THE EFFECTIVENESS OF LEAN SIX SIGMA IMPLEMENTATION IN HEALTH-CARE FACILITIES

This study was conducted to investigate the effectiveness of implementing Lean Six Sigma within the field of health care facilities. Lean Six Sigma is a powerful tool that can increase the organization performance. In this study A systematic review was performed in accordance with current best practices through close adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. This study was found that the implementation of Lean Six Sigma enables the hospital to reduce the consumption of plasminogen by 69%, block utilization was increase by 13%-28%, book appointment increases by 24-276%, time saving were increase by 17% to 21%. And for service quality in blood collection was increased by 55% housewide. Lean Six Sigma is an inexpensive methodology to implement, it can bring many benefits to the organization in the health-care facilities. The successful implementation of Lean Six Sigma was able to reduce waste, reduce defect rate, increasing the quality of service, and reduce process variability that led to patient satisfaction and cost effective.


INTRODUCTION
Business environment is dynamic and constantly change especially for health care facilities during pandemic Covid-19.This push hospital and other health care facilities to discover best practices to improve productivity and service quality.Lean Six Sigma (LSS) are the concept that can help the organization to continuously improve productivity and service quality (Drohomeretski et al., 2014).
Six Sigma promote concept of attributes of the most importance to the customer (critical to quality), failing to deliver what the customer wants (defect), what the process can deliver (process capability), what the customer sees and feels (variation), ensuring consistent, predictable processes to improve what the customer sees and feels (stable operations), designing to meet customer needs and process capability (design for six sigma) (Stern, 2019).Six Sigma has gained important attention in the academic and business field due to its financial impact and levels of customer satisfaction (Stern, 2019;Swink & Jacobs 2012).
Lean Manufacturing is a production practice that concentrates on the elimination of waste.TQM capitalizes on the involvement of management, workforce, suppliers and even customers, to meet or exceed customer expectations.Originally, Lean identified the following as the worst forms of waste: transportation, inventory, movement, waiting, over production, over processing, defects, and skill (Stern, 2019).
According to the report of Deloitte Indonesia Business and Industry Updates (2020), the biggest challenge for health care industry in Indonesia are the shortage of manpower and health care facilities.In other words, to face this challenge the health care industry should add more manpower, facilities, and improve the operational process to be more effective and efficient, and Lean Six Sigma is a method that can help the organization to achieve that objective.
Lean Six Sigma have been implemented in many organization (Aqlan & Al-fandi, 2018;D'Andreamatteo, et al., 2015;Grima et al., 2013;Kumar, Antony, & Tiwari, 2011).They have been used to effectively improve organizations' performance (Drohomeretski et al., 2014).However, according to Peimbert-Garc´ıa (2019) there are very few studies for Lean and Six Sigma in health care, and the healthcare industry is not well-versed in the long-term advantages of the Lean Six Sigma strategy, particularly in developing countries (Rathi et al., 2021).Hence, the systematic review was conducted to investigate the effectiveness of Lean Six Sigma implementation within the field of health care facilities.

RESEARCH METHOD
A systematic review was performed in accordance with current best practices through close adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (Liberati, et al., 2009) as show in figure 1 below.

Figure 1
Selection of studies for inclusion in the systematic review.

RESULT
Paper that included in the table are those that have at least have one outcome measure relating to cost effective, service quality, optimization or time save by health professionals or patients.However, there were two studies that related to implementation of Lean Six Sigma in health-care facilities was excluded because the focus was preparation of implementation and the other paper was measure the patient satisfactory.
The following table shows that Lean Six Sigma has given many benefits both for the organization and the patient.This study was found that Lean Six Sigma is effective to be implemented in the health-care facility, it significantly contributes to the performance in many health-care facilities, for cost-effective with the implementation of lean six sigma hospital were able to reduce the consumption of plasminogen by 69%.For the optimization in audiology, block utilization was an increase by 13%-28%, book appointments increase by 24-276%.Time saving was increased by 17% to 21%.Service quality in the blood collection process was increased by 55%.For patient, the implementation of Lean Six Sigma was giving a positive impact, the discharge process become faster compare to processing time before the implementation.Time discharge in the morning schedule was increased by 21.3 points and for the noon time increased by 7.5 points.
There is evidence from a study shows that the implementation of Lean Six Sigma in the hospital was helped the organization being mature.The other evidence also shows that there is significant improvement in turn-time, physician downtime, on-time patient arrival, on-time physician arrival, on-time start as well as sheath-pulls inside the Cath Lab.The implementation of Lean Six Sigma in the Children Operating Room over a 6-month period was help the health professional to demonstrate that a coordinated multidisciplinary process improvement redesign that can significantly improve efficiency in an academic Children's Hospital without preselecting specific services and removing surgical residents or incorporating new personnel or technology.Copyright @2023, UNKLAB Business School | ISSN: 2721-690X, E-ISSN: 2722-726X

DISCUSSION
Lean Six Sigma is a good methodology to implement in many organizations, however the preparation should be done prior to the establishment of the methodology.According to Fong et al., (2016) approaches to improving intraoperative efficiency can occur on many levels based, however, the level of resources and institutional support are required.Implementation of Lean Six Sigma principles to enhance performance in a health-care environment requires a preassessment of the organization's competences (Al Khamisi et al., 2018).Resistance to change can be exist in all level of organization when improvement is implemented (Stern, 2019).Hence, involving all stakeholders in value stream mapping is essential (Huddle et al., 2016).In addition, Fong, et al (2016) says data transparency and communication are critical to improvements.
Lean Six Sigma is an inexpensive methodology to implement but significantly increase the productivity and efficiency in the heath-care facilities.The successful implementation was able to reduce waste, increasing the quality of service, and reduce process variability that led to patient satisfaction and cost efficiency.If the health care facilities are implementing Lean Six Sigma, the process will be efficient and effective, which can help the organization to run the operation with a limited manpower and enable the organization to use the facilities more effective and efficient.Effective and efficient operation or process in the health care facilities will result to the higher number of patients that can be serve during this pandemic Covid-19.Copyright @2023, UNKLAB Business School | ISSN: 2721-690X, E-ISSN: 2722-726X To improve health care processes over time. Interview.

members
• The counterintuitive finding of this exercise is that the lead time decreases significantly, • More planes are completed despite the fact that everyone feels that their work is easier.Steere, Rousseau & Durland, (2018).
To identifying opportunities for improvement that influence efficiency while saving money.literature review 26-month study.October 2014 to December 2016.

•
Over the course of the 26-month study,

•
Hospital experienced a 69% total reduction in tissue plasminogen activator use representing a total 26-month savings of $107,315.
To improve efficiency in the operating room. Review.

Studies
• Approaches to improving intraoperative efficiency can occur on many levels based on the required level of resources and institutional support.Tagge, Thirumoorthi, Lenart & Mitchell, (2017).
To improve performance by systematically identifying root causes of problems.

Interview.
Six hundred twelve cases were included in the seven Children's Hospital operating rooms (OR) over a 6-month period.

•
These results demonstrate that a coordinated multidisciplinary process improvement redesign can significantly improve efficiency in an academic Children's Hospital without preselecting specific services,
To Improve the timeliness of patient discharge.ANOVA.

627-bed.
• Time saving in morning patient discharge increased by 21.3 points,
To improve preanalytical workflow and blood collection processes-both negatively affected by hemolyzed specimens. Interview.
819-bed.The ECC is a medium-sized facility of 60 beds with a mean of 90,000 patient visits each year.Approximately 80% of ECC patients require one or more laboratory tests.To assess the use of Lean Six Sigma methodology to improve the turnaround time (TAT) for inpatient peripherally inserted central catheter (PICC) placement.
The TAT for PICC line placement was recorded for the 6 months prior to implementation of changes, and subsequently, at the 6-month and 2-year follow-up points.
To verify how Lean Six Sigma (LSS) could influence the organizational sustainability through their projects. Qualitative.
520 LSS certified experts and invited to participate.
• Reduce waste, defect rate, increasing the quality of service, and reduce process variability.
Statistical analysis and data correlation.
14,931 consecutive shifts from 1342 patients were analyzed.
• Only 0.8% of patients presented median shifts >1 cm.The major observed discrepancy was the monthly percentage of fractions with almost zero shifts (AZS = 13.2% ± 6.1%).: LSSM was implemented in a RT department, allowing to redesign the breast repositioning matching procedure.
To improve the operational efficiency of our catheterization laboratory (Cath Lab).
Cleveland Clinic Institutional Review Board. All

Table 1
Lean Six Sigma Implementation in Health-care Facilities