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According to the literature concerned with this study, less than satisfactory outcomes have been achieved through implementing business process improvements methods (BPIMs) in industries, in general, and in healthcare, in particular. The existing methods used need to be enhanced in order to create more effective outcomes. There has also been a lack of studies documenting gaps or shortfalls in implementing BPIMs, to be presented to the BPI research community. Therefore, researchers of this paper have attempted to fill gaps between theory and practice. On the contrary, there is also a need to link practical outcomes in the healthcare domain with those of the BPI research community. The purpose of this paper is to review popular BPIMs, techniques and tools applied in the healthcare domain; it seeks to examine and highlight their significant roles, clarify their pros and cons, and find opportunities to enhance their impact on the achievement of more sustainable improvements in the healthcare domain.

This study has been carried out by using a methodology combining an in-depth literature review with a comparison framework, which is called as the “Framework for Comparing Business Process Improvement Methods.” The framework is composed of seven dimensions and has been adapted from four recognized, related frameworks. In addition to the in-depth review of related literature and the adapted comparison framework, researchers have conducted several interviews with healthcare BPI practitioners in different hospitals, to attain their opinions of BPI methods and tools used in their practices.

The main results have indicated that significant improvements have been achieved by implementing BPIMs in the healthcare domain according to related literature. However, there were some shortfalls in the existing methods that need to be resolved. The most important of these has been the shortfall in representing and analyzing targeted domain knowledge during improvement phases. The tool currently used for representing the domain, specifically flowcharts, is very abstract and does not present the domain in a clear form. The flowchart tool also fails to clearly present the separation of concerns between business processes and the information systems processes that support a business in a given domain.

The findings of this study can be useful for BPI practitioners and researchers, mainly within the healthcare domain. The findings can help these groups to understand BPIMs shortfalls and encourage them to consider how BPIMs can be potentially improved.

This researchers of this paper have proposed a comparison framework for highlighting popular BPIMs in the healthcare domain, along with their uses and shortfalls. In addition, they have conducted a deep literature review based on the practical results obtained from different healthcare institutions implementing unique BPIMs around the world. There has also been valuable interview feedback attained from BPI leaders of specific hospitals in Saudi Arabia. This combination is expected to contribute to knowledge of BPIMs from both theoretical and practical points of view.

This paper proposes the adoption of Industry 4.0 (I4) technologies and lean techniques for improving operational performance in the healthcare sector.

The research adopted a systematic literature review and feedback of healthcare professionals to identify the inefficiencies in the current healthcare system. A questionnaire was used to get feedback from the patients and the hospital staff about the current practices and issues, and the expected impact of technology on existing practices. Data were analysed using descriptive statistics, correlation analysis and multiple regression analysis.

The results indicate that I4 technologies lead to the improvement of the operational performance, and the perceptions about I4 technologies are made through the pre-medical diagnosis. However, a weak correlation between lean practices and healthcare operational performance compared to that of I4 technologies and operational performance indicate that lean practices are not fully implemented in the Sri Lankan healthcare sector to their full potential.

This study is limited to two government hospitals, with insights from only the doctors and nurses in Sri Lanka. Furthermore, the study is limited to only selected aspects of I4 technologies (big data, cloud computing and IoT) and lean concepts (value stream mapping and 5S). Therefore, recommendations on the adoption of I4 technologies in the healthcare sector need to be made within the scope of the study investigation.

The implementation of I4 technologies needs careful consideration of process improvement as part of the overall plan for achieving the maximum benefits of technology adoption.

The findings of the research can be used as a benchmark/guide for other hospitals to explore the adoption of I4 technologies, and how process improvement from lean concepts could influence the overall operational performance.

The purpose of this paper is to provide a comprehensive description, justification and modus operandi for implementation of cellular operations within healthcare delivery supply chains. The methodology outlined has a sound theoretical basis, has been proven in a wide range of market sectors (including hospitals) and hence qualifies for consideration as a contribution to “new management theory”.

Approach is based on the well established management‐by‐projects (MBP) methodology for analysis, design and effective implementation of change. There is detailed coverage of the five‐step MBP programme with specific applications in healthcare. The importance of “people involvement” as a core requirement is demonstrated via the set‐up of task forces to design and operate such cells. These groups integrate cognate activities so as to provide seamless patient flow within the healthcare delivery process. MBP is derived from a systems perspective. This in turn is concerned with maintaining quality, reducing uncertainty, smooth transference, synchronisation, schedule adherence, and minimisation of throughput times.

The outputs from case studies executed in a large UK teaching hospital confirm the substantial benefits accruing from cellular operation. In both materials supplies and urology admission processes significant improvements result form adoption of the MBP change methodology. This includes substantive 50 per cent reduction in patient throughput times, plus 25 per cent increase in bed utilisation. Measurable cost benefits are achieved in materials supply, especially via simplification of ordering systems.

The healthcare applications demonstrate the applicability of MBP within this specialised scenario. However, the solutions depend on the innovatory capability of the relevant task forces who execute the projects. Since these necessarily include participation by coal‐face “players”, i.e. doctors, nurses, support staff, etc. advised by internal “change experts” the solutions adopted are shaped to be the best and most appropriate “local” schema.

It is essential that task forces be properly constituted, well trained, well advised, and actively practice the plan‐do‐check‐act cyclic route of well‐tested improvement. “Train‐Do” is the key. However, in healthcare especially, the “Elephant Must Be Eaten in Bite Sized Chunks”. In other words the organisation needs visible progressive change, unit‐by‐unit, thus avoiding saturation of scarce resources.

Brings together the MBP methodology and cellular organisational concepts into an integrated, sustainable, systems based approach to the analysis, design and implementation of effective change.

The purpose of this paper is to introduce lean concept to the field of healthcare management, expands the conceptualization of lean management beyond the manufacturing companies to consider key waste reduction opportunities which are posited to be requisites to lean practices and implements the proposed framework in the three public hospitals in Abu Dhabi.

This research is designed by decomposing complex and unstructured issue into a set of components organized in a multi-level hierarchical form. To deal with this complexity of multi criteria decision-making process, analytical hierarchical process (AHP) method is used in this research.

AHP framework for this study resulted in a ranking of 21 healthcare wastes based on the evaluations of local situations by experienced healthcare professionals. It has been found that management in healthcare systems of Abu Dhabi is putting more emphasis on the inventory waste.

The future directions of the research would be to apply a lean set of tools for the value stream optimization of the prioritized key improvement areas.

This is a contribution to the continuing research into lean management, giving practitioners and designers a practical way for measuring and implementing lean practices across health organizations.

The contribution of this research, through successive stages of data collection, measurement analysis and refinement, is a set of reliable and valid framework that can be subsequently used in conceptualization, prioritization of the waste reduction strategies in healthcare management.

The purpose of this paper is to illuminate strengths and limitations in quality improvement work, when involving patients.

The experience-based co-design (EBCD) method was used when improving care for patients undergoing otosclerosis surgery. Individual interviews and focus groups were interpreted using qualitative content analysis.

Strengths mentioned by patients were that their participation made a difference. The first steps were found effective in giving an in-depth view of patients’ experiences and the staff got an increased understanding about specific patient needs. However, weaknesses were found in the latter phases, those of improving and follow-up, health care staff had difficulties to keep their focus on patients’ experiences and invite patients to be involved. Patients’ participation decreased, and there was a lack of tools to support the process.

The content in this paper is mainly based on one case. However, the findings are in congruence with earlier research and add further knowledge to the research area.

The findings can be used in healthcare when involving patients in improvement work.

There is no earlier study which involves patients with otosclerosis when using EBCD. Furthermore, this paper illuminates that there is a need to increase collaboration with patients. The latter phases often seem to be handled by health care professionals without involving patients; this paper suggest a development using dedicated quality tools.

The purpose of this paper is to conduct a comprehensive review and assessment of the extant Six Sigma healthcare literature, focusing on: application, process changes initiated and outcomes, including improvements in process metrics, cost and revenue.

Data were obtained from an extensive literature search. Healthcare Six Sigma applications were categorized by functional area and department, key process metric, cost savings and revenue generation (if any) and other key implementation characteristics.

Several inpatient care areas have seen most applications, including admission, discharge, medication administration, operating room (OR), cardiac and intensive care. About 42.1 percent of the applications have error rate as their driving metric, with the remainder focusing on process time (38 percent) and productivity (18.9 percent). While 67 percent had initial improvement in the key process metric, only 10 percent reported sustained improvement. Only 28 percent reported cost savings and 8 percent offered revenue enhancement. These results do not favorably assess Six Sigma's overall effectiveness and the value it offers healthcare. Results are based on reported applications. Future research can include directly surveying healthcare organizations to provide additional data for assessment.

Future application should emphasize obtaining improvements that lead to significant and sustainable value. Healthcare staff can use the results to target promising areas.

This article comprehensively assesses Six Sigma healthcare applications and impact.

Lean Six Sigma (LSS) implementation follows a structured approach called define-measure-analyze-improve-control (DMAIC). Earlier research about its application in emergency healthcare services shows that it requires organizational transformation, which many healthcare setups find difficult. The Kotter change management model facilitates organizational transformation but has not been attempted in LSS settings till now. This study aims to integrate the LSS framework with the Kotter change management model to come up with an integrated framework that will facilitate LSS deployment in emergency health services.

Two-stage Delphi method was conducted by using a literature review. First, the success factors and barriers of LSS are investigated, especially from an emergency healthcare point of view. The features and benefits of Kotter's change management models are then reviewed. Subsequently, they are integrated to form a framework specific to LSS deployment in an emergency healthcare set-up. The elements of this framework are analyzed using expert opinion ratings. A new framework for LSS deployment in emergency healthcare has been developed, which can prevent failures due to challenges faced by organizations in overcoming resistance to changes.

The eight steps of the Kotter model such as establishing a sense of urgency, forming a powerful guiding coalition, creating a vision, communicating the vision, empowering others to act on the vision, planning for and creating short-term wins, consolidating improvements and producing still more change, institutionalizing new approaches are derived from the eight common errors that managers make while implementing change in the institution. The study integrated LSS principles and Kotter’s change management model to apply in emergency care units in order to reduce waste and raise the level of service quality provided by healthcare companies.

The present study could contribute knowledge to the literature by providing a framework to integrate lean management and Kotter's change management model for the emergency care unit of the healthcare organization. This framework guides decision-makers and organizations as proper strategies are required for applying lean management practices in any system.

The proposed framework is unique and no other study has prescribed any integrated framework for LSS implementation in emergency healthcare that overcomes resistance to change.

The purpose of this study is to reflect upon the ramifications of two decades of Lean Six Sigma implementations in Dutch healthcare institutions in the light of the current COVID-19 pandemic.

The authors provide an evaluation of the impact that Lean Six Sigma implementations have had on the ability of Dutch healthcare institutions to respond adequately to healthcare needs during the COVID-19 crisis.

Process improvement in healthcare has had a tendency to cut capacity and flexibility which are needed to deal with excessive demand shocks, such as during a pandemic. The main reason for this failure seems to be an overly strong focus on cost reduction instigated by Lean Six Sigma during stable times.

Besides the research method being an inferential procedure, the research focuses on the Netherlands and so the generalizability might be limited. However, using Lean Six Sigma to improve healthcare processes has found broad acceptance, so the implications may well carry over to other countries.

The authors call for a more comprehensive approach of process improvement within healthcare that takes flexibility and buffering in anticipation of excess variability and disruption into greater account. Therefore, this study provides a new perspective on how and to which aim Lean Six Sigma should be applied in healthcare.

An assessment is given of the impact of Lean Six Sigma implementations on the ability to respond to the COVID-19 crisis. This is done by identifying the focus points of improvement projects and considering the impact on the resilience of healthcare operations.

The purpose of this paper is to promote a business process approach for developing and improving the efficiency of hospital service quality in order to reduce clinical risks and increase patients satisfaction. The problems healthcare facilities face are how to reduce waste and risk and improve quality. The adoption of a process-focused organization could reduce organizational errors which have a negative influence on performance.

The research is based on a case study methodology, analyzing a specific real-life case. It is shown a practical example in the surgery department of an Italian hospital, identifying, analyzing and managing critical situations, in terms of improvement. To this end, national and international contributions, public documents, institutional websites, conference papers, books, workshops and hospital websites have been analyzed. Moreover, other data were collected through questionnaires.

Results show how a comprehensive view of the processes may lead to improvement in operations by identifying different risks and bottlenecks, suggesting the rapid implementation of corrective policies and improvements, in terms of overall efficiency.

By implementing innovative organizational processes to identify and reduce bottleneck a healthcare system could achieve a competitive advantage.

Within the Italian healthcare system, limited attention has been paid to the design of healthcare facilities. Flexible solutions are necessary for lean management. The originality of this work lies in the analysis applied to a complex organization, through which hidden critical situations have been identified, and solutions to improve and provide better healthcare management have been suggested.

The healthcare system has been under pressure to provide timely and quality healthcare. The influx of patients in the emergency departments (EDs) is testing the capacity of the system to its limit. In order to increase EDs' capacity and performance, healthcare managers and practitioners are adopting process improvement (PI) approaches in their operations. Thus, this study aims to identify the main PI approaches implemented in EDs, as well as the benefits and barriers to implement these approaches.

The study is based on a rigorous systematic literature review of 115 papers. Furthermore, under the lens of thematic analysis, the authors present the descriptive and prescriptive findings.

The descriptive analysis found copious information related to PI approaches implemented in EDs, such as main PIs used in EDs, type of methodological procedures applied, as well as a set of barriers and benefits. Aiming to provide an in-depth analysis and prescriptive results, the authors carried out a thematic analysis that found underlying barriers (e.g. organisational, technical and behavioural) and benefits (e.g. for patients, the organisation and processes) of PI implementation in EDs.

The authors contribute to knowledge by providing a comprehensive review of the main PI methodologies applied in EDs, underscoring the most prominent ones. This study goes beyond descriptive studies that identify lists of barriers and benefits, and instead the authors categorize prescriptive elements that influence these barriers and benefits. Finally, this study raises discussions about the behavioural influence of patients and medical staff on the implementation of PI approaches.