Oper Manag Res (2009) 2:1327 DOI 10.

1007/s12063-009-0021-7

Implementation of Lean and Six Sigma quality initiatives in hospitals: A goal theoretic perspective
James R. Langabeer & Jami L. DelliFraine & Janelle Heineke & Ibrahim Abbass

Received: 27 May 2009 / Revised: 8 October 2009 / Accepted: 12 October 2009 / Published online: 21 October 2009 # Springer Science + Business Media, LLC 2009

Abstract Organizational quality improvement practices have gained wide acceptance in manufacturing industries over the last several decades. A substantial number of books have been written on Lean and Six Sigma alone, which today are the leading improvement initiatives. The healthcare industry however has been slower to adopt these methods, although anecdotal evidence suggests they are now being gradually diffused throughout hospitals on an increasing basis. Yet, these new practices have been developed substantially without a theoretical foundation (Linderman et al. J Oper Manag 21:193203, 2003) and the question of industry fit is the topic of debate for many physicians and administrators (Kassirer N Engl J Med 339:15431545, 1998). This article provides the descriptive results from our mixed methods research, combining survey questionnaire with semi-structured interviews, that examines implementation of two quality improvement initiatives (Lean and Six Sigma) in a cross-sectional sample of hospitals. We used correlations and non-parametric tests to examine relationships between goal attainment and quality management, and present descriptive findings about reported usage and adoption of quality initiatives. Importantly, we find that the efficacy of quality improvement initiatives in healthcare may be impeded by the lack of goal clarity and measurement. We build on these initial results by offering recommendations to improve results in practice, as well as an agenda for further
J. R. Langabeer (*) : J. L. DelliFraine : I. Abbass University of Texas at Houston, 1200 Herman Pressler, RAS E-341, Houston, TX 77030, USA e-mail: James.R.Langabeer@uth.tmc.edu J. Heineke Boston University, Boston, MA, USA

research of quality initiatives in healthcare. The objectives of our research are to better understand how Lean and Six Sigma fit in the healthcare industry and to explore goal and value attainment from these projects. Keywords Quality . Six Sigma . Lean . Goal theory . Healthcare

1 Introduction Manufacturing firms have long used structured methods to reduce process variability and standardize outcomes. Beginning with the introduction of statistical methods for measuring and analyzing quality in the late 1930s, Shewhart, Deming, Juran, Feigenbaum, Taguchi, and Ishikawa, among others, helped to formalize a discipline focused on quality. They advocated reducing outcome variation through control of processes, which they argued would increase customer satisfaction, and which would in turn result in increased profitability and enhanced product quality. Quality tools such as statistical process control evolved to help analyze behavior and variability of processes and to explore the relationships between inspections, defects, and operating costs (Schroeder et al. 2005). During the 1980s, quality control evolved into named initiatives or programs, such as Total Quality Management (TQM), Zero Defects, Quality Circles, Continuous Quality Improvement (CQI), Continuous Process Improvement, and many others. While each is perhaps technically different from the others, most involved identifying defects as they occurred through inspection and quality control and changing processes to sustain the improvements. It has been suggested that naming these quality initiatives

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contributed to their being perceived as short-term fads, and the decline in their popularity and use (Gibson and Tesone 2001). For many years, the healthcare industry focused on quality improvement initiatives such as TQM and CQI. However, these programs lost momentum and popularity due to their lack of data driven analysis, and many managers and physicians became disillusioned with the prospects of quality improvement. In recent years however, two new quality improvement practices have evolved that have moderate visibility in healthcare: Lean (L) and Six Sigma (SS). This article focuses on the use of Six Sigma and Lean in healthcare settings because both of these programs focus on data-driven analysis and rigorous methodology to improve quality, and seem to be gaining significant popularity in healthcare settings.

2 Six Sigma and Lean Six Sigma was developed in the mid-1980s at Motorola as an improvement concept that focuses on significant reduction of process defects by establishing aggressive goals for quality. Quality is specifically measured in terms of defect rates and is assessed from the customer s perspective. More formally, Six Sigma has been defined as an organized and systematic method for strategic process improvement and new product and service development that relies on statistical methods and the scientific method to make dramatic reductions in customer defined defect rates (Linderman et al. 2003). Six Sigmas core philosophy focuses mainly on reducing variability. It relies on the assumption that the output of every process should fall within acceptable limits (Carrigan and Kujawa 2006). Historically a process was considered to be capable if specifications were +/ 3 standard deviations from the mean, which would result in about 3 defects per thousand opportunities if the process remained centered. Six Sigma follows a much more stringent approach to defining process capabilities, and provides tools for mathematical computation of that capability. If a process is capable at six standard deviations, only 3.4 defects per million opportunities would occur (assuming a 1.5 standard deviation shift in the process mean). Some have argued that Six Sigma is just a replication and repackaging of old concepts (Stamatis 2000), but others have identified five characteristics that distinguish Six Sigma from other quality initiatives: process focus around customer expectations of outputs; emphasis on measurement of defects and errors; establishment of aggressive goals for tightening process capabilities within narrow acceptable limits; formal measurement tools for performance management of outcomes; and a formalized infrastructure for implementation involving systematic training, roles, and

recognition (Linderman et al. 2003; Black and Revere 2006). In addition, like many other improvement initiatives, it introduces new language or terminology and requires a cultural change within the organization. Lean quality management focuses on removing waste and unnecessary steps from processes. Originally started at Toyota, Lean quality management initiatives rely on creating standardized and stable processes in order to provide the best quality services or products as efficiently as possible. Any less than ideal outcome is investigated immediately in order to identify the root cause and to resolve the problem. Lean philosophy embraces a continuous improvement strategy that supports creating simple and direct pathways and eliminating loops or forks in a system (Printezis and Gopalakrishnan 2007). Lean also uses the customers perspective to define quality, but focuses on aggressive elimination of non-value added activities (Tsasis and Bruce-Barrett 2008). The primary approach is to standardize production and business processes so that flow can be leveled and all waste or inefficiencies removed. While overarching goals are similar for both initiatives, Lean focuses on doing the right things (value-adding activities) and Six Sigma focuses on doing things right (with no errors). Lean also requires a more traditional methodology centered around Demings PDSA cycle (plan, do, study, act), similar to the Six Sigma DMAIC (define, measure, analyze, improve, control) and relies on roles such as sensei (master teacher) and diffusion of beliefs and cultural value shifts much more than diffusion of analytical techniques. Critics of both Six Sigma and Lean highlight that these quality techniques focus on processes rather than the systems where the processes operate (Stamatis 2000). In healthcare, much like manufacturing, Six Sigma and Lean appear to be less effective when aiming to improve processes within a deep rooted culture, or current unchangeable workflow or environment, or with less commitment from physicians (Chassin 1998). Stamatis (2000) points out that Quality is only improved when the organizational culture is committed to change and is willing to make quality a priority characteristic or a metric throughout the entire organization. There are no shortcuts or silver bullets. If quality matters, it should become a way of life. Table 1 presents the key characteristics of both Lean and Six Sigma quality management initiatives. While very few stakeholders in the healthcare system would argue about the importance of quality performance improvement, the actual level of penetration or implementation of quality improvement initiatives is relatively unknown.

3 Goal theoretic framework Goal theory emphasizes cognitive processes and the role of intentional behavior (Locke 1970). It suggests that motivation

Implementation of Lean and Six Sigma quality initiatives in hospitals Table 1 Lean versus Six Sigma epistemology Dimension Goals Approach Principal Tool/ Method Infrastructure Methodology Performance Metrics Six Sigma Conformance to customer requirements; Elimination of defects (errors, re-work) Reduction of process variability Statistical process control, run charts, cause and effect diagrams Through formalized structures, titles, and roles DMAIC (define, measure, analyze, improve, control) Quantifiable, cost of quality; mapped into financial value Lean

15

Remove non-valued added activities; Eliminate waste (errors, wait times) Standardization, production flow leveling Value Stream Mapping, Kanban, 5S Cultural change; Sensei relationships PDSA (plan, do, study, act) Not consistent; Often result in new metrics

of employees is best achieved when clear, specific, and challenging goals are set. Employees and organizations must accept these goals, which makes leadership tasks vital (Saraph et al. 1989). Once accepted, more difficult goals have been proven in multiple studies to yield higher performance (Locke et al. 1981). Wright and Kacmar (1994) confirmed that greater goal specificity leads to the attainment of goals, and ultimately to improved performance. Likewise, the more nonspecific the goal, the lower the motivation of employees to attain goals, which ultimately leads to lower performance. Under goal theory, leaderships role is to set aggressive goals, and to ensure organizational commitment by making resources available and creating a suitable infrastructure (Landy 1989). This organizational commitment takes many forms, including allocation of resources necessary for training (Ahire et al. 1996), hiring of personnel and development of teams (Dow et al. 1999), and long-term focus and sustainability around initiatives (Schroeder et al. 2008). Although goal setting theory is not new to organizational research, the importance of setting goals is still crucial to task performance in todays competitive business environment. Goals help motivate people and organizations by directing attention to relevant problems, regulating effort and persistence to improve performance, and encouraging the development of strategies and action plans to improve performance (Locke and Latham 1990). Indeed, over 400 studies have shown that difficult, specific goals with clear, measurable standards and benchmarks lead to better job performance (Locke and Latham 1990). Although these studies were mainly at the individual level, organizational goal specificity has been shown to affect work motivation through its influence on job-level specificity (Wright 2004), thereby improving individual and organizational performance. Specifically, if the goals of the organization are ambiguous, then often goals at the joblevel are ambiguous, too (Wright 2004). Additionally, ambitious goals result in better performance than easy

goals; and specific, difficult goals result in a higher level of performance than no goals or generalized goals (Latham and Yukl 1975; Yukl and Latham 1978). Linderman et al. (2003) described a goal-theoretic model that suggests that organizations that establish specific and challenging goals are more likely to see a greater magnitude of improvement than those that adopt initiatives and fail to set specific goals. Essentially, greater goal specificity is expected to lead to higher goal attainment, which ultimately should lead to improved performance. This applies to public organizations as well (Perry and Porter 1982; Brewer and Selden 2000; Rodgers and Hunter 1992; Wilk and Redmon 1990). Six Sigma and Lean are performance improvement concepts focused on reducing process defects by establishing aggressive goals for quality improvement. Using goal theory, one would expect that quality initiatives should affect the organizations production process, which ultimately results in accomplishing goals and improving performance. Linderman et al. (2005) link Goal Theory and Six Sigma in a manufacturing firm, and found that goals were effective in Six Sigma quality improvement teams as long as the Six Sigma tools and methods were adhered to rigorously. However, there are no other studies on the effect of goals on quality improvement programs or quality management programs (Linderman et al. 2005). Based on theory and previous research, we assume that healthcare initiatives should work similarly. From a goal theory perspective, then, we propose that the use of either Six Sigma or Lean will lead to improved organizational performance because they establish very specific, ambitious goals and targets for the elimination of errors, and use data driven analysis to set and monitor benchmarks.

4 Application and alignment in healthcare contexts The healthcare industry has been under increased scrutiny in the last decade, as well as facing pressure from

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government, employers, payers, and patients to provide safer and more efficient services. The industry has been criticized for inefficient resource allocations and sloppy services, as well as significant medical errors. Eliminating medical errors and improving patient safety has been cited as a top priority by hospital accreditation agencies (Joint Commission 2009). When both quality and efficiency are questioned, there is significant impetus for change. The transformation of reimbursements for the services provided by hospitals has forced hospitals to seek new innovative ways to improve the quality of services while at the same time cutting cost. In their quest for better quality, the healthcare industry has adopted many different improvement techniques from other industries and some healthcare organizations have developed their own (Black and Revere 2006). The use of quality improvement techniques in healthcare goes back to the 1950s with the introduction of quality assurance and the establishment of the Joint Commission on Accreditation of Hospitals (JCAH) now known as the Joint Commission (Al-Assaf and Assaf 1997). Total quality management (TQM) was one of the first initiatives that gained a broad acceptance in healthcare in the 1990s after being championed by Berwick in 1989 as a better approach to finding and eliminating the causes of errors than the traditional quality assurance practices, which emphasized standards of care and auditing of practices to assure that the standards were being followed. TQM focused more on continual quality improvement, organizations member involvement and focusing on the roots of the problems. Nearly 69% of U.S. hospitals at the beginning of the 1990s revealed that they were using or intending to use TQM (Barsness et al. 1993). Although the evidence of the effectiveness of TQM was well-established in other industries, this was not the case in healthcare. A systematic review by Shortell et al. (1998) demonstrated that well-designed studies did not show evidence of the effectiveness of TQM. In fact, the randomized trials that investigated the effectiveness of TQM showed no difference in their outcomes (Shortell et al. 1998) and momentum for TQM slowed (Black and Revere 2006). In one of the rare studies of usage, one researcher discovered that Total Quality Management initiatives are used by fewer than 20% of healthcare institutions (Martin 2007). Despite the disillusionment with TQM, Six Sigma and Lean deployment appears to be gaining momentum and wider acceptance, although there have been few rigorous studies of effectiveness, and virtually no studies of the extent of usage and penetration in hospitals throughout the U.S. In our review of all Six Sigma and Lean research in journals over the last ten years (19982008) we found 140 journal articles that met search criteria involving the

combination of search terms health, quality improvement and either Six Sigma or Lean. Of these, the great majority (>75%) were purely subjective or conceptual review articles that discussed the concepts and their applicability to healthcare but did not use any specific methods or data to confirm quality changes. Very few employed any quantitative data beyond a single case study, with the notable exception of Shortell et al. (1994). Twelve percent of the articles used pre-post analysis of a single organizations project implementation, yet most had virtually no controls to moderate environmental or confounding factors that might have contributed to performance changes outside of the specific initiative. Another major problem discovered with the current state of Lean and Six Sigma researchwas that specification of organizational goals in advance of project initiatives was virtually absent. Fewer than 20% of all articles stated a project goal, and most of these were in qualitative or immeasurable terms. Common process improvement projects in healthcare settings included improving operating room (OR) throughput (Adams et al. 2004; Does et al. 2009; Fairbanks 2007; Leslie et al. 2006; Van den Heuvel et al. 2006), improving emergency department (ED) throughput (Ben-Tovim et al. 2008; Christianson et al. 2005; Dickson et al. 2008; Johnson et al. 2005; Kelly et al. 2007), reducing medication errors (Buck 2001; Chan and Pharm 2004; Chassin 2008; Christianson et al. 2005; Esimai 2005), reducing patient wait times (Ben-Tovim et al. 2008; Bush et al. 2007; Christianson et al. 2005; Johnson et al. 2005), reducing other turn-around times (not OR or ED) (Bush et al. 2007; Chan et al. 2005; Chassin 2008; Christianson et al. 2005; Daniels 2007; Godin et al. 2004; Gorman et al. 2007; Johnson et al. 2005; LeBlanc et al. 2004; Raab et al. 2008), reducing other non-medication errors (Chen et al. 2005; Kang et al. 2005), and following best practices of care (Drenckpohl et al. 2007; Elberfeld et al. 2004; Eldridge et al. 2006; Johnson et al. 2005; Neri et al. 2008, van den Heuvel et al. 2006). However, in these studies the outcomes were not stated as goals, and specific targets were not set prior to implementation. These findings raise the question: how would setting goals have impacted the performance of these organizations? Several studies estimated the role that quality improvement (QI) programs in general have on performance, although not specifically focusing on Lean or Six Sigma (Alexander et al. 2006; Hendricks and Singhal 2001). We found these difficult to assess because most hospitals do have some form of QI programs in place, partly because accreditation standards require them. Details of the specific methods, tools, infrastructure, and goals were lacking from several of these articles. In summary, previous literature has not adequately established a true empirical or theoretical foundation for

Implementation of Lean and Six Sigma quality initiatives in hospitals

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goal-specific improvements in healthcare organizations, or even manufacturing. Unfortunately, since goal specificity and value measurement are the foundation for L/SS, this suggests that they are not being implemented optimally, which could influence results. Given the lack of specificity regarding goals in previous healthcare studies, and the lack of research linking goal theory to quality improvement programs, we have further impetus for our research. The purpose of this research is to begin exploring the implementation of L/SS quality initiatives from a goal theory perspective, and provide initial descriptive results to guide a research agenda and propositions for further empirical analyses. From a theoretical perspective, these findings will help us better understand how specific management innovations influence the relationship between goal specificity and attainment in hospital quality initiatives. Under goal theory, one would expect that greater specificity of goals would yield goal attainment, and ultimately increased performance (Linderman et al. 2003) although this has not been examined in the healthcare industry or for quality initiative implementation. Clear, specific goals are positively related to the accomplishment of goals. Our literature review has partially suggested that there is currently more rhetoric than real results in the use of these initiatives in the healthcare context, but it is unclear to what extent health care organizations use these initiatives to achieve specific goals, and if these initiatives result in improved performance. Therefore, our research was fundamentally guided by questioning if the quantitative specification of goals for these initiatives ultimately yields better project results, which will be reflected in greater perception of goal accomplishments or attainment.

our own survey instrument and then augment this with post-survey phone interviews with ten quality officers. First, we organized the survey instrument around three dimensions discussed earlier, which include: 1) Goal specificity, goal attainment, and initiative outcomes. 2) Alignment or fit within the industry. These include structural issues or challenges that prevent the method from being used widely, as well as key success factors. 3) Organizational commitment. This includes estimate of initiative investment and overall infrastructure requirements. In addition, we collected a variety of demographic data for each organization. Nineteen (19) questions were developed around these areas. The survey used a combination of yes-no, Likert scales and open-ended formats. We assessed face validity by relying on a pilot test group of executives at five different hospitals, all of which were representative of the sample selected. Pre-test evaluations and responses led us to eliminate four questions, plus other minor revisions, yielding a total of 19 questions on the final instrument. We chose to administer the survey electronically. Appendix I shows the questions from the final survey instrument. No secondary database exists and there is no one dominant professional society covering all 6,000 U.S. hospitals quality management professionals. In addition, some hospitals have executive-level officers responsible for quality, but most still do not. We chose, therefore, to sample the entire population of 325 professionals with membership in the Performance Improvement Committee of Healthcare Information and Management Systems Society, a large professional society of over 20,000 members, whose mission is to promote the use of information technology and management systems to improve quality of care (HIMSS 2009). This group was accessible to the authors and committee membership is composed solely of quality and performance improvement professionals in hospitals. This sample included only U.S. hospitals, and was composed of approximately 60% tertiary care hospitals (which offer a full range of general and specialty services), and the balance being community hospitals (which offer general services, but less specialty care). The survey instrument was designed to capture information only from those hospitals with recent experience with either Lean or Six Sigma, and the first question screened out those with no relevant experience. In this case, 55 of 118 respondents (47%) did not have an active or recent L/SS initiative underway, but 63 out of 118 initial respondents (53%) had a L/SS quality management initiative. After multiple follow-ups conducted via email, we achieved 63 complete responses, for a total response rate of 19%. We

5 Research methods Based on existing goal theory and implementation of quality initiatives in the healthcare context, we generally were concerned about several broad questions, which guided our research methods. These questions centered around the nature of the relationship between goal specificity and goal attainment in Lean and Six Sigma implementation, the level of organizational commitment required in Lean and Six Sigma, and the types of industry and organizational stakeholders that are perceived to prevent further adoption and attainment of goals in these programs. To explore these areas, we relied on a mixed methods approach, combining a survey with follow-on interviews. 5.1 Survey, interviews, and data collection Since no previous studies have been done on goal attainment in healthcare organizations, we chose to develop

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found no evidence of significant differences in the responding organizations from the non-respondents in terms of facility size or other demographic factors. We chose to follow our survey research with interviews, and decided ten structured interviews would be sufficient. We randomly contacted survey respondents until we reached our desired sample, using a systematic sampling frame, where we listed all of the organizations in alphabetical order and chose every third organization on the list to further explore their responses. Each interview lasted from between 25 min and an hour. We started by exploring the survey results they provided. Since we were inquiring about Lean and Six Sigma, we chose to use the Lean technique called Five Whys, where for each question we asked them why they responded the way they did, and then followed their response with another why question to get to the root of the issue or query. We transcribed the interview notes so that we could extract quotations and thoughts to augment the survey findings, or explore the confounding results that we observed from the survey. 5.2 Measures and variables Each of the questions mapped to one of the three study dimension in the research framework. Accordingly, we defined the following dependent and independent variables: Goal Attainment (GA) Our research framework explored Goal Attainment (GA) as a dependent variable. GA was operationalized in binary terms, based on the manager s perceptions if goals were attained or accomplished for the quality initiatives within the organization. Specifically, the survey question asked respondents: Do you feel that your organization has achieved the stated goals from your Lean or Six Sigma quality initiative (Question 8). Value Attainment (GA$_adj) If the respondent responded affirmative to the goal attainment question, we asked for a specific estimate of annualized financial dollar value attained for the portfolio of quality projects completed (Question 8a). We normalized this by dividing the value by the average operating revenue, to adjust for scale. Goal Specificity (GS) We measured this as a binary variable, coded 1 if the organizations standard implementation protocol required all projects to have a specification of clearly stated, quantifiable goal defined in advance of projects (as goal theory suggests), and 0 if the organization did not require goals to be specified or were not clearly articulated in measurable terms. Specifically, the survey question asked respondents: Do you require project goals to be defined and clearly articulated prior to each projects initiation? (Question 7).

Organizational commitment was measured through several independent variables: adoption rates, infrastructure investment, and amount of experience with the initiatives. Adoption Rates (Ai) Adoption rates show a long-term commitment to the initiative. Adoption rates were measured using managers perceptions of overall penetration within each organization. Specifically, the survey used a threepoint Likert scale, where 0 indicated relatively minimal use, 1 indicated moderate usage, and 2 represented extensive use or institutionalization of the practices (Question 3). Infrastructure and Experience (Proj_Exp, Infra_Adj) Experience with either Lean or Six Sigma is an indicator for organizational sustainability and commitment to the initiative. Experienced was operationalized using a variable representing the organizations number of projects analyzed since the initiative began (Proj_Exp). We also captured the year that the initiative was initiated. Total financial investment is a measure of resource allocation and commitment, so we defined a variable (Infra_Adj) to represent estimated annual investment in the initiative. To normalize this for differences in size, we adjusted investment by dividing the total investment by the operating revenue for each organization (Questions 2, 2a, and 4). Organizational Resistance (Res_j) Given previous research, we expected to find obstacles or sources of resistance that limit the success or usage of the initiative. We identified multiple sources of organizational resistance, including: physician resistance (Res_physician), executives (Res_executive), and nursing (Res_nursing). These variables were coded as binary, where 1 indicated resistance and 0 indicates no perceived resistance from this group (Question 14). Penetration (Use) This measured the relative focus of the quality initiative, either on administrative or clinical areas. Clinical areas include pharmacy, nursing, medical, or other clinical processes. Administrative areas include financial, revenue cycle, supply chain, information systems, or other administrative processes (Question 5). Table 2 shows the descriptive statistics and Table 3 provides the correlation matrix for each of these variables.

5.3 Methods Most of the data from the survey are non-parametric in nature, and therefore we chose to employ descriptive statistics primarily, including correlation analyses and various tests of differences to explore differences between groups. We intend to use this research as a platform to

Implementation of Lean and Six Sigma quality initiatives in hospitals Table 2 Descriptive statistics Variable 1. GA 2. GA$_adj 3. GS 4. 5. 6. 7. 8. Ai Proj_Exp Infra_Adj Yr_Exp Res_Exec Definition Goal Attainment Value Attainment Goal Specificity Adoption Rates Number of projects since initiative began Annual Investment in initiative Years of experience with Lean/Six Sigma Executive resistance Physician resistance Nursing resistance Clinical versus administrative focus Scale/Units 1 = goals attained, 0 = goals not attained Annualized dollar value attained for portfolio of quality projects 1 = clearly stated goal; 0 = no clearly stated goal 0 = minimal, 1 = moderate, 2 = extensive Count Investment/operating revenue Count 0 = none perceived 1 = resistance perceived 0 = none perceived 1 = resistance perceived 0 = none perceived 1 = resistance perceived Mean 0.5238 0.0008 0.2063 0.6825 38.2222 226.9250 2.6508 0.5079 0.3175 0.2540 1.6032

19

Std Dev 0.5034 0.0010 0.4079 0.7997 65.7096 413.6630 2.4637 0.5040 0.4692 0.4388 0.4932

9. Res_Physician 10. Res_nursing 11. Use

better understand actual usage and guide an agenda for further research and practice.

6 Results 6.1 Goal specificity minimal, and linked to attainment We are curious about the relationship between goal specificity and attainment. Based on these data, there is a positive relationship between goal specificity (Question 7) and goal attainment (Question 8) using Pearson correlation analysis (r =.329, p <.01). Possibly more important than this relationship is the finding that so very few organizations are actually requiring specification of goals in advance of the project initiation (20.6%), which means that over 80% of the organizations do not articulate goals for the projects they pursue. Our interview data provided an interesting perspective on why goal specificity might be minimal. Many interviewees reported that when they initiated the program, they were simply not aware of the importance of setting goals. Most felt that the project team made their best attempt to deliver results, and so they did not feel a stated goal was required. Others admitted not even thinking about goal setting during their project rollouts. Others suggested that the reporting and controlling of projects post-completion is an area of weakness for them. However, we were able to find several hospitals that did specify project goals up front and then measured them post-project. One executive stated that if we didnt set aggressive goals, the hospital would not think we were taking this project seriously. When we questioned these interviewees about why their peer organizations might not be setting goals,

they felt that the industry is generally complacent and that setting goals in some places might lead to widespread organizational disruption that executives generally fear. These goal-cognizant organizations were the exceptions but they provide us with some evidence that goals could be specified and measured, and that they could be associated with goal attainment. 6.2 Value measurement is minimal Only 9 (14%) of the responding organizations reported measured goal accomplishment in financial value terms (Question 8a). Eighty-six percent did not routinely measure the financial value of the projects from these initiatives. In addition, only 19% reported measurement of goals or performance outcomes at all, financial or otherwise. This breaches the principles of both quality initiatives, which require delineation of stated goals and measurement of accomplishments in process terms as well as translation to financial values. These survey results were puzzling in light of the next question (Question 9): when asked if they felt the initiative was successful, 70% stated yes, and 30% stated they were unsure. No respondents reported no. In other words, despite the lack of measurement, most respondents still felt the projects were successful. In addition, 60% of the organizations reported that the initiative was moderately valuable or supported internally, while another 30% said the project was highly valuable or supported internally. Only 10% said they felt the initiative was not considered valuable to the organization. Interview data confirmed that overall value measurement is minimal. It was also commonly expressed that the

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J.R. Langabeer et al.

0.1327 0.2621* 0.1938 0.1010 0.1342 0.0026

healthcare industry is simply not used to converting results into value terms, so these organizations were similar to the norm. Where value measurement was done, the quality executive stated that they faced high levels of organizational pressure and that they spent a fair amount of time answering questions about why they tracked value in financial terms. One executive stated that Routinely, physicians ask me if Im an accountant, and if thats why I am obsessed with finances. Most interviewees suggest that they did not measure value because their information systems did not allow them to get data on their pre-project performance, or that the project teams just did not measure pre-project outcomes. We did find a few organizations that managed their results in project dashboards and intranet sites, and communicated this value regularly back to the organization. One hospital that measured value kept track of total patient days of waiting time saved to show the cumulative effect of their projects on wait times. Another organization measured only changes in quality measures (e.g., core clinical measures, such as percent of aspirin provided to patients on admissions), but did not translate these back into financial value or other terms. The organizations that did measure value claimed to have high levels of executive and board support for their efforts. Most interviewees however felt that the healthcare industry does not lend itself to measuring results as in other industries. One executive stated that the focus of their program is simply to improve quality, and quality cannot be measured in financial terms. None of the interviewees however could state why the industry was so different, except that it is complex, deals with humans, or has high levels of variability in customer (i.e., patient) mix. 6.3 Organizational commitment and initiative usage

11

10

1.0000 0.2616*

0.0345 0.0074 0.0473 0.0950 0.0272 0.0929

1.0000 0.0926 0.1257

0.5106** 0.3373** 0.2338 0.0735 0.0461 0.0206

1.0000

1.0000 0.1509 0.0903 0.0793 0.1912 0.0643

1.0000 0.1796 0.0002 0.0211 0.4079**

1.0000 0.0790 0.0637 0.1102

1.0000 0.3071** 0.0653

1.0000 0.1751

In this sample, respondents to Question 1 show that Six Sigma had lower usage than Lean (12% versus 32%). The majority reported usage of a combined or hybrid approach to Lean/Six Sigma (56%). With respect to the perceived level of adoption (Question 3), 21% of the organizations felt the quality initiative was institutionalized or deeply engrained in daily processes, while 52% felt that they were in early or minimal stages of adoption. Respondents indicated that the mean number of projects analyzed since inception of their quality initiative was 38.2 projects, although this ranged from one project to 350 projects with a median of 12 projects. Using the samples average of four years experience and 38 projects, suggests the average hospital undertakes approximately 9.5 projects per year. Examples of projects described in our sample include improving operating room throughput by reducing room turn-around times, reducing clinic waiting times for new appointments, and streamlining billing and collection processes. Clearly there are differences in the length

1.0000 0.7097** 0.3291** 0.0591 0.2719 1

Table 3 Correlation matrix

0.1374 0.0978 0.1756 0.2406* 0.0278 0.0588 6. Infra_Adj 7. Yr_Exp 8. Res_Exec 9. Res_Physician 10. Res_nursing 11. Use *p <.05; **p <.01

Variable

1. 2. 3. 4. 5.

GA GA$_adj GS Ai Proj_Exp

0.2556* 0.0473 0.0017 0.3096** 0.1876 0.1020

1.0000 0.2988* 0.0414 0.2407

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and scope of the projects in our sample, with some projects being relatively simple and short, and other projects being lengthier and more complex. Given the variety of projects described in our sample, it is likely that there each project will have different barriers to implementation and hence varying goal success. We had expected to find in our analyses that the level of resources committed and the amount of total organizational experience with the initiative would lead to a higher level of commitment and therefore a greater likelihood of achieving goals. We did find modest support for this, where the correlation between adjusted infrastructure invested into the initiative (Question 4) was positively related to the value attainment (Question 8) (r =.256, p <.05). But, overall, there was no relationship between years of experience or number of projects completed and goal attainment. The typical hospital began using the initiative in 2005, with the oldest adopting in 2002 and over 35% implementing the initiative in the last twelve months. Twenty-nine percent of the sample reported an initial investment in infrastructure (e.g., personnel, training, software, consultants) for the initiative between $250,000 and $500,000, and 24% reported an initial investment between $25,000 and $50,000, with a few organizations having less than or greater than these figures. Figure 1 presents the distribution of investment in infrastructure. Interviews confirmed that executive sponsorship is required for project implementation. Most felt that they did have their executive support, although some felt that it was too subtle or changed routinely from one initiative to another. 6.4 Applications of quality initiative Most of the respondents to Question 5(67%) stated that the focus of their quality initiative was enhancement of

clinical or medical service lines. Clinical service lines are multi-disciplinary teams of physicians, clinical staff and administrators formed to treat a specific disease, condition, or group of people (for example, a diabetes service line, heart disease service line, or a pediatrics service line). This was followed by projects in administrative areas (43%), pharmaceutical administration and distribution (33%), financial processes (33%), information systems (29%), and supply chain (23%). When asked about the primary objective of these initiatives, 38% stated that the primary goal was cost reduction or enhancement of efficiency. Surprisingly, the reduction of medical errors was the lowest overall expected value to be attained from quality initiatives. In addition, hospital accreditation organizations, such as the Joint Commission, report that eliminating costly medical errors is a top priority (Joint Commission 2009), so one would have expected to find greater expected outcomes in this area. Figure 2 shows the other reported benefits to be attained from these initiatives. 6.5 Organizational resistance and industry fit Most respondents to Question 10 (74%) reported that Lean and Six Sigma fit in the healthcare industry with no necessary modifications. Only 19% reported that any structural changes were necessary to make them better aligned in healthcare. Most of the suggestions for changes in the industry centered around greater incentives and communication to physicians to encourage buy-in and support from physicians. The greatest organizational obstacle to greater penetration of quality initiatives (Question 14) was physician resistance, where 37% of the sample reported physicians represented obstacles to quality initiatives. This was followed by executive management at 31.6% and nursing staff at 10.5%. Correlation analyses suggest that physician resistance was significantly related to goal attainment, although not in the
45 40 35 30

$>500k 14%

<$25k 9%

$25-50k 24% $250-500k 29%

% of Total

25 20 15 10

$100250k 10%

>$50k -100k 14%

5 0
Reducing Costs/Enhancing Efficiency I mproving Throughput or Patient Flow Enhancing Patient Reducing Medical Satisfaction Errors Others

Fig. 1 Infrastructure investment in quality initiatives

Fig. 2 Expected values/outcomes of quality initiatives

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expected direction (r =.241, p <.05). We would have expected an inverse relationship, where higher levels of resistance would lead to lower levels of goal attainment, but this was not found. This result could indicate the presence of a moderating factor that we were not able to model with this limited sample size. Interviews confirmed that organizational resistance can be quite high. As one quality executive stated If the physicians dont try to block our project, then nurses will. Another interviewee said that most of his peers felt that these projects represent the end of patient-centered care and a move towards industrialization of the healthcare industry. Many interviewees suggested that they incorporated both physicians and nurses in all projects, since they felt this was integral to project success. Another said that they generally spent most of their time explaining the rationale of these programs internally, and the rest of their time educating them on terminology and uses. Clearly, the level of organizational resistance is high, and while there is an industry fit, it is still in an early stage of diffusion and the actors in the industry generally do not recognize this fit beyond the quality department.

example, are physicians more likely to be resistant to efficiency projects rather than clinical quality improvement projects because they perceive efficiency projects to be constraining their ability to provide care? Or are they more likely to be resistant to clinical projects because clinical processes are typically fully under their control? Based on these questions, and the results of our findings from this pilot survey and interview data, we propose the following: Proposition 1. Hospitals will employ Lean and Six Sigma quality initiatives primarily for improvement of clinical processes and outcomes. Proposition 2. Physicians are more likely to be resistant to efficiency initiatives than to clinical process or outcome improvement efforts. Proposition 3. Goal setting and goal attainment are positively related in healthcare implementations of Lean and Six Sigma. Proposition 4. Lean and Six Sigma goals in healthcare organizations will primarily be established as clinically stated outcomes, not financial ones, particularly when physicians are involved in the projects. Both of these propositions need to be further explored in subsequent studies using a longitudinal study design and a larger sample size.

7 Research agenda and propositions This study uses both a survey and interviews to provide understanding of the implementation of Lean and Six Sigma in healthcare organizations. Based on these preliminary findings, and grounded by our goal-theoretic perspective, we have identified the need for future research in these areas. The following represents a research agenda and some propositions which we have identified for this area. 1. Goal setting and goal measurement. Why do healthcare organizations initiate quality improvement programs without specific and measurable goals? Why are the financial results of quality initiatives not being measured, when cost of care is so clearly an issue today? If quality initiatives are assessed to be successful when specific outcomes are not measured, what, then, does success mean? 2. Focus. How do healthcare organizations choose the projects to focus on? Why are clinical projects, where effectiveness is the goal, more common than efficiency process improvement projects, given the cost of care issues and financial performance issues that exist today? Who are the champions for efficiency projects? Effectiveness projects? 3. Resistance. What are the reasons behind the resistance of different organizational stakeholders? Why are physicians seen as most resistant? Is there a relationship between resistance and the types of projects chosen for

8 Discussion and conclusions In this research we explored the use of Lean and Six Sigma quality improvement initiatives in the healthcare industry. We applied a goal theory model to describe goal specificity with goal attainment, organizational commitment, and organizational resistance. Although the use of these initiatives in the healthcare industry is becoming more commonplace, we questioned the extent of penetration in the healthcare industry and whether the use of these initiatives would help organizations achieve their goals. However, given the lack of empirical research in this area, we proposed that the use of quality initiatives in healthcare will follow other industries, and that the use of L/SS initiatives will ultimately result in goal attainment and/or financial value. We discovered some interesting and confounding results. Specifically, we found initial evidence to suggest that goal specificity is linked with goal attainment. We also were surprised to find that the most hospitals are not measuring goal attainment in financial terms, or even in any concrete metric. We also expected to see a great focus on clinical

Implementation of Lean and Six Sigma quality initiatives in hospitals

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areas, which we did, but respondents selected improvement of medical errors as the lowest overall goal, while efficiency gains were the most common. We also found that the average hospital had less than four years of experience with either Lean or Six Sigma, indicating a fairly recent adoption of the initiative, although most respondents suggest a fairly moderate support and commitment to the initiative from the institution overall. Goal theory suggests that the greater the degree of specificity prior to an initiative being launched, the greater the ability of that organization to accomplish those stated goals. In this study, we find no evidence that hospitals are specifically defining goal expectations in advance of the initiative. Additionally, most organizations are not measuring financial valueor performance outcomes in general from their quality initiatives. Physician resistance was also a significant concern for quality managers in the industry, which suggests the need for better incorporation of physicians and other key stakeholders into quality initiatives from the point of initial deployment. There is an expected moderating or interacting effect between physician resistance and goal attainment, which was stated as a research proposition for future analysis. 8.1 Implications and recommendations for practice This research is relevant to practicing managers in a number of ways. As Lean and Six Sigma continue to be implemented, managers must adapt their implementations to ensure successful projects that attain value expectations. In this research, we start to outline attributes that are related to goal attainment, which managers should find useful. Goal theory suggests that quality managers should specify concrete goals from each project, to improve the probability of attaining these goals. Managers implementing quality initiatives should recognize this, and incorporate challenging goals into project charters at the time of project kickoff. Through continued exploration of this topic, managers can better understand the relationships between organizational commitment and resistance. If physicians, or any other organizational group, can impede or improve likelihood of goal attainment, change management and organizational behavior techniques can be used to remove obstacles. Modern healthcare focuses on improving efficiency of care, while simultaneously enhancing clinical quality. If Lean or Six Sigma utilization can impact either of these two performance outcomes, as claimed, then practicing managers need to be aware of it and identify how to best structure their initiatives to achieve maximum benefit. In addition, the infrastructure (or investment in the initiative) has a modest impact on goal attainment expressed in value terms, and

managers should recognize this link and make resource allocation decisions accordingly. Finally, with limited resources to invest, practicing managers need to ensure that the programs they invest in are not mere fads, but programs that improve operations. Understanding application areas where Lean and Six Sigma work (and where they do not), and how to best manage their deployment to achieve stated goals, has a benefit for practice. We hope to continue our inquiry to guide better practice. 8.2 Limitations and future research There are two limitations to this research. First, the sample size is small. We knew at the onset of this research that there could be a small population of hospitals employing these initiatives, and while we are comfortable that we had 63 organizations participate, we would have liked a much larger sample that would permit greater analyses. However, many other papers have been published with sample sizes in the 50100 respondent range (Lam et al. 2008; Johnston and Michel 2008; Shipton et al. 2008). Our results can be seen as an initial view into Lean and Six Sigma utilization in the industry. It is not intended to be conclusive, but rather to offer some initial discoveries that can continue to evolve. This small sample size dictated certain appropriate statistical techniques, and more robust sample would be needed to further test these relationships. Second, this research may be limited due to respondent bias. The sample was composed of professionals with similar interests organized into a common society, and their responses may not be representative of quality professionals who are not members of a professional society. However, based on these preliminary findings, and grounded by our goal-theoretic lens, we have identified the need for future research in these areas. With regard to goal setting and goal measurement, we think there are questions unanswered about why healthcare organizations initiate quality improvement programs without specific and measurable goals, particularly when quality of care is paramount and financial results are being so closely monitored. If quality initiatives are assessed to be successful when specific outcomes are not measured, what, then, does success mean? Future research should also further explore organizational commitment and factors that are associated with positive goal attainment. Analyzing the reasons behind the resistance of different organizational stakeholders, understanding why physicians are seen as most resistant, and if any relationship exists between resistance and the types of projects chosen (for example, are physicians more likely to be resistant to efficiency projects rather than clinical quality improvement projects because they perceive efficiency projects to be constraining their ability to provide care? Or are they more likely to be resistant to clinical projects because clinical

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processes are typically fully under their control?). These are all interesting areas for further research. Despite the limitations, our research suggests that the use of Lean and Six Sigma initiatives have moderate levels of adoption in this sample of hospitals, and that there is an apparent fit in the industry, despite concerns that they

originated in manufacturing industry. We believe that the efficacy of quality improvement initiatives in healthcare may be impeded by the lack of goal clarity and measurement. Given the industrys enhanced focus on quality and costs, we think that continuing this line of inquiry will yield be especially relevant and productive for both practice and theory.

Appendix I: Survey questions

1. Does your organization have a Lean or Six Sigma initiative underway? (note: the remainder of the survey will be based on your response to this question). _____ Lean _____ Six Sigma _____ Lean/SS Combination _____Neither Lean or SS _____ Year _____ # of Projects

2. What year did your hospital or system start the overall initiative? 2a. How many specific projects or processes have been examined to date? 3. What is your perception of overall penetration of this initiative in your organization? ____ Relatively Minimal ____ Moderate Usage

____ Extensive Daily Use

4. Approximately what size investment has your organization made in the initiative in the last year? (note: investment includes personnel, training, consultants, software, and other resources). _____ <$25,000 _____ $250,001-$500,000 _____$25,001 -$50,000 _____$50,001 -$100,000 _____$100,000-$250,000

_____$501,000 ->$1,000,000

5. What areas have you had the most penetration for these initiatives? (check all that apply) _____ Medical services _____ Financial processes _____ Other (please specify) 6. In your opinion, does this initiative have the GREATEST potential value in: _____ Reducing medical errors _____Reducing costs/enhancing efficiency _____ Pharmaceutical operations _____ Supply chain _____Administrative processes _____ Information systems

_____ Improving throughput or patient flow _____Enhancing patient/customer satisfaction _____Other (please specify) 7. Do you require project goals to be defined and clearly articulated prior to each projects initiation? _____ Yes _____ No

8. If yes, do you feel that your organization has achieved the stated goals from your Lean or Six Sigma quality initiative?_____ Yes _____ No

Implementation of Lean and Six Sigma quality initiatives in hospitals

25

8a. If you have measured these results in financial terms, what $ value can be placed on the total initiatives annually? ______

9. Do you feel that this initiative has been successful in your organization? _____ Yes _____ Not sure/unclear _____ No

10. Do you feel that this initiative will be or can be successful in the healthcare industry overall? _____ Yes _____ Not sure/unclear _____ No

11. What changes are or will be necessary to make the initiative better fit the healthcare industry? _________________________________ 12. What are the SUCCESS FACTORS in your organization that contributed to the initiatives success? _________________________________ 13. What are some of the OBSTACLES or barriers that your organization faced that minimized the value of the initiative? _________________________________

14. Which group is least likely in your organization to support the initiative (check all that apply)? _____ Executive management _____Physicians _____Front-line nursing staff

15. What is the overall opinion of this initiative in your organization? _____ Highly Valuable/Highly Supported _____ Not Valued/Not Supported 16. Would you be willing to share more details about your initiatives? ____No ____ Yes _____ Moderately Valuable/Moderately Support

17. What is the estimated size of your organization (hospital or system in which you reside)? ____ # Employees ____ $ Operating Revenue _____ Beds

18. Describe your organization's performance in the following categories (3 point Likert scale, from better than competition, average, and below average): Overall Performance Rankings (e.g., US News, Solucient) Quality Ratings (e.g., JCAHO) Profit Margins _____ _____ _____

19. Please provide the following demographic information, for classification purposes only. Name and Title of Respondent Hospital Name City, State Email Phone ___________________ ___________________ ___________________ ___________________ ___________________

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