Applicability of Lean Six Sigma

in Hospitals

Vimal Kumar Deshmukh , Suraj Kumar Mukti and Animesh Agrawal

Abstract Most of previous researches on Lean Six Sigma focused on various per-
spective of Six Sigma, lean philosophy then role of Lean Six Sigma in sustainability
but never paid much attention in field of health service sector, e.g., hospital. This
article concentrates on checking feasibility of Six Sigma in hospitals. Defects and
loopholes in hospital and healthcare industries can sentence a difference between
a life and death. Since to mitigate mishaps and increase patient experiences during
the visit of hospitals, this research is an extreme effort to reduce variation in service
quality using quality management tool Lean Six Sigma (LSS) in registration counter
at hospitals. Data-driven methodology approach and applicability of LSS in service
sector encompass not only the people but information and resource utilization. This
is a mainstream pillar to be used as a methodology for research. DMAIC tool was
found useful to enhance service quality during the study. Improvisation of outcomes
is comparatively discussed in a chronological sense for ease of understanding. This
research work will contribute to academia as well as service sectors like hospitals,
restaurants, banks etc.

Keywords Lean Six Sigma · Quality management · Service sector · Hospital ·

DMAIC tool

1 Introduction

The Modern era of competition challenges the health service providers to survive in
markets. For the hospital, the patient satisfaction reflects the outcomes and extent of
service quality being served. Improving the patient satisfaction and happiness always
remains ideal. Since the health service providers continuously rely on increasing
patient satisfaction and it starts with the patient entrance into hospitals [1]. Partic-
ularly in hospitals, it is mandatory for a patient to make registration and prepare a

V. K. Deshmukh (B) · S. K. Mukti · A. Agrawal

Department of Mechanical Engineering, National Institute of Technology,
Raipur 492001, India
e-mail: deshmukh.vimal1920@gmail.com

© Springer Nature Singapore Pte Ltd. 2019 861

K. Shanker et al. (eds.), Advances in Industrial and Production Engineering, Lecture
Notes in Mechanical Engineering, https://doi.org/10.1007/978-981-13-6412-9_80
862 V. K. Deshmukh et al.

slip or file before going for checkups to the doctors. Employees in hospitals reg-
istration and admitting departments smoothens the patient care and patient flow in
the hospital. For a patient, time is very crucial since management plays a vital role
to minimize the time associated with these processes. From patient’s perspective, at
the registration desk, the patient’s behavior and understanding reflect the difficulties
faced in filling the registration form. The terminologies used sometimes are out of
the domain of the patient’s knowledge. This does not show only patient’s incapability
but also lack of management and working knowledge of emergency preparedness
procedures which is an essential element. It results that time taken by the patient is
much higher than standard time. Waiting in a queue shows a systematic structure but
it has no value if a patient dies due to unavailability of medical services at right time.
We have various quality management and an industrial tool to reduce unnecessary
time. Hospitals have already various criterion and standard time but practical they
are not self-constraint. There are a few research articles focusing on patient problem
at various stages hospitals. This research article encompasses the problem of patient
at registration or reception desk.

1.1 Six Sigma and Lean Philosophy

Most of the time, management issues are identifiable and can be eliminated by man-
agement tools. The Six Sigma has proven its significance in this area. It is not only
a systematic data-driven approach but also can be used as a cost-effective tool. The
purpose of management is to develop a complete cycle process of hospital opera-
tional system that will eliminate medical errors entirely [2]. Since 1985 and onwards,
Motorola took advantage and made working cycle smoothen. 34 defects per ten mil-
lion are the extent to which Six Sigma serves or deliver services. Theoretically, we
can say, If the six sigma is applied in healthcare services particularly at the recep-
tion desk at the hospital it shows that 9,999,966 out of 1,000,000 patients will be
satisfied [3–5] these expected outcomes encourage the management and hospital
administration to implement Six Sigma in hospitals. Also, unnecessary process and
movement of hospital staff can be seen which are of no value. To mitigate these, lean
philosophy may become an opportunity. It believes that errors can be eliminated
by cutout in-efficient processes. Taiichi Ohno and associates architected the lean
philosophy at Toyota Production System to stay in the scenario of the competition
of resources and capital, which were consequences of the Second World War. The
Toyota production system is additionally credited with being the origination of just
in time (JIT) production strategies, an embedded component of lean philosophy, and
hence the Toyota production system remains a model of brilliance for an advocate of
lean philosophy. Lean philosophy assumed that defects are produced due to irrele-
vant process or unnecessary activity. Whereas Six Sigma emphasizes on incapability
of the process. The idea of Lean ended up plainly prominent through Womack and
Jones (1990) book ‘The Machine That Changed the World’ [6, 7]. Implementation of
Lean Six Sigma basically brings processes within Six Sigma control limit and lean
Applicability of Lean Six Sigma in Hospitals 863

management cutout irrelevant processes. Six Sigma and lean philosophy are used
parallelly since last twenty years and together called Lean Six Sigma (LSS).

1.2 The Flow of Patient in Hospital

The cycle of patient flow in the hospital starts from the ambulance arrived at the
reception counter; the patient has to wait for registration. The receptionist appoints
a time slot and refers to doctors from which treatment of patient starts. The doctor
examines and investigates by various diagnosis methods. It depends upon the patient’s
condition that patient would refer either to general ward or to the operation theater.
Here the patient also has to wait for the preparation for operation if referred but time
associated with operation can’t be manipulated because of the risk of failure of the
operation. Time taken by doctors for diagnosis and medical tests cannot be a focus
for management to reduce it. After treatment, the patient again goes to reception to
clear pending bills and medicine charges. The waiting time at the various stage is
the main focus in throughout movement of the patient in the hospital. The potential
subject in terms of time identified from field survey is
⎫
Waiting time at the reception desk⎪ ⎬
Reduce Rework At reception/registration desk
⎪
⎭
Time is taken for filling forms
Billing and post documentation
Turn over time (for operation theatre)

2 Methodology

For this research, the subject is restricted to first four only, which take place at the
reception desk or front desk in hospital. It includes people and process (registration
form). The strategy for this research is divided into two phases in first phase root
cause will be identified, and in the second phase, an attempt will be done to solve
the problem using Six Sigma tools, i.e., DMAIC or DMADV based on data and
information gathered. Since the second phase includes analysis and problem-solving
techniques. Both the tools are equally useful and essential. But DMAIC is used
more frequently over DMADV because it uses existing resources to give a solution.
DMADV is used where some new methods are adopted to resolve the problem.
Despite first three steps are same in both the technique and last two processes for the
outcomes are totally different (Table 1).
864 V. K. Deshmukh et al.

Table 1 Steps involved in DMAIC and DMADV

DMAIC DMADV
D—Define
Includes identification and determination of problem to conduct business process to define we
can use a cause-effect diagram, interview and survey and method study. This is a Foremost
critical step
M—Measure
Suitable measurement should be taken to identify the culprit and compare different processes.
Stopwatch and work measurement method can be used for measurement
A—Analysis
Includes critically examine the steps involved in each process from demand’s perspective to
approach the goal
I—Improve D—Design
Include attempt to make changes for reducing Includes adaptation of a new process or idea
error and improve existing process. Change to achieve a goal and eliminate error or
management is a management tool to improve defects. Brainstorming and BPR can be an
an existing process effective tool
C—Control V—Verify
If the improved process works properly and Includes testing of new process or idea and
satisfied then Next step is to maintain it verify it up to enormity

2.1 Identification and Determination of Problem (Define)

For the first phase, we have to understand the functions and responsibilities performed
by the receptionist and carefully analyze registration form and find loopholes and
find that why unnecessary time is taking place. The function to be performed by
receptionists at the front desk in hospital includes
• Listening to patient comfort and communicating in an affirmative, friendly manner
and act with confidence with patients at the front desk and over the phone too.
Setting up appointments and schedule meetings at the truthful time and with the
exact doctor.
• Tackle invoicing and manage errors, human interruption and detailing patient’s
documents. Provide different modes for collecting fee to ease of payment for
patients and ensure a profit.
• Listen to patient’s complaints at first and take suitable action and verify the health
insurance grievances and complete related legal procedures with it.
Generally, the staff employed at reception do not focus on the patient. This makes
incapable him/her to rectify the actual problem of the patient and this may lead
to refer the patient to wrong doctors. Not addressing the actual problem can result
in a lot of rework and unnecessary travel of patient and precious time of doctor,
since the patient has to go to the right doctor. The reason behind this may be lack
of training of staff. The flow of patient should be smooth in hospitals. Training of
hospital staff plays a vital role in this perspective. Also, the hospitals should have a
number of employees to accomplish tasks and responsibilities. In EHR (Electronic
Applicability of Lean Six Sigma in Hospitals 865

Management Machine

No customer focused Much travelling No EHR implemented

unnecessary software
Receptionist
Not trained Computer
rework Hospital staff
Not addressing Insufficient capacity
Poor patient service and
actual Problem
increased waiting time

Difficult terminology
Not documented Properly
Poor design
Patient call Forms
tracking

Difficult to complete
Slow
Registration form
Method
(material)

Fig. 1 Cause effect diagram to identify and define problem and after effect

Health Record) implemented hospitals, the receptionist asks the patient a series of
question which includes name, age, gender, health insurance, reference and health
problems. An automatic system generates a digital report for patients and receptionist
refers him to a right doctor. The reports automatically send to doctors too by various
management software here, the waiting time in the queue depends on skills of the
computer operator since training of operator may reduce this time. In conventional
type, receptionist gives a registration form and patient himself/herself has to fill the
form. In conventional type, the patient fills general information quickly but feels
uncomfortable while completing legal procedure and writing brief detail about the
medical condition and problem due to lack of knowledge of medical terminology
asked in the registration form. Since each patient takes their own time which defers
from patient to patient. Rework is the main culprit for waiting time. Most of the
staff at reception are busy to complete the health insurance formalities and arrange
and prepare documents of patients when the case file of the patient is referred again
by health insurance company. They search for various information of past and this
process takes a huge time. The frequency of these type rework is also large. Since
the patient needs to suffer due to an overload of staff work and lack of management.
Figure 1 shows main and sub-causes and their final due to which the waiting time
increases and the patient suffer poor service.
866 V. K. Deshmukh et al.

Table 2 Average time taken by various processes

S. No. Processes Average time taken for a patient
1 Waiting time in queue 3.41
(min)
2 Time Taken by For conventional type For computer generated
receptionist or patient to 17.20 min (if filled by slips 4.2 min
fill reception form the patient)
3 Rework (if documented) 13.66 7.4
(min)
4 Delay due to overload 2.4 1.33
and pre-consultation
(min)
5 Due to software lag, – 9.4
insufficient capacity and
another computer-related
issue if occurs (min)
Total time spent at the reception desk For conventional type For digital type window
window system   25.74 min
36.67 min

2.2 Measurement of Processes at the Reception Desk

Measurement parameter selection is a critical situation and may lead to chaos. A

measurement parameter should also capable to measure all procedure in a single
scale. In this Research ‘Time’ is associated at all stages. Since it is used as measur-
ing parameter here. Stopwatch method is used to evaluate the process and waiting
time. Table 2 shows time taken at hospital reception. Time taken are an average of
10 reading at each hospital and it included 5 local government hospital reception
counters in Drug district, Chhattisgarh, India.

2.3 Analysis of Processes at the Registration Desk

Analysis phase includes critically examine the processes involved and identify loop-
holes. It is seen that waiting time in the queue cannot be reduced alone without
changing other processes. Without reducing waiting time, management can increase
the patient satisfaction by implementing a token system but this idea adds additional
cost and space which diminishing its value. The process should not only cost-effective
but also goal approached. The time taken to fill registration form depends upon:
Length of pages in the form.
The terminology used in a form for a medical condition. It defers person to person
depends upon knowledge and understanding.
Applicability of Lean Six Sigma in Hospitals 867

The specially categorized section should not mix with general patient information
health insurance related question and eligibility criteria for a medical condition.
Patient’s domain of knowledge is a behavior constraint and management cannot
deal with it because it is different for each patient. But management can simplify
medical terms used and categorize the patient information. Also, to save time, paper
and money, management should use a different form for the different patient based
on their medical condition. The form should be in the different color code for ease
of patient. The patient takes much time to overview all the section in the form and
spend unnecessary time. The receptionist should mark a cross sign and guide patient
to fill the mandatory information. If the patient is waiting for his previous records,
waiting time depends on skills of the receptionist in the way that how he/she manage
documentation of patient and for how long time they store it. Storing a documented
medical history of patient consists of a variety of clinical observation, diagnostic test
results, pre- & post-operative reports, previous surgery or operation records, refer-
ences, routine improvement report of patient and surgical notes of operation it also
includes a list of medicines prescribed by doctors in past. It does not sound good but
it is true that management knows the importance and value of patient record keeping
but feels paralyzed when coming to implementation. In Indian scenario, the condition
is in a promising step. However, customized software like EHR (electronic health
record) refrain this situation up to gratifying level. Hospital administration should
keep multiple windows at reception to cope up difficulty faced due to terminology
and legal processes by the patient.

2.4 Improvisation or Alternation of Processes

To improve certain processes, management does not change the process but make
some small changes in it to achieve the goal with less time and money. The economy
of change is also a very important factor. The improvised model shows that motion of
general patient will be smooth entirely if management starts a multi-window token
system and provides a healthy environment to a patient in waiting hall. Magazine,
newspaper and book of clinical safety and benefits of cleanness, etc. should be there
to entertain patient in unoccupied time. Patient need not submit same information
if he/she is a regular patient of same doctor or hospital. There must be a dedicated
window for previous or frequent patient to collect their reports or file. There should
be sufficient staff to tackle phones and help desk if the patient feels uncomfort-
able during filling form. For emergency case, receptionist should follow emergency
response preparedness protocol (ERPP). The objective of ERPP is to take action in
initial minutes to save patients life. Paperwork is done either parallel or later by the
person associated with the patient. Hospitals and doctors are not responsible for a
sentence of death of patient according to this protocol. So, it does not require that
much paperwork, unlike general patients. For EHR or such customized software
implemented hospital, the time is taken for registration entirely depends on skills
868 V. K. Deshmukh et al.

of the receptionist. To reduce this time, there are two ways. First, improve the staff
for dedicated work at reception by giving proper training and second make software
customized such that it asked general but essential information precisely. With the
advancement of AI (artificial intelligence), it would be great if the system would
suggest right doctors available in hospital in sight of the receptionist. And the same
information should send to the referred doctor. Online appointment is a good solution
to refrain from waiting in the queue.

2.5 Control and Verification of Implemented Model

of DMAIC or DMADV

The last step is to control the implemented model and maintain its efficiency. It is the
sole responsibility of hospital administration to maintain the process effectiveness
and collect feedback from the patient from time to time. There should be discussion
with the patient about service and satisfaction in Likert scale for simplicity. Likert
scale is a scale used to represent people’s opinion and quantify it. Likert scale can
be used on parameter from 1 to 5 where 1 stands for extremely dissatisfied and
5 stands for very satisfied. Needs always changes itself with time since feedback
is necessary to be ready in position to meet patient’s demand. A periodic audit is
conducted to assess the model and make all the process within Six Sigma control
limits. Sustainability of model depends on flexibility, timeliness, fast responsiveness
and corrective measurements of the model.

3 Results and Discussion

Reduction in total time spent at reception desk enables receptionist to serve a number
of the patient which shows well-structured and determined system and enhance
patient satisfaction. After comparing the time taken with the super specialty hospital
which already implemented EHR and use an electronic medium to save time, the
time saved came out was about 32% of previous, i.e., 15.32 min patient spent time at
reception in EHR enabled front desk. Although LSS did not change drastically the
whole processes but made some small potential changes (Fig. 2).
An inverse relationship between waiting time in queue and patient’s satisfaction
was observed by previous researchers. Since health service providers always try to
give their best and make their customer happy [8]. Training of clinical staff should
be such that patient should feel comfortable while conversation. Staff will aware of
their role and importance in health service industries. Organizational culture may
be affected while changes take place but people’s positive attitude and willingness
to serve clients enthusiastically can overcome this problem. LSS makes a strategy
to optimize things and make more control over the flow of processes. Results show
Applicability of Lean Six Sigma in Hospitals 869

Reduce waiting time at Define problem Training of receptionist to work

DMAIC

Objective
reception
Reduce waiting time in queue
Increase patient's satisfaction
serve more number of patients
Solution
Measure problem efficiently and help patient
Analyse situation Differentiate registration form
based on medical condition and
Improve processes colour codes
Control implemented model Multiwindow with token
system
arrangement for patients for
unoccupied time in waiting hall
implementation of EHR system
or such customized software.
online appointment system if
applicable
feedback from patients

Fig. 2 Continuous process diagram of improvised model of processes at registration desk

that implementing such changes in hospitals, the total time can be reduced by near
about 32% as compared to the non-implemented hospital which satisfies its economic
value. Now a number of patients served will also increase because reception desk can
handle more patients. DMAIC is preferred over DMADV due to economic variance
and time-saving characteristic. However, big changes need DMADV, which also
satisfy its cost-effectiveness.

4 Conclusion

The objective of management tools is not only to refrain from errors or defect but for
enhancement of safety of patient and employee. In the hospital, management took
errors as the absence of standardization and work to eliminate it completely. Service
and patient satisfaction are the barterings, in which healthcare service provider pro-
vides services and expect satisfaction from the patient. LSS proved its potentiality
and emerges an effective quality management tool. Hospital with conventional type
registration desk is not in situation handle a large number of the patient but most of
the patient arrives with general diseases at the reception desk. Since LSS has a lot of
opportunities to eliminate this problematic scenario. Reduction of time from 25.74 to
15.32 min even both hospital use electronic medium shows having customized MIS
software and computers are not enough. Utilization of resources and optimization
of techniques is the key to every problem in the domain of LSS. For conventional
paperwork-based registration desk, LSS minimizes the use of paper, time to fill the
registration form and prove its utility here too. Since all these evidences conclude
that it is feasible to implement Six Sigma at hospital which has sufficient fund. This
research article opened a new perspective to standardize processes at the various
stations from the patient entrance to exit from the hospital.
870 V. K. Deshmukh et al.

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