘wastes’ in the process (Graban, 2011; Zidel, 2007).
Based on hypothesis testing the solutions to the root causes were generated based on lean
tools and techniques. Results of the improved process were collected and system was
established to sustain the results. Minitab statistical software was used to analyse the data
collected at different stages in the case study. ARENA simulation software was utilised to
calculate the key performance indicators of the process (El-Haik and Al-Aomar, 2006;
Yu and Yang, 2008).
 Application of LSS methodology to reduce the cycle time of OPD service 225

3 About the case study

The case study was carried out in an Indian rural hospital. Hospital was established in the
year 1967 by the SRA Sisters for the service and welfare of the people in and around the
village. It is one of the most well equipped hospitals in the rural area and one of only few
charitable institutions that serves the people of that state. It is a fully functioning
50 bed multi-specialty hospital. The hospital is fully equipped with state-of-the-art
equipments, full fledged operation theatres and intensive care units, diagnostic services
such as CT scan, X-ray, ultrasound, dental clinic, and laboratory. The hospital has a
dedicated team of doctors. Four doctors work full time and about 15 visiting doctors who
are well experienced. The nursing and supporting staff of the hospital are also well
trained. Since it is a charitable hospital, service to the patients is offered at minimum
charges. On an average 50 patients use the OPD services per day and 15 patients use
in-patient services per day. On the whole the hospital has been providing top-notch
medical services.
The hospital has a decentralised medical records department (MRD) with two
sections namely OPD and in-patient department. The MRD activities are handled by one
staff and an attendant. OPD is in operation between 9.00 am and 11.00 am only. The staff
responsible for OPD service is also engaged in the in-patient service activities during
remaining part of scheduled duty time. The attendant of the department is responsible for
collecting medical records from different departments and other in-patient service
activities. The project was carried out in the OPD, which is responsible for patients’
registration and revisit. The process flow chart of OPD is shown in Figure 1. At OPD,
patients hand over the revisit card to the staff on his/her subsequent visit to the hospital.
Once revisit card is received, the staff looks for the medical records based on medical
records number (MRN) specified on the card. Once staff cross verifies patient’s name on
the card and medical record, the staff enters the current date of visit in the card. Then
medical records are handed over to the patient. If the record is not found, misplaced
records are searched in other departments and same is handed over to the patient once it
is found. On the other hand, if the patient has forgotten to bring the revisit card, MRN is
searched in the computer based on the information (patient name, date of last visit, etc.)
provided by the patient and then record is handed over to the patient. In case of new visit
to the OPD service (hospital), a new registration is carried out and revisit card is handed
over to the patient.
Since the organisation is a charitable hospital, no out-patient consultation fee is
collected. Thus, the number of patients availing OPD service is increasing every time. It
was observed that service time of the process was very high, which in turn was creating
problem of increased waiting time of patients to avail the service. Thus, lots of people
were assembling in and around the area causing hindrance in the smooth working of the
department. Past attempts such as intuition based decisions, brainstorming had been tried
out to tackle this problem but all of them were unsuccessful. Thus, the management
decided to adopt some scientific methodology to improve the process. Based on the
consultation with resource person, LSS methodology was adopted to tackle the issue.
226 S. Bhat and N.A. Jnanesh

Figure 1 Flow chart

4 LSS to OPD

The project was started with an objective of reducing average waiting time of the patient
in OPD using LSS methodology. The team decided to apply integrated approach of lean
and Six Sigma, since lean looks at what we should not carry out and finds ways to
remove them; Six Sigma looks at what we should be doing and aims to get it right every
single time. Further the team decided to follow basic, tried and tested DMAIC approach
from Six Sigma, but with the integrations of lean flow tools as well as Six Sigma
statistical tools (Arthur, 2011; Butler et al., 2009).
 Application of LSS methodology to reduce the cycle time of OPD service 227

4.1 Define
The first phase starts with an objective to identify the goal of the project by forming a
case study, identifying the scope of the project and the areas of the process to be
improved. Since in LSS projects lot of effort has to be undertaken, a team was formulated
with specific roles and responsibilities at different phases of the project in order to ensure
that all members work together to achieve a common goal without any confusion. The
champion for the project was the medical director (responsible to remove roadblocks,
monitor project progress, approve project) and a black belt (BB) in Six Sigma as the
resource person (responsible to mentor team members, transfer knowledge of LSS tools,
statistical analysis, etc.). The team comprised the nursing superintendent of the hospital
who was selected as the team leader (responsible to facilitate meetings, manage project,
mentor team members, and implement improvements), a medical record staff and two
attendants of the hospital (responsible for data collection).
Table 1 Project charter

Project title: Reducing the cycle time of OPD service process by lean Six Sigma methodology.
Back ground and reason for selecting the project: Average cycle time of the OPD service
process in the hospital is exceeding desired limit of 2 minutes, leading to an increase in average
waiting time of the patients up to 32 minutes in the system and an average queue length of
11 patients with the current one staff level. The current situation is giving slow service and
decreasing productivity in the organisation, thus affecting quality and timely service to the
patients.
Aim of the project: To reduce the average cycle time of the OPD process from 4 minutes to less
than 2 minutes.
Project champion Medical director
Resource person BB in Six Sigma
Project leader Nursing superintendent
Team members OPD staff, two attendants
Characteristics of product/process output and its measure
CTQ Measure and specification Defect definition
OPD service cycle time Minutes Time crossing: 2 minutes
Expected benefits Reduction in waiting time to less than 5 minutes and in queue length
less than two patients, as a result of reduced cycle time of the OPD
service process. This will help the organisation to improve the
quality and timely service to the patients.
Schedule Define: 1 week Measure: 1 week
Analyse: 2 week Improve: 2 week
Control: 2 week

The team then prepared a project charter, i.e., a document stating the purpose of the
project (refer to Table 1). It serves as a platform that helps the team to stay on track with
the goal of the project to be carried out. It consists of project title, background and aim of
the project, expected benefit, schedules etc. Time study for three consecutive days, at the
scheduled working time, revealed that arrival rate of the patients was 25 per hour and the
service rate was 4 minutes per patient. Owing to the resource and technical constraint,
to calculate key performance indicator (waiting time, queue length, etc.), ARENA
228 S. Bhat and N.A. Jnanesh

simulation software was utilised to analyse the process. Simulation model was generated
based on the process flow chart and collected data was given as input. Simulation results
showed an average waiting time of the patients in the system was 32 minutes per hour.
Also it was observed that average queue length was 11 patients per hour. After having
discussions on the various aspects of the problem, the team decided to consider cycle
time of OPD service as critical-to-quality (CTQ) characteristics. Simulation study also
shown that, to reduce waiting time from 30 minute to less than 5 minutes (as expected by
the management), cycle time of the process has to be reduced to less than 2 minutes. Thus
the team decided to take the specification limit for CTQ as 2 minutes.
Before undertaking any process management or improvement activity, it is important
to get a high-level knowledge regarding the scope of the process first. A supplier, input,
process, output, and customer (SIPOC) process definition was developed for this purpose.
This helps the project team to agree on the limitations or boundaries within which they
will be working (refer to Figure 2).

Figure 2 SIPOC

Suppliers Inputs Process Outputs Customer

Hospital store Preparing
Stationeries
room medical records Patients detailed
Patient
Patients (admission/regis record
Patients tration)
information

4.2 Measure
The main objective of this phase is to convert the problem into a quantifiable form, to
check the measurement system and measurement of the situation at hand. The project
team first prepared a detailed data collection plan for CTQ consisting of information such
as types of data to be collected, units, type of sampling technique, related conditions, and
the measurement system to be used to collect the data. A digital stop watch having least
count 1 second was used to measure the cycle time. Stop watch was calibrated before the
commencement of data collection and found acceptable for the time study.
A random sampling technique was adopted to collect the baseline status. As per the
plan, a sample size of 56 was collected for a week. Further this data was subjected to the
‘Anderson Darling normality test’ with the help of Minitab software. From the Minitab
software output, the p-value of the test was found to be more than 0.05
(at 95% confidence interval), which leads to the conclusion that the data is from a
population that is normal. I-chart of the collected data depicted that there were no
assignable causes present in the process and the process is statistically under control
(refer to Figure 3). Based on the process capability analysis of the data (refer to Figure 4),
baseline status was deduced. Cycle time of more than 2 minutes (120 seconds) was
considered as a defect. From the Minitab output parts per million (ppm) total was
 Application of LSS methodology to reduce the cycle time of OPD service 229

identified as 868,835.93 with a mean of 256.214 seconds (4.27 minutes) and standard
deviation of 121.552 seconds (2.02 minutes). This implied that the process was at 0.38
sigma level and the same was considered as the baseline of the process.

Figure 3 I-chart for cycle time (see online version for colours)

700

UCL=621.6
600

500
Cycle time (Seconds)

400

300 _
X=256.2
200

100

-100 LCL=-109.2

-200
1 7 13 19 25 31 37 43 49 55
Observation

Figure 4 Process capability analysis of cycle time (see online version for colours)

USL
P rocess Data O v erall C apability
LS L * Pp *
Target * Low er C L *
USL 120 U pper C L *
S ample M ean 256.214 PPL *
S ample N 56 PPU -0.37
S tDev (O v erall) 121.522 P pk -0.37
Low er C L *
U pper C L *
C pm *
Low er C L *

0 120 240 360 480

O bserv ed P erformance Exp. O v erall P erformance
P P M < LS L * P P M < LS L *
PPM > USL 857142.86 P P M > U S L 868835.93
P P M Total 857142.86 P P M Total 868835.93
230 S. Bhat and N.A. Jnanesh

4.3 Analyse
The purpose of this phase is to identify the influencing factors and causes that determine
CTQ’s behaviour. The team performed a brainstorming session with involvement of
champion, team members and senior doctors to identify the potential causes of longer
cycle time. These causes are presented in the form of a cause and effect diagram in
Figure 5.

Figure 5 Cause and effect diagram

The root causes for longer cycle time at the OPD have to be identified through data based
validation of these causes. The team, along with the Champion and BB had a detailed
discussion to identify the possible validation methods for the root causes. Wherever
direct measureable data was possible to be collected on the causes, statistical techniques
were adopted. One such analysis used was the ‘two sample T-test’ to validate the cause
‘lack of training’. It was observed that, sometimes due to the urgency of in-patient service
work, OPD services were handled by the attendant of the department. Since attendant
was untrained in the OPD activities, team suspected that there could be a variation
between the cycle time among the staff and attendant. Thus the data was collected on
service rate (cycle time) of the staff and attendant. Collected data was subjected to
normality test and found that data was normally distributed. Thus, two sample T-test was
planned and p-value (p < 0.05) of the test indicated that there is a significance effect of
training on longer cycle time. Thus, ‘lack of training’ was considered as the root cause of
the problem.
For all other causes, where direct measurable data was not possible to be collected,
the GEMBA method was used to validate such causes. In the GEMBA method of
validation, the process was observed for a specified period of time and the presence or
absence of the specific cause was recorded (Womack, 2011). In this methodology, team
observed the process for one week and occurrences of specific causes were recorded and
conclusion was made regarding the root cause. Table 2 summarises the cause validation
method, GEMBA observations and analysis results of the root causes.
 Application of LSS methodology to reduce the cycle time of OPD service 231

Table 2 Cause validation method, GEMBA observations and results

GEMBA observation (‘waste’ as per

SI. Type of
Causes lean methodology is presented inside Conclusion
no. analysis
the bracket for root causes)
1 Lack of training Two sample (Non-utilisation of talents) Root cause
T-test
2 Lack of positive GEMBA It was observed that the OPD service Not a root
attitude towards provider was utilising the available time cause
work towards the work, without any service gap
between two consecutive service
3 Lack of computer GEMBA Computer was quick enough to search Not a root
with higher MRN in the absence of card and new cause
configuration registration
4 Non-availability GEMBA Since stationery were ordered in Not a root
of stationeries advance, there was no shortage cause
of same in the department
5 Improper GEMBA Stationery were misplaced from its Root cause
arrangement of position, causing excessive stretching
stationeries and bending, thus leading to increased
cycle time (motion)
6 Misplacement of GEMBA During the process, medical records were Root cause
records moving to different parts of the hospital. If
same was not returned back to the OPD,
during revisit of the patient it would be
difficult to track the whereabouts of the
medical records. Study revealed that six
out of ten times, misplacement of records
were significantly affected the increased
cycle time (transportation)
7 Interference in GEMBA It was observed that queue was disturbed Root cause
queue system every now and then by the patients,
causing increased cycle time of the
system (waiting)
8 Improper/errors GEMBA The information given by the patients Root cause
in patient were not found to be correct, the name
information and addresses usually were not uniquely
identified hence there was difficulty in
finding the medical records. Also
improper information given by the patients
during the time of new registration led
to the increased cycle time (defects)
9 Lack of visual GEMBA Since there were no codes/numbers on Root cause
management the medical records shelf, staff was
finding it difficult to identify the files,
which was in turn increased the cycle
time of the process (defects)
10 Improper GEMBA It was observed that work place, Root cause
ergonomic design position of computer systems were
of work place not as per ergonomic design, causing
variation in the cycle time (motion)
232 S. Bhat and N.A. Jnanesh

4.4 Improve
During the improve phase of this project, the solutions to the root causes were identified.
A risk analysis was performed for all the selected solutions to identify possible negative
side effects of these solutions before they were implemented. Then solutions were
implemented with a detailed implementation plan. Following are the solutions
implemented for the root causes.
• To address the root cause ‘lack of training’, training was arranged for a few selected
supporting staff of the hospital, so that they can handle the department more
effectively in the absence of regular OPD staff.
• Location of stationary was marked on the desk and arranged through desk organisers.
Stationary was positioned close to the staff to avoid excessive stretching and bending
during the activity.
• Another root cause, ‘misplacement of records’ was tackled by the implementation
single card ‘kanban’ system (Jackson, 2013). This helps in tracking of the medical
records (refer to Figure 6).
• Queue maker was implemented so as to maintain a queue and to provide service on
first come first served basis.
• Submitting patient’s identity proof (any card consisting of full name, address, date
of birth) is made mandatory for new registration and in the absence of revisit card,
to address the root cause ‘improper/errors in patient information’.
• Stickers are prepared for each rack of the medical records shelf, containing the range
MRN stored in it. This would help the staff to gear up the process of searching
medical records in the shelf.
• To improve the ergonomic design of the work place, medical records shelf was
kept closer to the staff in the department. Also old records (one year and above)
are placed in the top rack of the shelf and new records are placed in the next
subsequent racks of the shelf. This reduced the cycle time by drastically decreasing
the movements (foot-steps) within the department, to search and hand over the
records. The keyboard is placed directly in front of chair, screen directly in front of
chair and keyboard. Monitor is placed 18 to 30 inches away from eyes. Workstation
chair is used and chair height is adjusted at a level so that feet rest flat on the floor
(Grandjean, 1986; McKeown, 2007).

Figure 6 Medical record before and after the implementation of ‘kanban’ card (see online version
for colours)
 Application of LSS methodology to reduce the cycle time of OPD service 233

Figure 7 I-chart for cycle time (after improvement) (see online version for colours)

180

160 UCL=160.5

140
Cycle time (Seconds)

120

100
_
80 X=78.4

60

40

20

0 LCL=-3.6

1 7 13 19 25 31 37 43 49 55
Observation

Figure 8 Process capability analysis of cycle time (after improvement) (see online version
for colours)
USL
P rocess Data O v erall C apability
LS L * Pp *
Target * Low er C L *
USL 120 U pper C L *
S ample M ean 78.4464 PPL *
S ample N 56 PPU 0.54
S tDev (O v erall) 25.8309 P pk 0.54
Low er C L 0.40
U pper C L 0.67
C pm *
Low er C L *

20 40 60 80 100 120 140

O bserv ed P erformance E xp. O v erall P erformance
P P M < LS L * P P M < LS L *
P P M > U S L 0.00 P P M > U S L 53843.46
P P M Total 0.00 P P M Total 53843.46

Data was collected on the improved process, subjected to normality test and found
normal. An I-chart was prepared based on the data and found that improved process is
statistically under control (refer to Figure 7). Then process capability analysis (refer to
Figure 8) was carried out and improved results were identified. Analysis with a target
cycle time of 2 minutes (120 seconds) yielded ppm of 53,843.46, confirming 3.11 sigma
level. The average cycle time was reduced to 1.5 minutes (78.446 seconds) from
4.27 minutes (256.214 seconds) and standard deviation 2.02 minutes (121.552 seconds)
234 S. Bhat and N.A. Jnanesh

to 0.43 minutes (25.83 seconds). Thus there was a reduction of 65% on average cycle
time and 79% in standard deviation for cycle time. Due to the project 97% reduction in
average waiting time in the system (from 32 minutes to 1 minute) and 91% decreases in
queue length (from 11 to 1 # of patients) were reported.

4.5 Control
This is the last phase in the DMAIC approach, in which it is ensured that the processes
continue to work well, produce desired output results and maintain the level of quality
required. Once the results are achieved, the challenge for the organisation is to sustain the
improvements of the achieved results. Thus, following control plans were planned.

• For reasons such as people changing location of work quite often owing to living
conditions, etc., maintaining the result is difficult. Thus, to ensure ‘knowledge
management’, all the process changes made were documented. A system was
established to train the newly appointed supporting staff based on these documents.

• Standardisation of improved factors and element that affect the working of the MRD
and continuous monitoring of the results alone can ensure the sustainability of the
result. Thus, it is planned to record five data daily on the cycle time on a sample
basis, plotted on a run chart and variations were studied. Immediate action plan was
prepared to address assignable causes if present in the process. Summary of all these
are presented in the monthly review meeting.

• It is also important to ensure that the operating personnel in the process feel
ownership of the solutions implemented, so that without any external intervention
the process can be maintained. A programme was arranged to felicitate the team
members along with three day workshop on LSS tools and techniques by a resource
person. Also a LSS team was formed including senior doctors and a few selected
supporting staff to identify the improvement opportunities in the hospital. It was
decided to provide financial benefits for all team members of such successful
projects. Monthly review meeting was arranged to discuss and implement LSS
projects.

• 5S methodology is applied to ensure workplace organisation (Buesa, 2009).

• Standard operating procedures were prepared and displayed near the workplace.

5 Lessons learned and managerial implications

LSS provides the concepts, tools and methods in a more structured manner for the drastic
changes to the process. Also the five-phase approach DMAIC is an effective sequence,
which links the statistical and other tools that have been found to be effective in
improving processes. Incorporating the concepts of standardised procedures and
workplace improvement via the ergonomic design, 5S’s can improve efficiency and
responsiveness and thus reduce waste and time in the organisation. Simulation-based LSS
help to reduce the time, efforts and resources for the improvements.
 Application of LSS methodology to reduce the cycle time of OPD service 235

Improvement initiatives, especially in Indian rural hospitals, are hardly based on the
industrial engineering tools and techniques. This is mainly due to the lack of interaction
among the engineering and medical practitioners. From the project it is evident that LSS
methodology can be effectively implemented not only in the manufacturing sector but
also in the rural healthcare sector to reduce or eliminate the waste by stabilising process
and eliminating the root causes of the process. During the project team members had
shown keen interest in statistical tools, lean tools. From the project, it is evident that
leadership, training about LSS tools, involvement of people, careful implementation of
results, and the motivation of the employees play a large role in the success of the
process.
This case study was an eye opener for the management as it resulted in significant
improvement in the process. Data and its analysis gave confidence to the people and top
management for making decisions about the process. This has changed the mindset, ‘IT
Dept. is not invented here, hence not applicable to our processes’. Also LSS opened a
new window of opportunities for the optimum utilization of available resources and to get
quick results. The management formed a new team to initiate improvement projects in the
hospital with senior doctors and few selected supporting staff as members. Ultimately,
the project brought a cultural change within the organisation by involving everyone in the
organisation towards excellence.

6 Conclusions

OPD is one of the most highly congested hospital activities and undergoes a lot of work
load compared with other departments in the healthcare system of a hospital. The delays
caused in the OPD activities may result in difficulties of working for the MRD staff; the
patients may be unsatisfied, etc. This would affect the quality and timely service to the
community. One such problem of OPD in a rural hospital was addressed through LSS
methodology. Statistical techniques and tools with lean thinking and simulation were
simultaneously used under DMAIC umbrella while carrying out the project.
The process sigma level was improved from 0.38 to 3.11. As a result of the project
average cycle time was reduced to 1.5 minutes from 4.27 minutes (65% improvement)
and standard deviation 2.02 minutes to 0.43 minutes (79% improvement). Due to the
project 97% reduction in average waiting time in the system (from 32 minutes to
1 minute) and 91% decrease in queue length (from 11 to 1 # of patients) were reported.
Even though the case study gave fruitful results, the project faced many typical
challenges. At the beginning, the employees had no knowledge of LSS methodology.
Hence, methodology and steps were briefed to all the people associated with the process
before the commencement of the project. Once briefed the next problem arose when
collecting data as the staff were busy or had the fear of revealing certain critical things
about the hospital. There was also no system from where the information could be
directly accessed and retrieved, so collecting data became a tedious task. With the help
and cooperation from the management and the combined effort of all the members of the
group all obstacles were overcome. The dedication, hard work and team effort helped to
complete the project successfully. Thus, training, involvement of people, leadership are
critical success factors for the successful implementation of the LSS projects.
236 S. Bhat and N.A. Jnanesh

References
Aboelmaged, M.G. (2010) ‘Six Sigma quality: a structured review and implications for
future research’, International Journal of Quality & Reliability Management, Vol. 27, No. 3,
pp.268–317.
Adams, R., Warner, P., Hubbard, B. and Goulding, T. (2004) ‘Decreasing turnaround time between
general surgery cases: a Six Sigma initiative’, Journal of Nursing Administration, Vol. 34,
No. 3, pp.140–148.
Ahmed, S., Manaf, N.H.A. and Islam, R. (2013) ‘Effects of lean Six Sigma application in health
care service’, Review on Environmental Health, Vol. 28, No. 4, pp.189–194.
Arthur, J. (2011) Lean Six Sigma for Hospitals: Simple Steps to Fast, Affordable, and Flawless
Healthcare, McGraw Hill, New York.
Banuelas, R. and Antony, J. (2003) ‘Going from Six Sigma to design for Six Sigma: an exploratory
study using analytic hierarchy process’, The TQM Magazine, Vol. 15, No. 5, pp.334–344.
Buesa, R.J. (2009) ‘Adapting lean to histology laboratories’, Annals of Diagnostic Pathology,
Vol. 13, No. 5, pp.322–333.
Butler, G., Caldwell, C. and Poston, N. (2009) Lean-Six Sigma for Healthcare: A Senior Leader
Guide to Improving Cost and Throughput, 2nd ed., ASQ Quality Press, Milwaukee,
Wisconsin.
Chan, W.P., Chiu, W.T., Chen, W.M., Lin, M.F. and Chu, B. (2005) ‘Applying Six Sigma
methodology to maximise magnetic resonance imaging capacity in a hospital’, International
Journal of Healthcare Technology and Management, Vol. 6, No. 3, pp.321–330.
Cima, R.R., Brown, M.J., Hebl, J.R., Moore, R., Rogers, J.C., Kollengode, A., Amstutz, G.J.,
Weisbrod, C.A., Narr, B.J. and Deschamps, C. (2011) ‘Use of lean and six sigma methodology
to improve operating room efficiency in a high-volume tertiary-care academic medical center’,
J. Am. Coll. Surg., Vol. 213, No. 1, pp.83–92.
Cooper, D.R. and Schindler, P.S. (2006) Business Research Methods, Tata-McGraw Hill,
New Delhi.
El-Haik, B. and Al-Aomar, R. (2006) Simulation-based Lean Six-Sigma and Design for Six-Sigma,
Wiley-Interscience, Hoboken, N.J.
Feng, Q. and Manuel, C.M. (2008) ‘Under the knife: a national survey of six sigma programs in US
healthcare organizations’, International Journal of Health Care Quality Assurance, Vol. 21,
No. 6, pp.535–547.
George, M.L. (2002) Lean Six Sigma: Combining Six Sigma Quality with Lean Production Speed:
Combining Six Sigma Quality with Lean Speed, McGraw Hill, New York.
George, M.L. (2003) Lean Six Sigma for Service: How to Use Lean Speed and Six Sigma Quality to
Improve Services and Transactions, McGraw Hill, New York.
Gijo, E.V. and Antony, J. (2013) ‘Reducing patient waiting time in outpatient department using
lean Six Sigma methodology’, Quality and Reliability Engineering International, doi:
10.1002/qre.1552 [online] (accessed 9 September 2013).
Graban, M. (2009) Lean Hospitals: Improving Quality, Patient Safety, and Employee Engagement,
2nd ed., Productivity Press, New York.
Grandjean, E. (1986) Ergonomics in Computerized Offices, Taylor & Francis, London.
Jackson, T.L. (2013) Kanban for Lean Healthcare, Taylor & Francis, London.
Johnstone, C., Pairaudeau, G. and Pettersson, A.J. (2011) ‘Creativity, innovation and lean sigma: a
controversial combination?’, Drug Discovery Today, Vol. 16, Nos. 1/2, pp.50–57.
LaGanga, L.R. (2011) ‘Lean service operations: reflections and new directions for
capacity expansion in outpatient clinics’, Journal of Operations Management, Vol. 29, No. 5,
pp.422–433.
Liker, J.K. (2004) The Toyota Way: 14 Management Principles from the World’s Greatest
Automaker, McGraw-Hill, New York.
 Application of LSS methodology to reduce the cycle time of OPD service 237

McKeown, C. (2007) Office Ergonomics: Practical Applications, CRC Press, Boca Raton.
Parker, B.M., Henderson, J.M., Vitagliano, S., Nair, B.G., Petre, J., Maurer, W.G., Roizen, M.F.,
Weber, M., DeWitt, L., Beedlow, J., Fahey, B., Calvert, A., Ribar, K. and Gordon, S. (2007)
‘Six Sigma methodology can be used to improve adherence for antibiotic prophylaxis in
patients undergoing noncardiac surgery’, Anesth. Analg., Vol. 104, No. 1, pp.140–146.
Pyzdek, T. (2003) The Six Sigma Handbook, McGraw-Hill, New York.
Riley, W.J. et al. (2010) ‘Defining quality improvement in public health’, Journal of Public Health
Management, Vol. 16, No. 1, pp. 5-7.
Salah, S., Carretero, J.A. and Rahim, A. (2009) ‘Six Sigma and total quality management (TQM):
similarities, differences and relationship’, International Journal of Six sigma and Competitive
Advantage, Vol. 5, No. 3, pp.237–250.
Salah, S., Carretero, J.A. and Rahim, A. (2010a) ‘The integration of quality management and
continuous improvement methodologies with management systems’, International Journal of
Productivity and Quality Management, Vol. 6, No. 3, pp.269–288.
Salah, S., Rahim, A. and Carretero, J.A. (2010b) ‘The integration of Six Sigma and lean
management’, International Journal of Lean Six Sigma, Vol. 1, No. 3, pp.249–274.
Salah, S., Rahim, A. and Carretero, J.A. (2011) ‘Implementation of lean Six Sigma (LSS) in supply
chain management (SCM): an integrated management philosophy’, International Journal of
Transitions and Innovation Systems, Vol. 1, No. 2, pp.138–162.
Womack, J. (2011) Gemba Walks, Lean Enterprise Institute, Inc, Cambridge, MA.
Womack, J.P., Jones, D.T. and Roos, D. (1990) The Machine that Changed the World, Rawson
Associates, New York.
Yin, R.K. (1994) Case Study Research: Design and Methods, Sage Publications, Thousand Oaks.
Yu, Q. and Yang, K. (2008) ‘Hospital registration waiting time reduction through process
redesign’, International Journal of Six Sigma and Competitive Advantage, Vol. 4, No. 3,
pp.240–253.
Zidel, T.G. (2007) A Lean Guide to Transforming Healthcare: How to Implement Lean Principles
in Hospitals, Medical Offices, Clinics, and Other Healthcare Organizations, ASQ Quality
Press, Milwaukee.

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