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Lessons for Lean in Healthcare from Using Six

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Article in Public Money & Management · February 2008

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 Lessons for Lean in healthcare from a major initiative to implement Six Sigma in
the NHS

Nathan Proudlove, Claire Moxham and Ruth Boaden

Abstract

A commitment to delivering high quality care has led healthcare providers to consider
the application of quality improvement approaches that have originated from
manufacturing. In the UK the National Health Service (NHS) has applied a number of
these, often in a piecemeal fashion; most notably Six Sigma and (more recently) Lean.
This paper draws on the formal evaluation of a Six Sigma Green Belt Programme within
the NHS to consider what can be learned about the application of such approaches –
including what themes also apply to Lean, and its implementation, particularly in the
healthcare context

Introduction

Much of the expertise in process and quality improvement is built on the work of
pioneering ‘gurus’ (including Shewhart, Deming, Juran, Shingo and Ohno) and the
development of their ideas within manufacturing companies (including Motorola, General
Electric and Toyota). However, it is very difficult to synthesise a single unified theoretical
framework from these ideas and practices, which differ (at minimum) in emphasis (Dale,
2003). The different emphases amongst gurus, companies and consultants has led to
the development of different packaging of ideas and tools into relatively comprehensive
approaches under labels including Six Sigma and Lean.

This article examines the implementation of Six Sigma and uses the experience to draw
out lessons for Lean implementation. It considers the relationship between Six Sigma
and Lean in theory, the experience of implementing Six Sigma in the NHS and identifies
learning that might be carried across to Lean implementation in the NHS, as shown in
Figure 1.

Six Sigma – the theory

Six Sigma is a process or product improvement or (re-) design approach developed

initially by Motorola in the 1980s, then further by Allied Signal and General Electric.
Having achieved widespread acceptance in manufacturing, Six Sigma is currently
becoming very popular in the service sector (especially with US-owned firms)
(Schroeder et al, 2007). Its structured framework and analytical-tool-based approach
make it a very attractive training ‘product’. Six Sigma builds on the work of Shewart and
Deming, and the Total Quality Management (TQM) approach.

Proudlove and Boaden (2006) discuss the nature of Six Sigma:

 Underlying philosophy and underpinning elements, including deployment,
support and training infrastructure, ‘belt’ certification structure. A major
deployment of Six Sigma involves training and coaching by very experienced
Master Black Belts (MBBs) of practitioners (typically Green Belts (GBs)) and
expert practitioners (Black Belts (BBs)) who undertake improvement projects with
the support of Champions. Schroeder et al (2007) emphasise these

p.1
 underpinnings, which they characterise as creating a very strong improvement
structure in parallel with the management hierarchy in an organisation, as the key
strength and differentiator of Six Sigma.
 Methodologies used: primarily Define-Measure-Analyse-Improve-Control
(DMAIC) and Design for Six Sigma (DFSS), that guide practitioners through
problem solving steps providing structure for using tools which include process
mapping and SPC. Pyzdek (2003) provides a comprehensive guide to tools.

The general literature on Six Sigma is comprehensively reviewed by Hendry and

Nonthaleerak (2005) who conclude that, despite the great claims made for it, there is
little rigorous empirical evidence for financial returns or on enablers and barriers to
success. Looking at applications to healthcare improvement, accounts of independent
evaluation are still lacking, with the exception of Merry and Wing (1993). [contracted]

Lean – the theory

The theory of Lean is comprehensively covered elsewhere in this issue (see the editorial
to this special issue) and often acknowledged to be based on five key principles
(Womack and Jones, 2003):
 Specify the value desired by the customer
 Identify the value stream for each product providing that value and challenge all of
the wasted steps
 Make the product flow continuously
 Introduce pull between all steps where continuous flow is impossible
 Manage toward perfection so that the number of steps and the amount of time and
information needed to serve the customer continually falls.

Applications of Lean within healthcare and the wider public sector are often reported
(Jones and Mitchell, 2006, Radnor et al, 2006) but rarely evaluated formally from an
academic perspective. Outside the UK the most well known examples appear to be
Virginia Mason (Seattle), Thedacare (Wisconsin) and Flinders (Adelaide) (Fillingham,
2007).

Lean Six Sigma – the theory

Many academic authors e.g. (Bicheno, 2005, Kaplan and Rona, 2004, Hines et al, 2004)
and practitioners e.g. (George and Rowlands, 2003) believe that it is possible to
integrate improvement approaches in practice without contradicting their core objectives.
Lean and Six Sigma are often considered to offer features which complement each other
(a “synergy made in heaven” according to Bossert (2003), and are increasingly being
integrated in practice (e.g. Dahlgaard and Park Dahlgaard (2005), George et al (2005)),
though there is no consensus on how this should be done. Many approaches urge that
the notion of Six Sigma and Lean being rival initiatives is now disregarded, and that the
approaches should be blended because they “both enable the reduction of the cost of
complexity” (US Army Business Transformation Knowledge Center, 2007).

The distinctions between Lean and Six Sigma in practice are not as clear cut as the
academic literature might suggest, for example Lean uses data-analytic techniques and
Six Sigma has rapid improvement ‘workout’ events. However, there are different
emphases: in particular whilst they both take a process view and converge in their focus
on variation, flow and the customer, the prime focus of Six Sigma is variation while for

p.2
Lean it is flow. The relationship between Lean and Six Sigma, together with the
healthcare context, is considered at greater length in Boaden et al (2005a) and can be
summarised as shown in Table 1. (See also Bicheno (2005), p.133).

Table 1
LEAN SIX SIGMA
Driven by Customer value: defines Customer Critical to Quality:
waste defines defects
Proven insights into flow, Reliance on evidence to analyse
which increase speed and symptoms & potential causes to
capacity demonstrate root causes
Learning “learning to see” – identifying Learning to be rigorous:
waste and flow effect linked to root cause
Focus Look ever outward along value Maintain focus within the project
chain scope
Culture and Lean culture Adhere to powerful DMAIC
approach roadmap
Strong support infrastructure

The natural synergy between these emphases has given rise to combinations often
termed ‘Lean Six Sigma’. Different hybrids have emerged since and, whilst the toolkits
dovetail, there is no widely-accepted common or integrated methodology (roadmap).
One approach is to use the DMAIC roadmap, calling on flow diagnosis and solution tools
when appropriate, in particular during the Measure and Improve stages, e.g. (George et
al, 2005).

Nave (2002) argues that Six Sigma and Lean (and Theory of Constraints) have the
same effects when secondary effects are considered in addition to the primary focus, so
they may all produce the same results. Dan Jones (Jones, 2006) agrees that the precise
approach(es) used are not critical whilst there is still “a lot of undergrowth to clear”
(which is argued to be the case in the public sector). However, once this is stripped
away to expose the trickier problems, the understanding of an approach and the rigour
of application does become crucial.

Process and Quality Improvement Initiatives in practice: the NHS

There has been a large amount of work carried out in the NHS to improve processes
and quality, although it has not always been co-ordinated centrally. Overall it can be
argued that the stream of work to improve/re-engineer NHS processes may have been
the largest such single-organisation efforts in history (NHS Modernisation Board, 2002).
The NHS Modernisation Agency (MA) and its successor, the NHS Institute for Innovation
and Improvement (NHSII) have both been influenced by improvement approaches in the
US coordinated by the Institute for Healthcare Improvement (IHI), and have focused in
particular on the improvement and re-design of processes (Young, 2005) and so have
looked to Operations Management expertise, e.g. (Mango and Shapiro, 2001, Walley,
2003, Young et al, 2004). Whilst it is widely acknowledged that operations management
approaches are applicable in healthcare, and all the principal approaches have been
tried, implementation has been little researched.

Six Sigma in the NHS in England

p.3
The motivation to try Six Sigma within the NHS was recognition from the MA (who were
spearheading improvement initiatives at that time) that very few improvement projects
included much measurement, despite promotion of PDSA as an improvement
methodology. Six Sigma was seen as offering a rigorous methodology, a focus on root
causes and more confidence that changes would lead to intended outcomes. The MA
therefore established what will be referred to as the Six Sigma Green Belt (GB) project,
to test the viability of Six Sigma in the NHS, and also to create Six Sigma capability and
to identify the issues involved in translating the approach to healthcare. The features of
the GB project were:

 It was conducted from June 2004-March 2005 and consisted of two periods of
residential training with work on improvement projects in between (not on a full-time
basis)
 Formal training, GB certification and support throughout the period of the projects
was provided by Juran Institute MBBs, experienced in healthcare improvement
projects in the US, with some additional support from 2 previously-trained MA Black
Belts (BB) who were NHS staff and experienced in NHS change projects.
 It involved over 50 NHS staff – the majority of whom were already working for the MA
in a variety of roles - working in 14 project teams in organisations across the NHS in
England.
 The 14 teams worked on projects including: reducing waiting times and variation for
patients referred for Magnetic Resonance examination, reducing the length of stay
for low risk chest pain patients, eliminating late follow ups in ophthalmology
outpatients and reducing variability in nurse rostering.
 The project was formally evaluated through participant observation and a series of
interviews with the GBs (in teams and individually), the MBBs and BBs, and domain
experts (Boaden et al, 2005b).

The timing and context of the pilot project was potentially influential: it was undertaken at
a time of significant organisational change, particularly for the MA which was working
towards its dissolution in March 2005. This led to uncertainty about future jobs for many
of the participants but is not considered to have significantly affected the outcome of the
programme, although it did cause pressures on individuals during the process. The
relevant details of the GB projects are included in the discussion below.

Participants in the Six Sigma pilot project experienced chaotic or unstable processes
(i.e. systems needing fundamental redesign rather than improvement) that reinforced
growing interest within the MA in Lean. As a result the Juran Institute also provided a 3-
day (theory only) training event in (their version of) Lean Six Sigma (Boaden et al,
2005a).

Discussion

This discussion is structured by Goldratt’s three questions: What to change? What to

change to? How to change? It draws on both theory and practice to identify lessons for
Lean implementation in the NHS.

What to Change?

p.4
Six Sigma The issue of deciding what process to change (from the point of view of
strategic priorities and alignment) receives relatively little attention in the Six Sigma
literature – it is a top-down, pre-DMAIC stage. Since “DMAIC encourages creative
thinking within boundaries” (George et al, 2005), it risks failing to look widely enough
when answering this question, and sub-optimising the wider system (a criticism also
levelled at TQM (Folaron, 2003). This aspect relies on effective underpinnings –
described as the meso-structure that parallels the organisation’s normal way of
operating (Schroeder et al, 2007) and does suggest that “the decision rights to initiate a
project are allocated to senior management” (Schroeder et al, 2007, p6). This ‘macro
view’ of Six Sigma (Hendry and Nonthaleerak, 2005) allows some to claim it is a
comprehensive business system (e.g. Pande et al (2000)).

Lean The way in which improvement is targeted in Lean is often rather vague in the
literature but seems in practice to be a more participative, bottom-up approach than Six
Sigma. One reason for this might be that Lean is characterised as relying more on
intuition and deep insight (for example when producing future state value stream maps
{Bicheno, 2005 #2267}; an image reinforced by Ohno’s resistance to codification of the
Toyota Production System (TPS) (noted for example by Seddon (2005)). Another is
focus on Lean as an operational technique, with strategy and scope aspects tending to
have been ignored until recently (Hines, 2004).

Six Sigma implementation An issue identified on several of the GB projects was the lack
of a clear link to business strategy within the organisations where the projects were
taking place, even if they were focused on national targets and priority areas. Although
this aspect was beyond the scope of the GB project it resulted in severe problems in
buy-in from the hosts. The Green Belts also found identification of ‘customers’ and
‘processes’ in the complexity of the NHS particularly difficult, especially because
organisations were not structured around key processes.

Many of the target processes (even when they could be identified) had very high defect
rates, indicating they were intrinsically chaotic or ineffective and required fundamental
(re-) design rather than being ready for improvement. Teams that experienced chaotic
processes had considerable difficulty applying the Six Sigma approach. One GB
mentioned public health as an area that would be particularly challenging to handle with
the types of approaches that work on the basis of identifiable processes and customers.

Issues for Lean

 Strategic Focus Currently the only NHS approach to Lean which explicitly starts from
a wider strategic framework is Bolton (Fillingham, 2007); with others having a more
tactical or operational focus. It is too early in any of the implementation processes to
be clear about whether this will be important but the learning from Six Sigma
suggests that it will be – without a clear strategic framework attempts to improve
using a Lean approach will have at best localised impact. They also run the risk of
improvements not being sustained because they are not part of a clear strategic
direction for the organisation. Any project selection system needs to consider the
implications of various ‘voices’ (of the customer, process, organisation, regulator etc)
to focus, coordinate and align improvement activity. Because Lean is naturally a
more bottom-up approach; extra care may be needed to make best use of resources
and to ensure that sub-optimisation does not occur.
 Identification of processes Identification of processes that contribute to the value
stream is key to Lean. In the GB initiative, many of the target processes were very

p.5
 hard to define and there is no reason to think that Lean implementation would be any
different. The ‘silo’ nature of NHS organisations and structures is not naturally
conducive to identifying processes; “most organisations simply do not have this
process focus” (Fillingham, 2007, p.232), although the increasing emphasis on
networks to support certain conditions (e.g. diabetes) is beginning to challenge this.
 Current state of processes If processes are very chaotic then the application of any
improvement approach or tool may initially produce dramatic results, but once the
‘undergrowth’ has been cleared it may become more difficult to sustain improvement
– something noted in applications of Lean in the public sector to date (Radnor et al,
2006).
 Identification of customers Difficulties identifying customers are likely to be Formatted: Bullets and Numbering
exacerbated with Lean when ‘value’ (e.g. ratio of benefits to costs) has also to be
considered, and if its logic of looking ever-outwards along the value chain is to be
pursued. The assumption in some Lean implementations to date (e.g. Fillingham,
(2007)) that the patient is the customer may not be sustainable when complexities of
healthcare commissioning are taken into account.

Table 2 summaries the key issues concerning what to change.

Table 2: What to change?

Six Sigma Lean NHS Six Sigma GB Questions for Lean
experience
 Decided by senior  Customer value  Intended to be  Is it used as part
team focus, though fairly bottom-up, of a overall
 Customer focus only can be hard to but resulted in strategy?
included once identify lack of links to  Are processes
DMAIC process local strategy the basis of
starts – using Voice and therefore analysis and
of the Customer poor buy-in to improvement?
(VOC) and Critical to projects  Is it understood
Quality (CTQ) tools  Difficult to deal that it will be
 Targeted scope of with the lack of complex to
improvement work clarity concerning identify the
means that both processes & customers and
compartmentalisatio customers their needs?
n may sub-optimise  Chaotic
system processes
discovered which
were not at all in
control

What to Change To?

Six Sigma is a generic, root-cause & solution unknown problem-solving approach.

Precisely what components of the process to change and what to change them to should
emerge from the rigorous, analytical, data-driven methodology. However, the DMAIC
roadmap and the requirements of formal belt-certification training can emphasise tools
over problem-solving (what Seddon (2005) calls the ‘toolhead’ mentality) and complex
tools may unnecessarily complicate improvement attempts (Slack et al, 2006). A further

p.6
issue is that there can be an over-emphasis on being data-, rather than problem-, driven
within Six Sigma.

Lean, in contrast, brings principles for improving flow and some tried-and-tested
solutions. These may be used at an early stage to construct a vision of the future
configuration of the value stream, which may be used to guide and coordinate
improvements. In addition, the 5 principles of Lean underpin any particular improvement
projects. Many of the tools identified as suitable for a Lean approach are common to
other approaches, including Six Sigma and other approaches: “the tools/techniques of
six sigma are strikingly similar to prior quality management approaches” (Schroeder et
al, 2007, p.2).

Six Sigma implementation The use of the DMAIC process was found to be beneficial but
difficult: especially its structure and rigour, and its focus on data, measurement and
analysis through clearly prescribed steps. In practice some found it difficult to stick with
the rigour of the approach, especially where they believed they could see some ‘quick
wins’ that did not appear to require the application of each step of the process – as they
had often done with previous improvement projects - Walley and Gowland (2004) note
that too many NHS projects jump straight to ‘Do’ (or Improve). In particular, the time and
effort required for Define and Measure were a source of frustration for many GBs, but
several commented in retrospect on the value of this discipline. The MBBs had to spend
considerable time pulling teams back to address parts of the process rigorously.
Participants did find that as a result of this process they gained a thorough
understanding of the problem and its causes. Overall there was considerable
enthusiasm for the DMAIC structure, and several suggested that they would continue to
use it, though probably in a less formal manner and with a smaller set of tools.

The tools considered most useful were:

 Project Charter - initially considered confusing, but eventually one of the best
received tools according to our questionnaire survey (to which 35 of the GBs
responded), perhaps reflecting the unfamiliarity of constructing a “business case” for
an improvement project for NHS staff, and also the initial lack of integration of many
teams into the host organisation;
 Voice of the Customer (VOC) - judged to be the most useful single component of Six
Sigma, and something mentioned frequently when future use of tools was discussed;
 Critical to Quality (CTQ) - seen as having a useful discipline but not easy to apply;
 Process mapping;
 Pareto Analysis;
 Fishbone diagrams.

There was a general view that although Six Sigma tools could, and did, fit with other
improvement techniques, more work was needed to clarify the exact relationship.
Approximately a third of the GB project participants who responded to the survey agreed
that Six Sigma fitted well or complemented other techniques already in use but it is
surprising that this proportion was not higher, considering the wide dissemination of
process mapping, SPC and PDSA in the NHS. In addition, the jargon was
overwhelmingly unpopular and described by Green Belts as “a barrier to getting things
done in the NHS.”

p.7
Issues for Lean
 Degree of rigour Different types of process problems may be addressed most
appropriately by different improvement approaches. Whilst the rigour of formal Six
Sigma may be justified in some cases (e.g. in very high importance, high-volume and
non-chaotic processes with root-cause & solution unknown problems) in some cases
this may be too rigorous, slowing improvement (Upton and Cox, 2004), sometimes to
the point of being counter to commonsense (Sharma, 2003). Many issues in the NHS
arise from problems with flow (Silvester et al, 2004), so it is valuable to have access
to flow improvement tools. However, as approaches to improvement in the NHS
have at times previously lacked rigour, there is an argument for a more systematic
approach.
 Relationship between speed and rigour There is obviously a tension between speed
and rigour in process improvement, particularly in the early stages. This would be
difficult to resolve without support from a source outside of the individual
improvement project – perhaps an improvement support function suggesting
appropriate approaches for particular problems and encouraging rigour. The Lean
equivalent of emphasis on Define and Measure might be Specify Value and Define
the Value Stream.
 Structure and support The methodological structure of Lean is somewhat less strong
than DMAIC, though the structure of Rapid Improvement Events (RIEs – a process
of facilitated problem solving over the space of a few weeks targed at a particular
value stream) is probably the nearest equivalent. Seddon's (2005) suggestion of a
‘pull’ for tools from the change agents rather than a push from trainers would seem
sensible, provided there can be timely support and some initial awareness of the
tools available. A further role of strategic support should be release of resources to
conduct and support projects.
 Improvement terminology Whilst the intuition and metaphors in Lean may be more
appealing to an NHS audience (Boaden et al, 2005a), the reaction to Six Sigma
jargon suggests great care needs to be taken with this. In particular the ‘lean and
mean’ issue (Fillingham, 2007) needs careful attention and has already led to
problems in public-sector implementations.

Table 3 summarises the issues concerned with what to change to.

Table 3: What to change to?

Six Sigma Lean NHS Six Sigma GB Questions for
experience Lean
 No a priori  5 Lean principles  Frustrating (but  How much
assumptions; good  vision-led (future- ultimately rigour is
for root-cause/ state VSM) rewarding) needed?
solution unknown  tried & tested discipline of D & M  What is the
problems flow solutions  Data-driven relationship
 Discipline & rigour  natural look to  Most useful tools: between speed
of DMA stages Lean if obvious DMAIC, Charter, and rigour?
important flow problems VOC, CTQ,  What support is
process mapping, needed?
Pareto, Fishbone  What about the
terminology?

How to Bring About Change?

p.8
Whichever approach is used, Grol et al (2004) argue that “simple improvement
measures are seldom effective. The problems related to the improvement of patient care
are large” (p3). They argue that any “simple” approach to change management in the
health care context is “naïve and will fail” (p3). However, there are still some differences
in the more technical aspects of the various approaches to improvement which will have
varying impacts.

Six Sigma The ‘people’ aspects of Six Sigma have not been much investigated (Hendry
and Nonthaleerak, 2005), and are part of (only) advanced training (e.g. Black Belt – see
Pyzdek (2003)). A related criticism of Six Sigma is the emphasis on a ‘cadre’ of experts
parachuted in to ‘sort out’ a process more than empowering the process operators
(Seddon, 2005). Six Sigma may seek to combine breakthrough and continuous
improvement philosophies (Slack et al, 2006), however targeting specific functions or
individual processes (as opposed to an organisation-wide approach) promotes a task-
force focus (Sanders and Hild, 2000) and so a single-hit breakthrough-change mindset
over a culture of continuous improvement.

Lean The ‘people’ aspects of Lean are often argued to be secondary in the original TPS
although it did have an impact on morale and motivation (Vasilash, 2001) whilst others
believe that there was an equally important regard for the human aspects (Ohno, 1988).
Reviews of literature highlight that Lean needs to be regarded as a long-term change
project (Bhasin and Burcher, 2006) and empowerment of staff is claimed as a key
benefit (Bowen and Youngdahl, 1998) through the involvement of staff in RIEs.
However, there are some authors sceptical about the impact of Lean on individuals
within the organisation (Parker, 2003). As noted earlier, in general Lean has often been
a more operational-level, “bottom up” approach to improvement and involving staff than
Six Sigma.

Six Sigma Implementation In the GB projects, management and leadership were

problematic, both within the host organisation and nationally (which may have been due
at least in part to the organisational changes going on within the NHS at the time).
However, this may also have been due to the fact that the Six Sigma projects were not
part of any wider strategic approach to improvement, or supported by any meso-
structure (Schroeder et al, 2007) within the host organisations.

The main weakness of Six Sigma mentioned was its lack of emphasis on the
soft/people/cultural factors, something which had been a concern of the MA at the start
of the project and which materialised as an issue throughout.

The functioning of the project teams was affected by the geographical spread of the
members and the skill mix within the team, as well as the links of team members to the
host organisation. Team effectiveness (as perceived by the team members) was clearly
related to project progress in terms of both speed and quality of work (as assessed by
the Juran MBBs); nearly three quarters of interviewees reporting having experienced
problems within their team. Another issue raised was the assumption of a common goal
within a Six Sigma team, something which is not necessarily the case in the NHS and
can also be related to the issue of links between improvement projects and strategy
discussed earlier. Only 8 out of the 14 teams had a member who also worked for the
host organisation and this was seen as affecting both the process (momentum) and
outcome of the projects. Some teams were more successful than others at establishing

p.9
extended teams, which included key staff from the host organisation, and others were
affected by changes in (or a lack of) key personnel in the host organisation.

Black Belt support was limited, and the use made of it variable, although this was not a
significant success factor for the projects. MBB coaching was important in guiding teams
through difficulties, maintaining momentum and rigour. The skills, experience and
pragmatism of the change agents, or effective coaching by MBBs, (eventually) overcame
weaknesses in Six Sigma as applied.

Issues for Lean

 Organisational change Whichever improvement approach is employed, it should be
regarded as a key organisational change and simplistic approaches avoided.
 People it is possible that the emphasis on people within Lean will make it a more
acceptable approach than Six Sigma within the NHS. However despite much
exhortation that Lean is not an approach to cost cutting (Jones and Mitchell, 2006)
the long-term implications for job design and numbers of staff from extensive Lean
implementation have not yet been faced in the NHS due to the current piecemeal
implementations.
 Team working This is not an issue covered by much theory but in practice this was
found to be key in effective improvement within the GB project. It is likely therefore to
be a key issue when Lean implementation is considered, especially where work
continues over a longer period than the intensive few days of an RIE. Issues of team
working, professional hierarchies and resource availability are going to be equally
important whether it is Lean, Six Sigma, or any other approach being employed.
 Support The importance of experienced coaches was noted in the GB projects, and
there is considerable support from external consultants in this role in NHS
organisations pursuing Lean. However, organisations will need to consider how to
develop internal support mechanisms if Lean is to be a sustainable approach to
improvement more widely in the NHS.

Table 4 summarises the issues concerned with how to bring about change.

Table 4: How to bring about change?

Six Sigma Lean NHS Six Sigma Questions for Lean
GB experience
 People issues  RIE or continuous  Discipline &  Is Lean being
not emphasised improvement motivation from considered as
 Experts sent in to approach, aims to MBBs organisational
sort things out leave new Lean  Local buy-in change or “just
rather than thinkers patchy, most another project”?
developing  Should be successful  Have the implications
internal expertise regarded as where GB from for individuals been
 Single organisational host trust considered?
project/task change  Team dynamics  Have the way teams
mentality rather  Some scepticism issues work together been
than continuous about effect on taken into account?
improvement people  Is there effective
philosophy  Long-term issues long-term support for
not yet faced in Lean
NHS implementation?

p.10
Conclusions – lessons for Lean in healthcare

Considerable learning was obtained from the GB initiative about the strengths and
challenges of applying the Six Sigma process improvement approach in the messy,
complex environment of the NHS. The value of a structured methodology (or ‘roadmap’),
in particular the discipline of the early stages of the process and the guidance on how to
use a sequence of tools, was appreciated. The importance of project selection, team
coaching and local buy-in was apparent.

Many of these lessons can be carried across to Lean. Of particular significance to Lean
are the difficulties in identifying customers and processes in a healthcare setting and the
use of clear and appropriate terminology. The tensions experienced between speed and
rigour are also equally applicable to Lean as to Six Sigma. Lean is currently the main
focus of attention in the NHS and there is undoubtedly huge potential for wider use of
Lean thinking. The results of this study indicate that once the “undergrowth is cleared” a
deeper appreciation of Lean may be necessary and consideration on how to translate
concepts such as customers and value to complex organisations such as healthcare will
be required.

In addition, this study has also identified the scope for a more ‘unified’ presentation of
process improvement approaches (including the use of combinations of Lean and Six
Sigma) and more strategic improvement support functions within organisations. In
practice, there may not be huge differences to how ideas from both Lean and Six Sigma
could be (intelligently & pragmatically) used in the NHS, and the outcomes would
probably similar, at least initially. Implementation is a bigger issue and perhaps where
attention should be focused, rather than on the techniques themselves.

References

Bhasin S and Burcher P (2006). Lean viewed as a philosophy. Journal of Manufacturing

Technology Management 17: 56-72.
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