International Journal of Scientific & Engineering Research, Volume 4, Issue 8, August-2013 183

ISSN 2229-5518

Enhancing Service Quality of a Healthcare

Organization through Lean Six Sigma Methods

Sudipta Saha, A.M.M. Nazmul Ahsan, Md. Imran Mahmud, Prof. Dr. Tarapada Bhowmick, Hemendra Nath Roy

Abstract— The issue of customer satisfaction has gained increasing attention from executives across the healthcare industry. One of the primary challenges is sustaining customer satisfaction improvement initiatives in the face of competing priorities and diminishing resources. Lean Six-sigma methodology has been implemented in a public healthcare organization to fulfil the organization’s mission of enhancing its customer satisfaction. Thirty key criteria of patient satisfaction have been identified to correlate most highly to a patient’s overall satisfaction with the hospital. This paper demonstrates how significant each of those thirty criteria for the overall satisfaction. The coordination of care has been found to have the most powerful effect in terms of patient satisfaction during a hospital stay. Through the implementation of the procedural steps of Lean Six-sigma methodology, it has been possible to enhance the healthcare service quality of the organization.

Index Terms— DMAIC; Six Sigma, RPF, performance matrix, Lean, control chart, process capability, cause-effect diagram

—————————— ——————————


N Bangladesh, unfortunately, the health care delivery sys- tem is overwhelmed with a variety of problems. Even with the increased allocation to health care, access to the system continues to be problematic and is evident from a variety of indicators: Critical staff are absent, essential supplies are gen- erally unavailable, facilities are inadequate, and the quality of staffing is poor. Problems of supervision and accountability exacerbate the problems, while corrupt practices seem to be on
the increase as media reports indicate [1].
One of the primary concerns in healthcare sector centres
around the issue of patient/customer satisfaction. There have
been more and more enterprises implementing six sigma since
Motorola practiced 6σ in 1989. And many healthcare organiza-
tions are positive about the applicability of Lean and/or Six
Sigma within their healthcare industries. Recent activities in-
clude minimizing patients’ length of stay [2], improving effi-
ciency [3], enhancing patient and staff satisfaction [4], reduc-
ing waiting time [5] using Six Sigma philosophy etc. Besides,
Heuvel et al. [6-8] presented different cases where Lean and/or Six Sigma are used as tools to undertake present healthcare challenges at a Red Cross hospital through some projects.
In this paper, Lean and Six Sigma tools are integrated to enhance customer satisfaction of Khulna Medical College & Hospital (KMCH). The study focuses on increasing patient satisfaction through lean embedded DMAIC, an effective management of available capacity and information. The paper is organized as follows: Section 2 presents a review of six sig- ma and lean methodology, Section 3 illustrates the implemen- tation process of lean six sigma methodology, Section 4 pre- sents the findings of the study and Section 5 contains the con- clusions.

Sudipta Saha passed bachelor degree program in industrial & production engineering in Khulna University of Engineering & Technology,Bangladesh, PH-8801718148975. E-mail:

Md. Imran Mahmud passed bachelor degree program in industrial & production engi- neering in Khulna University of Engineering & Technology,Bangladesh, PH-


Prof. Dr. Tarapada Bhowmick, Professor & Head, Department of industrial & produc-

tion engineering, Khulna University of Engineering & Technology,Bangladesh

Hemendra Nath Roy passed bachelor degree program in industrial & production engi-

neering in Khulna University of Engineering & Technology,Bangladesh


Lean focuses on smoothing and accelerating flow by elimi- nating wastes, Six Sigma focuses on improving quality by re- ducing variation [9]. Six Sigma eliminates defects but does not address the question of how to optimize the process flow [10] . The procedural steps of six sigma comprise Define, Measure, Analyze, Improve and Control [11]. Six Sigma problem solving methodol- ogy is recommended by Snee and Hoerl [12] when the causes of the problems is ambiguous, whereas lean tools are used to identify and eliminate wastes through continuous improve- ment. Antony et al. [13] showed that the application of the Six Sigma– DMAIC reduced the number of defects in the engine cylinder manufacturing process and hence enhanced the cus- tomer satisfaction and profitability of the company. With a view to enhancing customer satisfaction, this paper presents the implementation of Lean Six Sigma in a healthcare organi- zation.


The lean embedded six sigma is implemented in KMCH through its procedural steps: Define, Measure, Analyze, Im- prove and Control. The implementation phase is conducted as follows:

3.1 Define

Mandahawi et al., [14] stated that, “The Define phase con- centrates on forming the team, defining the project’s goals, mapping the process, identifying customers, and identifying the high impact characteristics or the critical to quality (CTQs)”. In this study, Performance Matrix [10] and Risk Pri- ority Factor analysis are utilized to identify potential criteria responsible for customer dissatisfaction.
A survey of questionnaire demonstrated by Parasuraman, Zeithaml, and Berry [15] is conducted on a sample of custom- ers of KMCH based on five dimensions for both customer’s importance and satisfaction along 30 service criteria. A 5-point scale is used to measure customer’s importance and satisfac- tion of each service criteria of the hospital. On the 5-point scale

A.M.M Nazmul Ahsan,Associate Professor, Department of industrial & production IJSER © 2013

engineering, Khulna University of Engineering & Technology,Bangladesh

International Journal of Scientific & Engineering Research, Volume 4, Issue 8, August-2013 184

ISSN 2229-5518

1, 2, 3, 4, or 5 have been used to score each criterion if it is highly unimportant, unimportant, moderately important, im- portant, or highly important, respectively and the same scores is used if customers are highly dissatisfied, dissatisfied, mod- erately satisfied, satisfied, or very satisfied, respectively with that criterion. Thus A higher score means greater importance and greater satisfaction. The satisfaction and importance indi- ces of the aforesaid 30 service criteria are defined according to as follows:

Pi =(μi –min /R (1)

Ps =(μ s –min)/R (2)

Where, Pi and Ps represent the importance index and satis- faction index of the service criteria of the hospital respectively. After getting these indices (Table 1), the performance matrix is constructed as shown in Fig.1.





IJSER © 2013

International Journal of Scientific & Engineering Research, Volume 4, Issue 8, August-2013 185

ISSN 2229-5518

Fig. 1. Performance matrix of the hospital

3.2.2 5S

In 5S score sheet the name of factors and the description are listed. A criterion having four, three, two, one or zero problems is considered to have one, two, three, four or five scores, respectively. To prepare a 5S score sheet, all thirty criteria are categorized into main seven main categories which are related to customer satisfaction in the hospital and the major problems are also detected associated with those seven categories respectively. The 5S score sheet is shown in Table 2. From the 5S score sheet, the overall 5S score is found as 2.14 which is much less than maximum score 5. So Actions are to
be taken to get a safe, organized, clean and high-performance
environment that will ensure a high level of customer



3.2 Measure

Measure is the second step of DMAIC model, this step is necessary to measure the existing state of process. In this study Control Chart is used to measure the customer satisfac- tion state. Another Lean tool 5S scoring is also integrated for measuring the current status of the service level and hospital environment.

3.2.1 Control Chart

A Control Chart of customer satisfaction values for all the service criteria is constructed as shown in Fig. 2. UCL is 4.46, centre line is 3.04 and the LCL is 1.61. Customer satisfaction criteria 10, 14 and 26 lie beyond the lower 2σ line (2.10). The lower 2σ line is set according to KMCH infrastructure and expected customer satisfaction value. The 2σ line is selected to reduce the deviation of customer satisfaction at the same time.

Fig. 2. chart of customer satisfaction value

IJSER © 2013

International Journal of Scientific & Engineering Research, Volume 4, Issue 8, August-2013 186

ISSN 2229-5518



3.3 Analyze

After measuring, which criteria are responsible for poor customer satisfaction and how much they are responsible are found out and analyses are made on the causes of poor satis- faction. Several techniques and tools are available to analyze a process. Cause-Effect analysis is done in this study. A Cause- Effect diagram shown in Fig. 3 is developed based on the ob- servations on the hospital and discussions with groups of ex- perienced individuals from the hospital. In conducting the analysis, four main categories of causes are created, including Facility, Personnel, System and Environment. Causes under each of the four categories are causes that contributed to the problems.

3.4 Improve

Following action plans are taken on several areas –

3.4.1 Person

The hospital staffs must be trained to:

Know the different “types” of patients and how to satisfy them.

Communicate clearly and effectively with patients, families and other staff members.

Work as a team to achieve extraordinary results.

Improve patient flow and processes between depart- ments.

Identify and resolve any issues or concerns as they occur.

3.4.2 Facility

‘Improved’ water supply generally involves better physical access and the protection of water sources, including stand post, borehole, protected spring or well or collected rain wa- ter. Improvement does not mean that the water is necessarily safe, but rather that it meets minimum criteria for accessibility and measures are taken to protect the water source from con- tamination. Lounge, a specific space with a minimum size of
10x10 m, are provided for the significant purpose of providing a social space for patients to meet, relax, play games, socialize, bond, and have activities which will take them away and break from the rigors of their hospital stay.

3.4.3 System

Recently, KMCH has been piloting interventions such as more frequent rounding to ensure that patients’ needs are be- ing met. We are seeing improvements in their performance.

3.4.4 Environment

Lighting in healthcare Settings:

• Provide windows for access to natural daylight in patient rooms, along with provisions for controlling glare and temperature.

• Orient patient rooms to maximize early-morning sun exposure.

Recent efforts to increase quietness, not only to enhance patient care experience, but also to improve working condi- tions for all:
• Allowing a very limited number people to stay with
the patients at the wards.
• Providing patients with sleep aids such as ear plugs.

3.4.5 Action plan after 5S scoring

Some action plans have to be taken to reduce the number of problems as much as possible. The action plan for improve- ment after 5S scoring is shown in table 3 as below.
Fig. 3. Cause and effect diagrams for poor customer satis- faction

SER © 2013


International Journal of Scientific & Engineering Research, Volume 4, Issue 8, August-2013 187

ISSN 2229-5518



3.5 Control

Once a facility is redesigned and employees are relocated into the new or renovated space, it is usually time to ‘put out the next fire’. The DMAIC approach attempts to ‘hold the gains’ made through the project, using a control phase. The key components are the implementation of a monitoring plan, creation of a response plan, transfer of ownership (project clo- sure) and sharing the ‘lessons learned’ with the organization. As part of the monitoring plan, the use of the tools application (survey and reports from a database) is implemented as a part of permanent feedback. The information collected is a source of data for the performance matrix. Control chart, which is used for assessing the ongoing quality of the hospital envi- ronment. These tools will be being used to collect data to track the variance in performance on each of the KPIs over time. In this case, the response plan is a simple set of steps (the root cause analysis) which allows the team to identify and rank any problems and brainstorm design responses as required. Final- ly, the data being gathered are shared with the organization through meetings involving leads of the facility management staffs and tools including a PowerPoint presentation and a case study.


After proposing the action plans to the KMCH authority another survey is conducted regarding to the customer satis- faction value after six months. The survey is limited only with those five criteria that were found in our top priority after conducting performance matrix and control chart. From the second survey again average customer satisfaction value (µs ) among five people and satisfaction index from the equation 2 for all those seven criteria is calculated.
In table 4 it is easily seen that the average customer satisfac-
tion value (µs) is changed for all those five criteria compared to the previous average customer satisfaction value (µs). Con- sequently the customer satisfaction index (Ps) is also changed for those five criteria. Finally using the importance index and customer satisfaction index value, another performance matrix is constructed as shown in fig.4, from which it is easily seen that the (Pi - Ps) value for all the thirty criteria is less than 0.33 and as a result all the customer satisfaction criteria lie in block
1. That means customer satisfaction values of all the thirty
criteria are in allowable zone of performance matrix.



Fig. 4. Performance matrix after improvement

IJSER © 2013

International Journal of Scientific & Engineering Research, Volume 4, Issue 8, August-2013 188

ISSN 2229-5518

Another Control Chart of customer satisfaction values for all the service criteria is constructed after implementing Lean Six Sigma as shown in Fig. 5. In this control chart, UCL is 4.72, centre line is 3.32 and the LCL is 1.91. It is found that satisfac- tion value for all the thirty criteria are within lower 2σ line.
After implementing the action plans mentioned earlier, an-
other 5S score sheet is prepared again as shown in table 5,

from which it is easily seen that the 5S score is changed to 3.86 from its previous score 2.14, which means 5S score has been increased by 1.72

Fig. 5. chart after implementation

IJSER © 2013



International Journal of Scientific & Engineering Research, Volume 4, Issue 8, August-2013 189

ISSN 2229-5518


In a situation where customers are expecting as well as de- manding higher level of service quality and new competitors are increasing, healthcare organizations are facing a tough challenge of how to boost customer satisfaction. This Research proves to be an extremely rewarding experience. From re- viewing extensive literature, a deep understanding of the Lean Six Sigma approach, and the implementation framework of the methodology is attained that is later applied in the case study at the KMCH. A set of statistical tools are used in the case study of the hospital. The objective was to implement the Lean Six Sigma methodology to improve the process capabil- ity and reduce customer dissatisfaction. The DMAIC cycle is executed to achieve the objective, going through the Define, Measure, Analyze, Improve, and Control phases. At the com- pletion of the case work, some root causes for the dissatisfac- tion are defined and analyzed and some actions are imple- mented as well as some ideas are proposed for improvements and control. A significant improvement in service quality is noticed after post-implementation analysis. The hybrid of Lean and Six Sigma has thus proven to be a powerful and ef- fective approach to attain the organization’s goal. by adopting this methodology, the organizations could prompt the service quality to be sustainable enough to achieve customer satisfac- tion


The authors would like to convey their gratitude and re- spect to their honorable teacher & supervisor Mr. A.M.M. Nazmul Ahsan, Lecturer, Department of Industrial Engineer- ing and Management, KUET, Khulna whose active guidance through the thesis period enabled the authors to complete it.


[1] Kawnine, N., Killingworth, J., and Thomas S. (1995) A public expenditure review of the health and population sectors, Health Economics Unit, Ministry of Health and Family Welfare, Government of Bangladesh.

[2] Bisgaard, S. and Does, R. (2009) ‘Quality quandaries: health care quality – reducing the length of stay at a hospital’, Quality Engineering, Vol. 21, No. 4, pp.117–131.

[3] Arbos, L. (2002) ‘Design of a rapid response and high efficiency service by Lean production principles: methodology and evaluation of variability of performance’, International Journal of Production Economics, Vol. 80, pp.169–


[4] Dickson, E., Singh, S., Cheung, D., Wyatt, C. and Nugent, A. (2009)

‘Application of Lean manufacturing techniques in the emergency

department’, The Journal of Emergency Medicine, Vol. 37, No. 2, pp.177–182.

[5] Yu, Q. and Yang, K. (2008) ‘Hospital registration waiting time reduction through process redesigns’, International Journal of Six Sigma and Competitive Advantage, Vol. 4, No. 3, pp.240–253.

[6] Heuvel, J.V.D., Does, R.J.M.M. and Koning, H. D. (2006) ‘Lean Six Sigma in a hospital’, International Journal of Six Sigma and Competitive Advantage, Vol.

2, No. 4, pp.377–388.

[7] Heuvel, J.V.D., Does, R.J.M.M. and Bisgaard, S. (2005a) ‘Dutch hospital implements Six Sigma’, Six Sigma Forum Magazine, Vol. 4, pp.11–14.

[8] Heuvel, J.V.D., Does, R.J.M.M. and Verver, J.P.S. (2005b) ‘Six Sigma in healthcare: lessons learned from a hospital’, International Journal of Six Sigma and Competitive Advantage, Vol. 1, No. 4, pp.380–388.

[9] Sampson, M. (2004) Non profit, payload process improvement through Lean management, PhD thesis, University of Colorado, Colorado, USA.

[10] Hung, Y.H., Huang, M.L., and Chen, K.S. (2003) ‘Service quality evaluation by service quality performance matrix’, Total Quality Management & Business Excellence. Vol. 14, No. 1, pp.79–89.

[11] George, M.L. (2002), Lean Six Sigma for services, McGraw-Hill, New York,

pp. 170–177.

[12] Snee, R. and Hoerl, R. (2003) Leading Six Sigma: A Step-by-Step Guide Based on Experience with GE and Other Six Sigma Companies, Pearson Education, New York.

[13] Antony, J, Kumar, M, Tiwari, M.K. (2005) ‘An application of Six Sigma methodology to reduce the engine-overheating problem in an automotive company’, Proceedings of the Institution of Mechanical Engineers, Vol. 219, No. 8, pp. 633–646.

[14] Mandahawi, N., Al-Araidah, O., Boran, A. and Khasawneh, M. (2011)

‘Application of Lean Six Sigma tools to minimize length of stay for ophthalmology day case surgery’, International Journal of Six Sigma and Competitive Advantage, Vol. 6, No. 3, pp.156–172.

[15] Parasuraman, A., Zeithaml, V.A., and Berry, L.L. (1988) ‘SERVQUAL: a

multi-item scale for measuring consumer perceptions of service quality’, Journal of Retailing, Vol. 64, No. 1, pp.12–40.

IJSER © 2013