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 manage-
ment, 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
14
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 customers
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 manage-
ment of outcomes; and a formalized infrastructure for
implementation involving systematic training, roles, and
J.R. Langabeer et al.
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 implementa-
tion 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 15

Table 1 Lean versus Six Sigma

epistemology Dimension Six Sigma Lean

Goals Conformance to customer requirements; Remove non-valued added activities;

Elimination of defects (errors, re-work) Eliminate waste (errors, wait times)
Approach Reduction of process variability Standardization, production flow
leveling
Principal Tool/ Statistical process control, run charts, Value Stream Mapping, Kanban, 5S
Method cause and effect diagrams
Infrastructure Through formalized structures, titles, and Cultural change; Sensei relationships
roles
Methodology DMAIC (define, measure, analyze, PDSA (plan, do, study, act)
improve, control)
Performance Metrics Quantifiable, cost of quality; mapped into Not consistent; Often result in new
financial value 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 environ-
ment. 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 bench-
marks 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 job-
level 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 establish-
ing 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
16
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
J.R. Langabeer et al.
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 environ-
mental 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
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 manage-
ment 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 funda-
mentally guided by questioning if the quantitative specifi-
cation of goals for these initiatives ultimately yields better
project results, which will be reflected in greater perception
of goal accomplishments or attainment.
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 attain-
ment 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
17
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
18
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 managers
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 implemen-
tation 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).
J.R. Langabeer et al.
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 three-
point 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 invest-
ment 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), execu-
tives (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 19

Table 2 Descriptive statistics

Variable Definition Scale/Units Mean Std Dev

1. GA Goal Attainment 1 = goals attained, 0 = goals not attained 0.5238 0.5034

2. GA$_adj Value Attainment Annualized dollar value attained for portfolio 0.0008 0.0010
of quality projects
3. GS Goal Specificity 1 = clearly stated goal; 0 = no clearly stated 0.2063 0.4079
goal
4. Ai Adoption Rates 0 = minimal, 1 = moderate, 2 = extensive 0.6825 0.7997
5. Proj_Exp Number of projects since initiative began Count 38.2222 65.7096
6. Infra_Adj Annual Investment in initiative Investment/operating revenue 226.9250 413.6630
7. Yr_Exp Years of experience with Lean/Six Sigma Count 2.6508 2.4637
8. Res_Exec Executive resistance 0 = none perceived 0.5079 0.5040
1 = resistance perceived
9. Res_Physician Physician resistance 0 = none perceived 0.3175 0.4692
1 = resistance perceived
10. Res_nursing Nursing resistance 0 = none perceived 0.2540 0.4388
1 = resistance perceived
11. Use Clinical versus administrative focus 1.6032 0.4932

better understand actual usage and guide an agenda for
further research and practice.
6 Results
6.1 Goal specificity minimal, and linked to attainment
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.

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,
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
20 J.R. Langabeer et al.

1.0000
healthcare industry is simply not used to converting results
11 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 organiza-

1.0000
0.1751
tional pressure and that they spent a fair amount of time
10

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

0.3071**
1.0000

0.0653
I am obsessed with finances.
Most interviewees suggest that they did not measure value
9

because their information systems did not allow them to get

data on their pre-project performance, or that the project teams
1.0000
0.0790
0.0637
0.1102
just did not measure pre-project outcomes. We did find a
few organizations that managed their results in project
8

dashboards and intranet sites, and communicated this value

regularly back to the organization. One hospital that measured
0.4079**

value kept track of total patient days of waiting time saved

1.0000
0.1796
0.0002
0.0211

to show the cumulative effect of their projects on wait times.

Another organization measured only changes in quality
7

measures (e.g., core clinical measures, such as percent of

aspirin provided to patients on admissions), but did not
1.0000
0.1509
0.0903
0.0793
0.1912
0.0643

translate these back into financial value or other terms. The

organizations that did measure value claimed to have high
6

levels of executive and board support for their efforts. Most

interviewees however felt that the healthcare industry does not
0.5106**
0.3373**

lend itself to measuring results as in other industries. One

1.0000

0.2338
0.0735
0.0461
0.0206

executive stated that the focus of their program is simply to

improve quality, and quality cannot be measured in financial
5

terms. None of the interviewees however could state why the

industry was so different, except that it is complex, deals with
0.2616*

0.2621*
1.0000

0.1327

0.1938
0.1010
0.1342
0.0026

humans, or has high levels of variability in customer (i.e.,

patient) mix.
4

6.3 Organizational commitment and initiative usage

1.0000
0.0926
0.1257
0.0345
0.0074
0.0473
0.0950
0.0272
0.0929

In this sample, respondents to Question 1 show that Six Sigma

3

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
0.3096**
0.2988*

0.2556*
1.0000

0.0414
0.2407

0.0473
0.0017

0.1876
0.1020

(Question 3), 21% of the organizations felt the quality

initiative was institutionalized or deeply engrained in daily
2

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
0.7097**
0.3291**

0.2406*
1.0000

0.0591
0.2719
0.1374
0.0978
0.1756

0.0278
0.0588

initiative was 38.2 projects, although this ranged from one

Table 3 Correlation matrix

project to 350 projects with a median of 12 projects. Using the

1

samples average of four years experience and 38 projects,

suggests the average hospital undertakes approximately 9.5
*p<.05; **p<.01
9. Res_Physician

projects per year. Examples of projects described in our

10. Res_nursing

sample include improving operating room throughput by

8. Res_Exec
6. Infra_Adj
Proj_Exp
GA$_adj

7. Yr_Exp

reducing room turn-around times, reducing clinic waiting

Variable

11. Use
GA

GS

times for new appointments, and streamlining billing and

Ai

collection processes. Clearly there are differences in the length

1.
2.
3.
4.
5.
Implementation of Lean and Six Sigma quality initiatives in hospitals
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
<$25k
$>500k 9%
14%
$25-50k
24%
$250-500k
29%
>$50k -100k
$100- 14%
250k
10%
Fig. 1 Infrastructure investment in quality initiatives
21
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%), pharma-
ceutical 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 Commis-
sion, 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
%
25
of Total
20
15
10
5
0
Reducing I mproving Enhancing Patient Reducing Medical Others
Costs/Enhancing
Efficiency
Throughput or
Patient Flow
Satisfaction Errors
Fig. 2 Expected values/outcomes of quality initiatives
22
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.
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
J.R. Langabeer et al.
example, are physicians more likely to be resistant to
efficiency projects rather than clinical quality improve-
ment 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 implemen-
tations 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.
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
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 commit-
ment 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 measur-
ing 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 stake-
holders 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 initia-
tives 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 organi-
zational 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
23
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 measur-
able 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 out-
comes 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
24 J.R. Langabeer et al.

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

2. What year did your hospital or system start the overall initiative? _____ Year

2a. How many specific projects or processes have been examined to date? _____ # of Projects

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 _____$25,001 -$50,000 _____$50,001 -$100,000 _____$100,000-$250,000

_____ $250,001-$500,000 _____$501,000 ->$1,000,000

5. What areas have you had the most penetration for these initiatives? (check all that apply)

_____ Medical services _____ Pharmaceutical operations _____Administrative processes

_____ Financial processes _____ Supply chain _____ Information systems

_____ Other (please specify)

6. In your opinion, does this initiative have the GREATEST potential value in:

_____ Reducing medical errors _____Reducing costs/enhancing efficiency

_____ 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 _____ Moderately Valuable/Moderately Support

_____ Not Valued/Not Supported

16. Would you be willing to share more details about your initiatives? ____No ____ Yes

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 ___________________
26
References
Adams R, Warner P, Hubbard B, Goulding T (2004) Decreasing
turnaround time between general surgery cases. J Nurs Adm
34:140148
Ahire P, Golhar D, Waller M (1996) Development and validation of
TQM implementation constructs. Decis Sci 27:2356
Al-Assaf AF, Assaf R (1997) Managed care quality: a practical guide.
CRC, New York
Alexander J, Weiner B, Griffith J (2006) Quality improvement and
hospital financial performance. J Organ Behav 27:10031029
Barsness ZI, Shortell SM, Gillies RR, et al (1993) The quality march:
national survey profiles quality improvement activities. Hosp
Health Network December 67(23):5255
Ben-Tovim DI, Bassham JE, Bennett DM et al (2008) Redesigning
care at the Flinders Medical Centre: clinical process redesign
using lean thinking. Med J Aust 188:S27S31
Black K, Revere L (2006) Six Sigma arises from the ashes of TQM
with a twist. Int J Health Care Qual Assur 19:259266
Brewer GA, Selden SC (2000) Why elephants gallop: assessing and
predicting organizational performance in federal agencies. J
Public Adm Res Theory 10:685712
Buck C (2001) Application of Six Sigma to reduce medical errors.
Annu Qual Congr P 55:739742
Bush SH, Lao MR, Simmons KL et al (2007) Patient access and
clinical efficiency improvement in a resident hospital-based
womens medicine center clinic. Am J Manag Care 13:686690
Carrigan MD, Kujawa D (2006) Six Sigma in health care management
and strategy. Health Care Manag 25:133141
Chan ALF, Pharm BS (2004) Use of Six Sigma to improve pharmacist
dispensing errors at an outpatient clinic. Am J Med Qual 19:128
131
Chan WP, Chiu W, Chen W et al (2005) Applying Six Sigma
methodology to maximize magnetic resonance imaging capacity
in a hospital. Int J Healthc Technol Manag 6:321330
Chassin MR (1998) Is health care ready for Six Sigma quality?
Milbank Q 76:565591
Chassin R (2008) The Six Sigma initiative at Mount Sinai Medical
Center. Mount Sinai J Med 75:4552
Chen Y, Lin J, Chang C (2005) Taiwan: improving radiography through
application of Six Sigma techniques. J Health Qual 27:4452
Christianson JB, Warrick LH, Howard R, Vollum J (2005) Deploying
Six Sigma in a health care system as a work in progress. J Qual
Patient Saf 31:603613
Daniels SE (2007) Six Sigma at Cigna. Qual Prog 40:4348
Dickson EW, Singh S, Cheung DS et al (2008) Application of Lean
manufacturing techniques in the emergency department. J Emerg
Med 11:16
Does RJ, Vermaat TM, Verver JP et al (2009) Reducing start time
delays in operating rooms. J Qual Technol 41:95109
Dow D, Samson D, Ford S (1999) Exploding the myth: do all quality
management practices contribute to superior quality performance?
Prod Oper Manag 8:127
Drenckpohl D, Bowers L, Cooper H (2007) Use of the Six Sigma
methodology to reduce incidence of breast milk administration
errors in the NICU. Neonatal Netw 26:161166
Elberfeld A, Goodman K, Van Kooy M (2004) Using the Six Sigma
approach to meet quality standards for cardiac medication
administration. J Clin Outcomes Manag 11:510516
Eldridge NE, Woods SS, Bonello RS et al (2006) Using the Six Sigma
process to implement the centers for disease control and
prevention guideline for hand hygiene in 4 intensive care units.
J Gen Intern Med 21:S35S42
Esimai G (2005) Lean Six Sigma reduces medication errors. Qual
Prog 38:5157
J.R. Langabeer et al.
Fairbanks C (2007) Using Six Sigma and Lean methodologies to
improve OR throughput. AORN J 86:7382
Gibson JW, Tesone D (2001) Management fads: emergence, evolution,
and implications for managers. Acad Manag Exec 15:122133
Godin E, Raven D, Sweetapple C, Del Giudice FR (2004) Faster test
results. Qual Prog 37:3339
Gorman A, Donnell L, Hepp H, Mack T (2007) Improving
communication and documentation concerning preliminary and
final radiology reports. J Healthc Qual. Available via: http://
www.nahq.org/journal/ce/article.html?article_id=276. Accessed
August 15, 2009
Healthcare Information and Management Systems Society (HIMSS)
(2009) Available via: http://www.himss.org/ASP/membershipHome.
asp. Accessed on August 16, 2009
Hendricks K, Singhal V (2001) Firm characteristics, total quality
management, and financial performance. J Oper Manag 19:269285
Johnson T, Currie G, Keill P et al (2005) New York-Presbyterian Hospital:
translating innovation into practice. J Qual Patient Saf 31:554560
Johnston R, Michel S (2008) Three outcomes of service recovery;
customer recovery, process recovery, and employee recovery. Int
J Oper Prod Manage 28:7999
Joint Commission (2009) National Patient Safety Goals. Available
via: http://www.jointcommission.org/patientsafety/nationalpa
tientsafetygoals/. Accessed August 16, 2009
Kang JO, Kim MH, Hong SE et al (2005) The application of the Six
Sigma program for the quality management of the PACS. Am J
Roentgenol 185:13611365
Kassirer JP (1998) Doctor discontent. N Engl J Med 339:15431545
Kelly A, Bryant M, Cox L, Jolley D (2007) Improving emergency
department efficiency by patient streaming to outcomes-based
teams. Aust Health Rev 31:1621
Lam MY, Poon GKK, Chin KS (2008) An organizational learning
model for vocational education in the context of TQM culture.
Int J Qual Reliab Manage 25:238255
Landy FJ (1989) The psychology of work behavior. Brooks-Cole,
Pacific Grove
Latham GP, Yukl GA (1975) A review of research on the application
of goal setting in organizations. Acad Manage J 18:824845
LeBlanc F, McLaughlin S, Freedman J et al (2004) A Six Sigma
approach to maximizing productivity in the cardiac cath lab. J
Cardiovasc Manag 15:1924
Leslie M, Hagood C, Royer A et al (2006) Using lean methods to
improve OR turnover times. AORN 84:849855
Linderman K, Schroeder R, Zaheer S, Choo A (2003) Six Sigma: a
goal-theoretic perspective. J Oper Manag 21:193203
Linderman K, Schroeder R, Choo A (2005) Six Sigma: the role of
goals in improvement teams. J Oper Manag 21:779790
Locke EA (1970) Job satisfaction and job performance: a theoretical
analysis. Organ Behav Hum Perform 3:157190
Locke EA, Latham GP (1990) A theory of goal setting and task
performance. Prentice-Hall, Englewood Cliffs
Locke EA, Shaw K, Saari L, Latham G (1981) Goal setting and task
performance. Psychol Bull 90:125152
Martin WF (2007) Quality models: selecting the best model to deliver
results. Physician Exec 33:2429
Neri RA, Mason CE, Demko LA (2008) Application of Six Sigma/
CAP methodology: controlling blood-product utilization and
costs. J Healthc Manag 53:183196
Perry JL, Porter LW (1982) Factors affecting the context for
motivation in public organizations. Acad Manag Rev 7:8998
Printezis A, Gopalakrishnan M (2007) Current pulse: can a production
system reduce medical errors in health care? Qual Manag Health
Care 16:226238
Raab SS, Grzybicki DM, Stewart WR et al (2008) Effect of Lean
method implementation in the histopathology section of an
anatomical pathology laboratory. J Clin Pathol 61:11931199
Implementation of Lean and Six Sigma quality initiatives in hospitals
Rodgers R, Hunter JE (1992) A foundation of good management
practice in government: management by objectives. Public
Admin Rev 52:2739
Saraph J, Benson P, Schroeder R (1989) An instrument for measuring
the critical factors of quality. Decis Sci 20:810829
Schroeder RG, Linderman K, Zhang D (2005) Evolution of quality:
first fifty issues of production and operations management. Prod
Oper Manag 14:468481
Schroeder RG, Linderman K, Liedtke C, Choo AS (2008) Six
Sigma: definition and underlying theory. J Oper Manag
26:236554
Shipton H, Armstrong C, West M, Dawson J (2008) The impact of
leadership and quality climate on hospital performance. Int J
Qual Health Care 20:439446
Shortell S, OBrien J, Hughes E et al (1994) Assessing the progress of
TQM in US hospitals: findings from two studies. Qual Lett
Healthc Lead 6:1417
Shortell SM, Bennett CL, Byck GR (1998) Assessing the impact of
continuous quality improvement on clinical practice: what it will
take to accelerate progress. Milbank Q 76:593624
27
Stamatis DH (2000) Who needs Six Sigma, anyway? Qual Digest.
Available via: http://www.qualitydigest.com/may00/html/sixsig
macon.html. Accessed August 15, 2009
Tsasis P, Bruce-Barrett C (2008) Organizational change through Lean
thinking. Health Serv Manag Res 21:192198
Van den Heuvel J, Does RJ, Bogers AJ, Berg M (2006)
Implementing Six Sigma in the Netherlands. J Qual Patient
Saf 32:393399
Wilk LA, Redmon WK (1990) A daily-adjusted goal-setting and
feedback procedure for improving productivity in a university
admissions office. J Organ Behav Manage 11:5575
Wright BE (2004) The role of work context in work motivation: a
public sector application of goal and social cognitive theories. J
Public Admin Res Theor 14:5978
Wright PM, Kacmar KM (1994) Goal specificity as determinant of
goal commitment and goal change. Org Behav Hum Decis
Process 59:242261
Yukl GA, Latham GP (1978) Interrelationships among employee par-
ticipation, individual differences, goal difficulty, goal acceptance,
goal instrumentality, and performance. Pers Psychol 31:305323