Barriers to Successful Implementation of Lean Six Sigma in Healthcare Institutions - Literature review Example

Barriers to Successful Implementation of Lean Six Sigma in Healthcare Institutions Name Institution Introduction This literature review is going to make an analytical discussion of the obstacles faced while implementing lean-six-sigma (LSS) in healthcare institutions. At a glance, lean-six-sigma is adopted from two techniques namely lean and the Six Sigma. Lean originates from Toyota automotive company in Japan (Radnor, 2009, p2). Lean is a term that defines the use of techniques or rather tools in an attempt to alter the culture in an institution or organization by implementing excellent operations or systems improvement that ensure waste is minimized, the flow of processes is also streamlined, and the biggest focus is on the consumers that is, the customers and their satisfaction. Basically, lean is based on five principles namely; identification of consumer wants and needs; elimination of useless elements in the value stream of each item or product; adopting best cultural practices that allow continuous smooth flow; work must go through each stage of production, and finally, focus on perfecting the value chain to eliminate unnecessary steps that consume time. Defects-free policy is a key concern that is identified lean management (TMD friction, 2011, p1). In addition, the lean process has three stages: the stage of acceptance. The second stage is the technical stage. Finally, the sustainment stage follows; where the culture has been built, but, constant review and reminding is required (Plenert, 2007 p.15). Cross-functional management is employed through utilization of teams in a flat hierarchy of supervising managers (Jackson, 1996, p.153). On the other hand, General electric and Motorola companies were the two major originators of the Six Sigma (Laureani, 2012 p2). This technique seeks to minimize costs incurred by institutions/organizations, and it enhances consumer satisfaction by eliminating defects through applying management tools and statistical techniques to foster improvement (Radnor, 2009 p1). It relies on DMAIC methodology (define, measure, analyze, improve and control) (Radnor, 2009 p1). Six Sigma is driven by a team whose structure is clear, and each team member has a defined role as follows; executive; sponsors a project and commits finances. Master Black belt; is in charge of coaching and training. Back belt; he is the leader of the improvement project. Green Belt; Is in charge of supporting and running the projects. Finally, the champion; is in charge of supporting the project and makes sure that improvements made become concrete (Radnor, 2009 p2). In this literature review, there is a trend of many authors agreeing on basic points that provide a firm conclusion to the major barriers and obstacles that are preventing an effective implementation of the Lean Six Sigma (LSS). The arguments are grouped together using common denominators such as the various approaches or rather arguments of the authors. Research gaps identified in every paper are also highlighted where authors that have pointed out the gaps of other papers have been linked to the identified gaps. In addition, each argument has been criticized and the discussion or analysis made on each argument has been linked with the purpose of this literature review. Finally, a conclusion on differences between arguments and a conclusion showing similarities on arguments has been drawn for the purpose of linking the various approaches used by different authors to the purpose of this study. Body of the Literature Review According to Antony (2008), one of the major barriers experienced in the implementation of LSS in NHS in Scotland is the current culture of the institute, whereby, not many staff members are willing to adopt change in order to introduce the Lean Six Sigma. The traditional bureaucratic systems of admitting patients and releasing them are not easy to abandon. Bureaucratic systems are found where processing of insurance of the patients is full of unnecessary steps that are costly to the institute. Therefore, there is always a likelihood in medical errors endangering employee safety. There is also low accuracy in results obtained from the laboratory. Finally, there are major bottlenecks in the emergency department. Also, in agreement with Antony, pine do-Cuenca (2012) links culture in an organization as a hindrance to Lean Six Sigma (LSS) implementation. Success of a given organization occurs at the instant of change acceptance by employees. Similarly, Gibbon (2010) insists for a paradigm change when handling matters of LSS since organizational traditions usually work against LSS. The same opinion from three different authors forms a basis for critical discussion on the influence of organizational culture on the entire workforce in a health institute. Human beings undergo five stages of grief in circumstances of change. These stages include denial stage, anger accumulation stage, bargaining stage, depression and acceptance. These stages play a vital role in change management in an organization. As such, employees have to undergo these stages as they assimilate change (Antony, 2008, p.434). Organization change depicts dynamics that occur in an organization with reference to state, quality and shape of the organization over time. These processes occur after the introduction of new operating, acting and thinking ways (Manuela & Fuentes, 1997). Therefore, the management of an organization needs to create time for employees to assimilate change effectively. However, resistance towards change may result from the context, in which, change is occurring. In addition, personal perceptions towards change act as a barrier to change acceptance. Change resistance may be eliminated through involving employees in the process of change or creating a room for employees to make changes themselves (Antony, 2008, p.434). Workforce attitude influences reception of the change (Nafei, 2014 p204). Managerial relationship with the ground personnel also influences response to change (Wiebe, 2005 p 242). In addition, Qianmei (2008) agrees with Antony by uncovering the same argument where he starts by stating that change is always faced by resistance. Most of the resistance and problem is found to be originating from the leaders and major stakeholders. In this journal, there seems to be sentiments on the commitment shown by the management. There is shortage trickling management where little resources seem to be allocated. Also some leaders commit a little time on the Lean Six Sigma (Qianmei et al 2008 P534). The journal insists that this be a major barrier especially in the healthcare industry. The primary role of strategic leaders is to maintain, and create company characteristics that encourage collective effort and reward. One of the fundamentals of this is a positive culture (Mgbere, 2009). According to Addis (2010) positive and strong culture helps an organization to cruise efficiently. It also cruises smoothly just like a well maintained car (Boes, 2006 p26). Antony (2008) also points out that poor training and inadequate training infrastructure and investments is another barrier facing implementation of Lean Six Sigma. This is where most health institutes have made little investment in the Belt System training. Most of the leaders have little knowledge on the systems supposed to be adopted in the successful implementation of Lean Six Sigma. As a result, this explains on the slow implementation of projects whereby ignorance settles in the institute, thus, many nurses and doctors end up keeping up with traditional systems and policies that oppose the Lean Six Sigma due to their high cost, wastage of resources and poor customer satisfaction. For instance, the institutes remain prone to medical errors risking patient safety out of ignorance and unawareness of ways of reducing medical errors. In addition, there is also no awareness on ways of increasing accuracy in obtaining correct laboratory results, and hence a lot of resources are wasted due to inaccuracy in the healthcare institute. According to Antony (2008), it is also a challenge in NHS for data to be readily available for collection so that it can be analyzed. He clarifies that there is a lot of data out there for collection especially in the healthcare industry. However, Antony is tentative on availability of the data. This means that it is always tiresome for experts to note down processes which will be easily measured to come up with errors in billions of opportunities. This argument is very important in this study since it uncovers the idea of massive data out there in the industry. Looking at this argument in a critical way, it is easy to say that there is data out there. However, how readily available is it? Even after an analysis has been made, the experts involved in the analysis come across hardships of pointing out errors since there are billions of opportunities in the data accumulated. For example, files of inpatients and outpatients in every hospital are available in millions. This means that it takes time to analyze these records, and hence it will not also be easy to show where errors are since the data is massive. This argument is valuable in this study because it uncovers a major barrier that is evident in NHS according to Antony. Similarly, Laureani agrees with Antony looking at the identification of measurement as a major barrier when applying Lean six Sigma in healthcare institutions. Measurement phenomenon is directed towards the difficulty in identifying systems in given data for the purpose of pointing out defects (Laureani, 2012 p11). The two arguments sync just as acknowledged by Antony that there is a major problem in identifying data defects. They both use the approach of measurement in discovering the barrier hence their arguments are in agreement of the same. Nevertheless, Laureani (2012) identifies another obstacle not stated by Antony by talking about the mentality of the workforce. The approach or rather argument used here is that medical workers do not admire business language usage in the healthcare sector. This relates to jargons such as cost reduction, minimum defects and customer satisfaction. One realizes that these words head in the direction of saving, minimizing wastage and minimum resource utilization that can be termed as cynical by professionals in medical centres. Even though Antony missed this point, it is logically correct as most healthcare centres are not regarded as business enterprises but as the institution meant for serving the community. A major barrier that seems to be missing from all the above authors is the lack of a strategic framework that should depict the way goals and aims of Lean Six Sigma should be achieved (Grover et al 2010, p.215). As a result, there is always a communication breakdown in most hospitals where most of the leaders do not come up with a clear strategy that shares all the roles and gives a chain of command or rather authoritative communication from the top to the bottom (Grover et al 2010, p.215). It is necessary for employees and managers to ensure information sent is correct, clear, complete, builds goodwill and saves time (Kienzler, 2008, p.34). Hence, in most cases, it becomes almost impossible to expedite a single project; thus, much time is likely to be wasted in trying to increase the number of wards, processing insurance policies, reducing the number of employees in a single unit and acquiring accurate results. It is important for listeners to commit to listening to what is being spoken without distractions and involvement in other activities. Hence, one is able to get all the details without missing technical information (Boyd, 1998 p55). The lack of a clear strategic framework then becomes prone to problems of resistance to change from both the management and the staff members (Grover et al 2010, p.215). It is vital that formal communications are well recognized by the institute officially. Information and instructions are passed either from up downwards or down upwards along the channels of formal communication (Kandlossui, 2010 p 55). Decision making, agreement on work to be done and the pattern of working relies upon this communication (Berry, 2011, p.30). In contrast with Laureani, Taner (2007) identifies the use of business language as the best way of presenting recommendations on the application of the Lean Six Sigma to the staff members in the organization. Laureani, on the other hand, is against the use of business jargons because he views the use of the jargons as intimidating to healthcare fraternity as it approaches use of business language as cynical to the healthcare industry as its objectives do not merge with those of the business mentality. For the sake of understanding of this statement in this study, the argument at this moment is that the business jargons such as cost reduction do not go together with healthcare expectations such as adequate allocation of resources in the healthcare institutions. So in this case, Taner (2007) is in disagreement with Laureani. Taner is clearly recommending the use of business language which has been rejected by Laureani. However, Taner has an additional point where, though he proposes for the use of business language, he is discouraging the use of statistical language which is mainly applied in the six-sigma part of the Lean Six Sigma. It is clear that Six Sigma utilizes statistical data in an effort to reduce defects in service delivery or product manufacturing. Taner terms the statistical language and figures as a barrier to application of the Six Sigma techniques since many people approach figures with negativity. The business language examples in the application of the techniques suggested by Taner are reducing cost by eliminating unnecessary tests in the laboratory where errors are made thus rework is done in order to correct the errors hence the unnecessary cost. In addition, Taner also views the aspect of a lengthy stay in healthcare institutions that also results to increased cost of handling the patients yet they could have been discharged earlier. Customer satisfaction is also achieved through reducing time for waiting for a given service such as surgery. Most people would hate scenarios where they are kept waiting even if is it is an ATM lobby. What about the sick waiting for surgery for hours? It is also important to understand that waiting while in the hospital subjects the hospital to an additional cost of feeding and offering other services to the patients who would also be inconveniencing to the customer him/herself (Taner et al 2007 p 413). However, Taner also identifies other barriers that were discussed by the above authors such as the challenge of investing in the Belt training system. Difficulty while obtaining data was also another challenge highlighted by Taner. Finally, the negative attitude and the psychology of the employees in the healthcare sector (Taner et al 2007 p 413). Mohammed (2011) is in agreement with most of the above authors on the barriers where he identifies poor dedication of professionals, inability to invest in the six-sigma and inadequate dedication from managers. However, Mohammed went ahead and identified a barrier that has not yet been mentioned by any other author so far. Satisfaction with other programs meant for quality such as total quality management motivation concepts. This is an evident barrier where some hospitals and pharmaceuticals have already implemented other programs that have costed billions of dollars and these systems working for them according to the hospitals. This argument seconds the barrier of organization culture and traditional systems that most healthcare institutions are not or may not be willing to abandon. Another barrier mentioned by Mohammed, unlike other authors, is the inadequate knowhow on the Six Sigma. According to him, Lean Six Sigma is still a new subject being introduced in the healthcare sector and hence it will take time for it to be internalized by both the leadership and the workforce. Mohammed (2011), went ahead by ranking the barriers in ranks form the most recognized one to the least. In this case, inadequate knowledge was ranked as number one. The others followed in the following order; namely; poor dedication of the professionals; inadequate resources; neglect of support from top management and finally, contention with other programs meant for inducing quality (Mohammed, 2011 p520). Chakraborty (2013) went a step further, just like Mohammed, by highlighting the strongest barriers for institution when implementing Lean Six Sigma. He identified two barriers that he termed as the strongest barriers namely; complex processes of identifying data and collecting process parameters. The second barrier is educating the workforce through training where most employees are likely to be indifferent. In other cases, most employees resist the change because they hold a feeling that the system being introduced may put their jobs at risk. Moreover, some believe that the new quality program implementation will subject them to learning new techniques and skills which would be tedious. Some techniques such as accuracy in laboratory results frightens many nurses and medical workers because it is likely to be challenging where some may think that they are not fit for the job. Just like automation, which led to reducing the number of workers in various organizations, most medical employees believe that most changes that are introduced in the institutions are likely to lead to loss of jobs for some people. Therefore, the workers feel that their jobs are threatened thus they end up resisting any form of change through boycotting training sessions, discouraging each other and spreading false propaganda and rumours even to the extent of using hate leaflets for the program in different offices. The most important aspect of this author is naming the above two barriers as the greatest barriers based on a survey conducted in both the institutions that have implemented the Lean Six Sigma and those that have not implemented. Thus, the study gets the privilege of getting the information from both sides which represent a complete argument with both sides of the coin. The argument on the two barriers is important for this study where one is able to get specific points through focusing on the crucial points of the research. Therefore, it will be easy to get the specific recommendations depending on concrete arguments that have specific targets on specific barriers. This will be easier than focusing on a wide range of barriers which branch from specific stems. Therefore, looking at the angle of this study, you realize that Chakraborty offers very crucial information for this paper. He has made a major contribution in addition to the approaches or rather arguments introduced by other authors. In fact, his approach now merges the various points gathered from other authors. On the other hand, Grover (2010) uses the approach of breaking the Lean six Sigma nutshell into pieces to enhance the understanding of the barrier of poor engagement and empowerment by the leadership in NHS, which has prevented the prosperity of implementation of the system in NHS. First, he has a brilliant approach on his argument which is based on the engagement needed to achieve implementation of the Lean Six Sigma methodology. His journal points out clearly that most managers in the healthcare sector expect an overnight transformation to a successful lean managed institute. Looking back, Toyota Company started applying lean management on its own in 1945. Therefore, it has taken years or rather decades for Toyota to attain its current stability. What about Motorola? It has also been years since Motorola started applying the lean Six Sigma. Thus, this explains the current high profiling of these companies in terms of application of the Lean Six Sigma (Groves, 2010 p 206). Therefore, healthcare managers have been relying on quick fix techniques in their trial to replicate the Lean Six Sigma. For the sake of this study, it is important that this argument is given clear analysis. This is where one is able to determine that there are basic principles that have to be the basis for the application of LSS in the healthcare institutes (Groves, 2010 p 206). In other words, it’s important for an organization to layout a procedure that outlines an action plan that is backed up by a shared vision from the lowest rank in the institute’s hierarchy to the executive position. In NHS, for instance, the medical workers are found unable to identify each process of the action independently and how each process is different from giving patients care (Groves, 2010 p 206). In this case, any other action that is not directed towards giving care to the patients was considered as a secondary process. For example, it is of no importance for movement of patients from a referral to visit that would be conducted, what concerned them was that the visit usually takes place in a given or rather specific time period (Groves, 2010 p 206). Statmatis (2011) introduced two more barriers that most authors have not discovered. One of the barriers according to Statmatis is the complexity of the methods and techniques of the LSS especially on the statistical part where statistical data is depended on in a healthcare institution even when troubleshooting a hospital equipment in order to identify any defect that may be resulting in to wastage thus compromising the value chain. The complexity is also termed as unnecessary where in a few scenarios one finds that some problems are simple and can be tackled with a simplistic approach. In such a scenario, if one decides to pursue the LSS methodology in an aggressive way one is likely to complicate a small problem. Statmatis terms this approach as inefficient or rather as overkill where one could be responding to a mosquito bite with a huge hammer. In addition, the second point from Statmatis is that when one is furthering optimization in a single process or step of service delivery in a healthcare institute, one is likely to end up neglecting the big picture which is the value chain in the entire process. In this case, an engineer could be in need of rectifying an error in surgery equipment and take days in correcting one error reflecting the attention of the whole process to only one machine. This may end up delaying processes that would be taking place in the surgery hence allowing the flow of processes in the surgery room without inconveniencing some customers where they wait for so long hence they are likely to be unhappy with the services being offered (Statmatis, 2011 p 34). According to Faltin et al (2012) the healthcare sector is and has always been vulnerable to re-organization. In this study, this point is similar and in agreement with the cultural perceptions and traditions in an organization as seen earlier. However, Faltin has used a simplistic approach of explaining the real situations and events in the healthcare centres that render it almost impossible to successfully implement Lean Six Sigma. The approach used is that healthcare centres are always vulnerable to change in a frequent order. Therefore, the tradition here is that people are always rushing for new training sessions, use of new equipments and sometimes change of management (Faltin et al, 2012 p 34). This explains how the staff members in the healthcare institutions are bus. There is also a lot of pressure for the workforce which usually originates from attention needed by masses of patient who at times need to be taken care of from their homes which are near the area where the hospital is located. A lot of pressure caused by change and workload is evident in the healthcare centres. Therefore, the workforce has developed this kind of feeling that they do not have enough time for utilizing in Lean Six Sigma projects. Thus, they either evade their tasks or simply find themselves in a situation they are not in control over (Faltin et al, 2012 p 34). This purely explains the challenge faced by healthcare centres which trickledown from the executive positions down to the personnel. This merges with an important point stated earlier that many people in most healthcare centres do not understand the complex techniques of the LSS. This ends up making the matters worse since the staff usually find it to be of no importance if they do not understand the intrinsic meaning of the Lean Six Sigma. Why apply something which you do not clearly understand its value? In this paper, this approach of arguing sounds challenging and thoughtful for holding all the facts together from a realistic angle (Faltin et al, 2012 p 34). It is evident that this argument is more realistic when viewed on the basis of real events described above. Most of the earlier barriers sound infinite due to their theoretical nature that may not be understood from a layman’s angle of view. The experiences described in this argument have outlined realistic events that merge with the topic of this assignment that hence end up creating a powerful argument. Conclusion In conclusion, various authors can be grouped together in terms of the agreement of arguments on the barriers against implementation of LSS. Most publications are focusing on inadequate investment in the belt training system and infrastructure, measurement and analysis of data available in healthcare centres, loopholes in leadership systems and communication and finally traditional bureaucratic systems that the workforce are unwilling to change. Some authors have also gone deeper to rank the barriers in terms of their weight or rather impact in the healthcare institutions. In addition, this literature review has also shown some arguments from other publications that have additional or differing approaches where barriers such as complexity of the LSS techniques and satisfaction with other quality management techniques such as TQM (total quality management have been discussed. This literature review is of importance to the study in showing differing theories/arguments and the similarity in some. It sums up most of the literature in the area of healthcare management, and it has gone deeper in critically analyzing the various approaches used in different publications. References ADDIS, S., 2010. Corporate Culture: Lessons Learned from Feathered Friends. Rough Notes, 153(12), pp. 84-84,86. Alessandro L. 2012. Lean Six Sigma in the Service Industry, Advanced Topics in Applied Operations Management. Mr. Yair Holtzman (Ed.). ISBN: 978-953-51-0345-5. InTech. Available at: < http://www.intechopen.com/books/advanced-topics-in-applied-operations-management/lean-six-sigma-in-theservice-industry> [accessed 23 July 2014] Antony, J. 2008, "Lean and Six Sigma methodologies in NHS Scotland: Some observations and key findings from a Pilot Survey", IIE Annual Conference.Proceedings, , pp. 433-439. Antony J. 2008. Six Sigma in Healthcare Industry: Some Common Barriers. Challenges and Critical Success Factors. [onlne] Available at: [Accessed 23 July 2014] Berry, G. R. 2011. Enhancing Effectiveness on Virtual Teams. Journal Of Business Communication. 48(2), 186-206. doi:10.1177/0021943610397270 Boes, K.T. 2006. Psychological contract violation and organizational change in Thailand. Alliant International University. San Diego. Boyd, S. D. 1998. Using active listening. Nursing Management. 29(7), 55-55. CHAKRABORTY, A. and TAN, K.C., 2013. An empirical analysis on Six Sigma implementation in service organisations. 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Business and Administrative Communication. Mc Graw Hill Companies. 8th ed Manuela, P, & Fuentes, M, 1997. Resistance to Change: A Literature Review and EmpiricalStudy. 46022 Valencia- Spain. MGBERE, O., 2009. Exploring the Relationship between Organizational Culture, Leadership Styles and Corporate Performance: An Overview. Journal of Strategic Management Education, 5(3), pp. 187-201. Mohamed, G.A. 2011. "Reconstructing Six Sigma barriers in manufacturing and service organizations". The International Journal of Quality & Reliability Management. vol. 28. no. 5. pp. 519-541. NAFEI, W.A., 2014. Assessing Employee Attitudes towards Organizational Commitment and Change: The Case of King Faisal Hospital in Al-Taif Governorate, Kingdom of Saudi Arabia. Journal of Management and Sustainability, 4(1), pp. 204-219. PINEDO-CUENCA, R., PABLO, G.O. and SETIJONO, D., 2012. Linking Six Sigma's critical success/hindering factors and organizational change (development). International Journal of Lean Six Sigma, 3(4), pp. 284-298. Plenert, 2007. Reinventing lean. Elsevier Inc p15. Qianmei (May) Feng & 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. 535-47. Radnor Z. 2009. Lean and Six Sigma. [online] Available at: [accessed 23 July 2014] STAMATIS, D. H. 2011. Essentials for the improvement of healthcare using Lean & Six Sigma. Boca Raton, CRC Press. Taner, M.T., Sezen, B. & Antony, J. 2007. "An overview of six sigma applications in healthcare industry". International journal of health care quality assurance. vol. 20, no. 4, pp. 329-340. TMD friction 2011. Lean Management. Retrieved from: http://www.tmdfriction.com/en/company/lean-management WIEBE, E.M., 2005. Momentum, organizational change, and time. University of Alberta (Canada). Read More