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The effectiveness of Six Sigma programs has varied across different industries and organizations, and leadership styles have been identified as a critical success factor for the installation of Six Sigma initiatives. Therefore, this study aims to investigate the specific elements of leadership styles that are linked with the successful deployment of Six Sigma programs in the automobile industry.

To conduct the study, the researchers utilized a Likert scale questionnaire with a rating system of 1–7 and a simple random sampling method. The survey was distributed to 2,325 potential participants, with 573 responses received, mostly from Germany, the United Kingdom and Sweden. Out of those responses, 260 completed questionnaires were received. The study utilized a mixed-methods research design and exploratory research approaches to investigate the implication of leadership style on the success of Six Sigma implementation. The research employed several analysis techniques, including Structural Equation Modeling (SEM), exploratory factor analysis (EFA), confirmatory factor analysis (CFA) and Survey methods.

Through various SEM methods, such as EFA and CFA, the study revealed two vital leadership elements: (1) the long-term success of Six Sigma depends on leadership’s support and recognition of it as an improvement strategy and (2) leadership must commit to the organization’s suppliers to ensure quality and the provision of defect-free products.

By incorporating the identified key elements of leadership into their strategies, organizations and researchers can ensure the sustainable implementation of Six Sigma.

This research presents a distinct contribution to the evaluation of leadership style components within the European automotive sector, utilizing a mixed-methods research design and incorporating a variety of descriptive statistics.

There is increasing interest in the connection between Industry 4.0 (I4.0) and operational excellence approaches; however, studies on the integration between Six Sigma (SS) and I4.0 have been absent from the literature. Integration with I4.0 technologies can maximize the positive effects of SS. The purpose of this study is to understand what types of relationships exist between SS and I4.0 and with I4.0's technologies, as well as the benefits derived from this integration and future directions for this field of study.

A Systematic Literature Review (SLR) was carried out to analyze studies about connections between I4.0 technologies and SS. SLR analyzed 59 articles from 2013 to 2021 extracted from the Web of Science and Scopus databases, including documents from journals and conferences.

The SLR identified relationships between SS and several I4.0 technologies, the most cited and with the greatest possibilities of relationships being Big Data/Big Data Analytics (BDA) and Internet of Things (IoT). Three main types of relationships were identified: (1) support of I4.0 technologies to SS; (2) assistance from the SS to the introduction of I4.0 technologies, and, to a lesser extent; (3) incompatibilities between SS and I4.0 technologies. The benefits are mainly related to availability of large data sets and real-time information, enabling better decision-making in less time.

In addition, the study can help managers to understand the integration relationships, which may encourage companies to adopt SS/Lean Six Sigma (LSS) in conjunction with I4.0 technologies. The results also drew attention to the incompatibilities between SS and I4.0 to anticipate potential barriers to implementation.

The study focuses on three previously unexplored subjects: the connection between SS and I4.0, the existing relationships with different technologies and the benefits resulting from the relationships. In addition, the study compiled and structured different types of relationships for SS and I4.0 and I4.0's technologies, identifying patterns and presenting evidence on how these relationships occur. Finally, exposes current trends and possible research directions.

The purpose of this paper is to conduct an empirical study derived from the previous literature from the perspective of benefits, tools and techniques, continuous improvement (CI) and quality improvement (QI) methodologies and critical failure factors (CFFs) of Lean and Six Sigma (SS) in the national health service (NHS).

A literature review was carried out to identify previous findings, empirical data and critical variables concerning Lean and SS in healthcare for over ten years. Second, primary research in quantitative surveys and qualitative interviews was carried out with 110 participants who have experience using Lean and SS in the NHS.

Lean and SS have evolved into common practices within the NHS and now have an established list of tools and techniques frequently employed by staff. Lean and SS are considered robust CI methodologies capable of effectively delivering extensive benefits across many different categories. The NHS must overcome a sizable amount of highly important CFFs and divided organizational culture.

This paper has developed the most extensive empirical study ever produced on Lean and SS in the NHS and has expanded on previous works to create new and updated research. The findings produced in this paper will assist NHS medical directors and practitioners in obtaining up-to-date insight into Lean and SS status in the NHS. The paper will also guide the NHS to critically evaluate their current CI strategy to ensure long-term sustainability and deliver improved levels of service to patients.

The purpose of this study is to determine the current status of Sustainable Lean Six Sigma (SLSS) practices execution in the industries by identifying the research gaps and also methodologies that are applied by different researchers and practitioners.

To find the current status of SLSS practices all over world, the literature review of the articles available through SCOPUS data base is given in different categories such as a country-wise and year-wise publication of the articles, journal-wise publication of articles, case study implementation focus in industry and data analysis techniques used by the researchers.

The different methodologies applied by the researchers and practitioners have been explained and the gaps for further research are identified. The extensive review of articles of last 18 years revealed that there are various opportunities such as quantitative study, framework modeling on the SLSS, and implementation of developed models in different industries, etc. which are required to be explored.

In the present study, a review of 129 articles for the time span of January 2000 to February 2018 is considered. The SCOPUS database was used for selecting the articles for review. A total of 129 articles were considered for the literature review, and the case study implementation in different industries with the focused areas such as cost reduction, defect reduction, economic, environmental and social aspects was explained.

Head and neck cancers are multi-factorial diseases that can affect many sides of people's life and are due to a lot of risk factors. According to their characteristics, the treatment can be surgical, use of radiation or chemotherapy. The use of a surgical treatment can lead to surgical infections that are a main theme in medicine. At the University hospital of Naples “Federico II”, two antibiotics were employed to tackle the issue of the infections and they are compared in this paper to find which one implies the lowest length of hospital stay (LOS) and the reduction of infections.

The Six Sigma methodology and its problem-solving strategy DMAIC (define, measure, analyse, improve, control), already employed in the healthcare sector, were used as a tool of a health technology assessment between two drugs. In this paper the DMAIC roadmap is used to compare the Ceftriaxone (administered to a group of 48 patients) and the association of Cefazolin plus Clindamycin (administered to a group of 45 patients).

The results show that the LOS of patients treated with Ceftriaxone is lower than those who were treated with the association of Cefazolin plus Clindamycin, the difference is about 41%. Moreover, a lower number of complications and infections was found in patients who received Ceftriaxone. Finally, a greater number of antibiotic shifts was needed by patients treated with Cefazolin plus Clindamycin.

While the paper enhances clearly the advantages for patients' outcomes regarding the LOS and the number of complications, it did not analyse the costs of the two antibiotics.

Employing the Ceftriaxone would allow the Department of Maxillofacial Surgery to obtain lower LOS and a limited number of complications/infections for recovered patients, consequently reducing the hospitalization costs.

There is a double value in this paper: first of all, the comparison between the two antibiotics gives an answer to one of the main issues in medicine that is the reduction of hospital-acquired infections; secondly, the Six Sigma through its DMAIC cycle can be employed also to compare two biomedical technologies as a tool of health technology assessment studies.

The best treatment for femur fractures is the surgical one within 48 h from the admission to the hospital. These fractures have serious consequences, both in terms of morbidity and socio-economic impact. In the hospital A.O.R.N. Cardarelli of Naples in Italy, the mean pre-operative length of hospital stay (LOS) was nine days and just 4 per cent of patients was operated within the suggested time. Therefore, a diagnostic-therapeutic-assistance path (DTAP) was implemented to improve the process.

This paper analyzes two groups of patients (534 and 562, respectively) before and after the introduction of DTAP, through six sigma (SS) based on define, measure, analyze, improve and control cycle. Age, gender, American Society of Anaesthesiologists (ASA) score, cardiovascular diseases, diabetes and allergies were used as independent subgrouping variables. The t-tests and chi-square were performed to compare the groups, tools of SS were used.

The analyses were conducted considering overall patients and some subgroups. The overall reduction in LOS was about 54 per cent, patients without cardiovascular diseases and with a low ASA score had the highest reduction, more than 60 per cent. All the p-values proved a high statistically significant difference between the two groups.

The influence of the Italian health-care system is a minor limitation while, unfortunately, the lack of a follow-up did not allow quantifying the real gain in health of patients. A lean thinking analysis would suit this context.

There are practical advantages for both hospital and patients: the hospital will have an increase in admissions and more beds available, while patients will benefit of a faster intervention and a shorter wait.

This is the first analysis through SS of DTAP showing its positive influences in terms of both socio-economic impact and patients’ outcome. Policy leaders could use this study as an example to evaluate the introduction of the same clinical pathway in other health facilities.