Six Sigma in healthcare: a systematic review of the literature

Reducing Emergency Department Hold Hours: A Hospital-wide Effort

ABSTRACT

Patient throughput issues are of significant concern for U.S. hospitals and have serious implications for patient care quality and safety as well as hospital finances. In 2021, leaders of a community hospital commissioned a quality improvement team to address a bottleneck of patients in the emergency department (ED). The bottleneck was causing significant increases in the number of hours patients were held in the ED because of a lack of available inpatient beds. The team used the DMAIC improvement framework to analyze patient flow challenges across the hospital, design an evidence-based set of interventions, and measure improvements. Analysis revealed problems with communication breakdowns and workflow silos, discharge predictability, readiness of patients for discharge, timeliness of discharges, and lack of standardization in patient hand-offs and documentation processes. Addressing these issues resulted in patient throughput improvements including a reduction of greater than 75% in monthly ED hold hours after implementation.

Using QI to develop a sustainable method for titrating taxane infusions to reduce hypersensitivity reactions

OBJECTIVE

To develop a sustainable three-step method for titrating first and second taxane exposures through integration of best practices in patient and environmental safety; and to evaluate the impact on immediate hypersensitivity rates.

METHODS

A quality improvement study was initiated at a large, NCI-designated comprehensive cancer center in the U.S. to determine a sustainable method of slow, upward titration for reducing taxane-related hypersensitivity reactions. Multidisciplinary collaboration led to the incorporation of best practices for safe preparation and administration of high risk, hazardous drugs. Retrospective data from the electronic health records of 690 patients who received 1221 taxane doses were analyzed. Non-titrated infusions were compared with infusions titrated using a method initially tested for efficacy; and infusions titrated using a method revised for greater compliance with safety standards. Two-sided Fisher's exact tests at a 0.1 level of significance were used to detect differences in the rate of HSR between the three groups.

RESULTS

A method of taxane titration that incorporated standardized, preprogrammed infusion rates and tubing primed with inert IV fluid showed a significant reduction in HSR incidence in comparison to non-titrated infusions (6% v. 19%, P = 0.001) and a similar decrease in the rate of HSR (6%) to the initial method previously studied (7%) (P = 0.659) which was not sustainable due to patient and environmental safety concerns.

CONCLUSIONS

A three-step titration method using standardized, preprogrammed infusion rates and tubing primed with inert IV fluid reduced taxane-related HSRs and was adopted as sustainable practice in ambulatory cancer care.

A cross-organizational Lean deployment in an Italian regional healthcare system

PURPOSE

This study explores how Lean was deployed in several hospitals in the Apulia region in Italy over 3.5 years.

DESIGN/METHODOLOGY/APPROACH

An exploratory qualitative design was drawn up based on semi-structured interviews.

FINDINGS

The drivers of Lean in hospitals were to increase patient satisfaction and improve workplace well-being by eliminating non-value-add waste. The participants highlighted three key elements of the pivotal implementation stages of Lean: introduction, spontaneous and informal dissemination and strategic level implementation and highlighted critical success and failure factors that emerged for each of these stages. During the introduction, training and coaching from an external consultant were among the most impactful factors in the success of pilot projects, while time constraints and the adoption of process analysis tools were the main barriers to implementation. The experiences of the Lean teams strongly influence the process of spontaneous dissemination aided by the celebration of project results and the commitment of the departmental hospital heads.

PRACTICAL IMPLICATIONS

Lean culture can spread to allow many projects be conducted spontaneously, but the Lean paradigm can struggle to be adopted strategically. Lean in healthcare can fail because of the lack of alignment of Lean with leadership in healthcare and with their strategic vision, a lack of employees' project management skills and crucially the absence of a Lean steering committee.

ORIGINALITY/VALUE

The absence of managerial expertise and a will to support Lean implementation do not allow for systemic adoption of Lean. This is one of the first and largest long-term case studies on a Lean cross-regional multi-hospital application in healthcare.

Quality analysis of the clinical laboratory literature and its effectiveness on clinical quality improvement: a systematic review

Quality improvement in clinical laboratories is crucial to ensure accurate and reliable test results. With increasing awareness of the potential adverse effects of errors in laboratory practice on patient outcomes, the need for continual improvement of laboratory services cannot be overemphasized. A literature search was conducted on PubMed and a web of science core collection between October and February 2021 to evaluate the scientific literature quality of clinical laboratory quality improvement; only peer-reviewed articles written in English that met quality improvement criteria were included. A structured template was used to extract data, and the papers were rated on a scale of 0-16 using the Quality Improvement Minimum Quality Criteria Set (QI-MQCS). Out of 776 studies, 726 were evaluated for clinical laboratory literature quality analysis. Studies were analyzed according to the quality improvement and control methods and interventions, such as training, education, task force, and observation. Results showed that the average score of QI-MQCS for quality improvement papers from 1981-2000 was 2.5, while from 2001-2020, it was 6.8, indicating continuous high-quality improvement in the clinical laboratory sector. However, there is still room to establish a proper system to judge the quality of clinical laboratory literature and improve accreditation programs within the sector.

A Three-Step Taxane Titration Protocol Decreases Hypersensitivity Reactions During First and Second Exposures

INTRODUCTION

Patients receiving taxanes are at risk for developing hypersensitivity reactions (HSRs) primarily during first and second lifetime exposures. Immediate HSRs require emergency care and can interfere with the continuation of preferred treatment. Although different approaches to slow titration have been used successfully for desensitization after HSR occurrence, there are no standardized recommendations for taxane titration to prevent HSRs.

PURPOSE

To determine if a gradual, three-step infusion rate titration decreases the rate and severity of immediate HSRs during first and second lifetime exposures to paclitaxel and docetaxel.

METHODS

We used a prospective, interventional design with historical comparisons to evaluate a sample of 222 first and second lifetime exposure paclitaxel and docetaxel infusions. The intervention was a three-step infusion rate titration provided at the initiation of first and second lifetime exposures. Ninety-nine titrated infusions were compared with 123 historical records of nontitrated infusions.

RESULTS

Compared with the nontitrated group (n = 123), the titrated group (n = 99) had significantly less HSRs (19% v 7%; P = .017). No significant difference in HSR severity was found between groups (P = 1.00). However, four nontitrated patients received epinephrine, and one required transfer to the emergency department (ED) because of reaction severity. In contrast, no titrated patients received epinephrine or required transfer to the ED. In the nontitrated group, seven patients did not complete their infusions versus one patient in the titrated group.

CONCLUSION

A standardized, three-step infusion rate titration prevented HSR occurrence. Significant issues affecting practice feasibility and sustainability were addressed.

The integration of lean and human resource management practices as an enabler for lean deployment –a systematic literature review

Purpose

The current research aims to map and investigate how human resource management and lean practices can be integrated. This investigation will help identify the HRM aspects critical in the success of lean initiatives while exploring the research gaps in the existing literature. The review also aims to delineate the benefits and challenges of integrating lean with HRM systems to discuss further research and practice areas.

Design/methodology/approach

This study utilizes a systematic literature review method to identify and synthesize the existing literature. As part of the process, a protocol that provided a plan for the review was followed, including the research questions and the data to be extracted.

Findings

The study results indicate that aspects of HRM practice and policies such as training and development, teamwork, motivation, communication, leadership, are key enablers of lean initiative deployment and success. The benefits of the integration of human resources with lean can help in lean training and development, communication of lean initiatives and successes, allocating and hiring continuous improvement personnel, and supporting leadership in lean deployment. Challenges to integrating lean and HRM practices included lack of integration and collaboration between disciplines. Further exploration areas in successful lean deployment would be practical longitudinal case studies on lean deployments with human resource (HR) partnerships and involvement.

Practical implications

This review paper has crucial implications for practice relating to, integration of lean with HRM structures and tailoring HRM initiatives to ensure the success of lean deployment and reduce risks of failure.

Originality/value

The systematic literature review study conducted in this paper is the first of its kind to integrate and map the HRM concepts that can be integrated with Lean to deploy the initiative successfully. This mapping is critical for ensuring the success of lean methodologies within an organization and paves the way for future research. In addition, managers and organizations can find support and guidance from this study to focus on vital areas of partnership between their lean and HR programs.

Lean Six Sigma to reduce the acute myocardial infarction mortality rate: a single center study

Purpose

Cardiovascular diseases are the leading cause of death worldwide. In Italy, acute myocardial infarction (AMI) is a major cause of hospitalization and healthcare costs. AMI is a myocardial necrosis event caused by an unstable ischemic syndrome. The Italian government has defined an indicator called “AMI: 30-day mortality” to assess the quality of the overall care pathway of the heart attacked patient. In order to guarantee high standards, all hospitals had to implement techniques to increase the quality of care pathway. The aim of the paper is to identify the root cause and understand the mortality rate for AMI and redesign the patient management process in order to improve it.

Design/methodology/approach

A Lean Six Sigma (LSS) approach was used in this study to analyze the patient flow in order to reduce 30-days mortality rate from AMI registered by Complex Operative Unit (COU) of Cardiology of an Italian hospital. Value stream mapping (VSM) and Ishikawa diagrams were implemented as tools of analysis.

Findings

Process improvement using LSS methodology made it possible to reduce the overall times from 115 minutes to 75 minutes, with a reduction of 35%. In addition, the corrective actions such as the activation of a post-discharge outpatient clinic and telephone contacts allowed the 30-day mortality rate to be lowered from 16% before the project to 8% after the project. In this way, the limit value set by the Italian government was reached.

Research limitations/implications

The limitation of the study is that it is single-centered and was applied to a facility with a limited number of cases.

Practical implications

The LSS approach has brought significant benefits to the process of managing patients with AMI. Corrective actions such as the activation of an effective shared protocol or telephone interview with checklist can become the gold standard in reducing mortality. The limitation of the study is that it is single-centered and was applied to a facility with a limited number of cases.

Originality/value

LSS, applied for the first time to the management of cardiovascular diseases in Italy, is a methodology which has proved to be strategic for the improvement of healthcare process. The simple solutions implemented could serve as a guide for other hospitals to pursue the national AMI mortality target.

A bibliometric analysis of IJQRM journal (2002–2022)

Purpose

The purpose of this study is to explore the trends in publications made to International Journal of Quality and Reliability Management (IJQRM) for time period ranging from 2002–2022. In this study authors performed bibliometric analysis on the publications extracted from Scopus database using citations, authors, keywords and bibliographic coupling methods. The analysis helped authors highlighting the achievements of the journal towards the development of field of “quality” and “reliability” management and explore future avenues to be researched upon in the domain.

Design/methodology/approach

In this paper outputs derived through VoS viewer and bibliographic data of Scopus were used to examine various tabular and pictorial aspects of the authors, sources, documents, countries and keywords analysis.

Findings

The analysis results revealed that International Journal of Quality and Reliability Management (IJQRM) has got incredible 33,344 citations since 2002 with average citation count per document at 22.69. Sohal A.S. from Monash University, Australia has topped the list of most influential authors in terms of citations per document (107.20 citations/doc) published with IJQRM. However, Antony J. with massive 39 publications in total with 2074 citations is the most prominent contributor for the journal. The author has gained 6% of the total journal citations. The contributions from India, United Kingdom (UK), United States of America (USA), Iran, Australia, Portugal, Brazil, Spain, Sweden, Malaysia and Saudi Arabia are more noteworthy.

Research limitations/implications

The study has implications for future researchers and journal editorial team to explore possibilities in tapping various uncovered and upcoming research areas related to the scope of journal. The findings of the study may prompt research initiatives linked to diverse fields in sync with changes happening across globe such as: Artificial Intelligence, Robotics, Data Science etc.

Originality/value

The study is an attempt to investigate the long standing heritage offered by IJQRM to the world of quality and reliability management. The authors tried to unearth some hidden facts about the IJQRM and attempted to showcase the past and explore future directions to the researchers and editorial team.

A balanced approach involving hard and soft factors for internalizing Lean Management and Six Sigma in hospitals

Purpose

This study examines the theoretical and empirical relationships between LM&SS, human resource management (HRM), climate for LM&SS and outcomes (employee well-being and performance) in hospitals. As part of this research, the authors examine the interplay between “hard” and “soft” practices for LM&SS and “soft” HR practices.

Design/methodology/approach

A cross-sectional, multisite survey study covering all internal service units at all eight Dutch university hospitals was conducted (42 units, N = 218 supervisors, N = 1,668 employees), and multivariate multilevel regression analyses were performed.

Findings

A systems approach involving “soft” LM&SS practices that are specifically HR-related has a positive effect (β is 0.46) on a climate for LM&SS. A climate for LM&SS is not related to perceived performance or employee health. It is, however, positively related to employee happiness and trusting relationships (both βs are 0.33). We did not find that a climate for LM&SS had a mediating effect.

Research limitations/implications

This study shows that a balanced approach involving both “hard” and “soft” factors is crucial to achieving the desired breadth and depth of LM&SS adoption at the macro, meso, and micro levels. The authors found that a climate for LM&SS positively affects employee well-being in hospitals.

Practical implications

In their attempt to create mutual gains for both their organization and their employees, hospitals that adopt LM&SS should foster a climate for LM&SS by embracing a balanced approach consisting of both “hard” and “soft” practices, thereby internalizing LM&SS at the macro, meso, and micro levels.

Originality/value

This is one of the first studies to examine in-depth the impact of “hard” and “soft” LM&SS on both employee well-being (subdivided into different components) and performance in healthcare, as well as the role of “soft” HRM in this relationship. Linking LM&SS, HRM and outcomes to a climate for LM&SS is relatively a new approach and has led to a deeper understanding of the mechanisms underpinning the internalization of LM&SS in healthcare.

Lean Six Sigma in Healthcare: A Systematic Literature Review on Challenges, Organisational Readiness and Critical Success Factors

Lean Six Sigma (LSS) has been applied in many healthcare organisations, but there has been limited research on the evolution of LSS application in healthcare. This paper aims to present the challenges, critical success factors (CSFs), readiness factors and most common tools and techniques used for LSS deployment in healthcare. A systematic literature review (SLR) was utilised to research the study objectives. Peer-reviewed literature over a 16-year period was studied to understand the deliverables of LSS. The SLR process identified relevant articles and screened a final selection for those under study. The systematic literature review helped the authors to identify the challenges and tools/techniques used for LSS in healthcare. Several CSFs and readiness factors for LSS deployment in healthcare are also presented. This work informs healthcare managers and professionals on the important factors for successful LSS deployment before embarking on the LSS journey. In addition, this work is a valuable resource for healthcare LSS practitioners and academic researchers to learn about, investigate and deploy LSS in the healthcare sector. This study is one of the most comprehensive SLRs covering the importance and specificity of understanding challenges, CSFs and organisational readiness for LSS in healthcare. This study provides knowledge of the successful deployment of LSS in healthcare.

Lean Six Sigma in Healthcare: A Systematic Literature Review on Motivations and Benefits

While Lean Six Sigma (LSS) has been applied extensively in healthcare organisations, there has been limited research on the trends of LSS application in healthcare in recent years. This paper aims to present the key motivations and benefits of LSS in healthcare with a view to highlighting the types of problems that LSS in healthcare can aid in solving. The authors used a systematic literature review (SLR) approach to achieving the article’s purpose. Peer-reviewed journal articles published between 2011 and 2021 are considered to achieve the study objectives. The systematic review helped the authors to identify the evolution, benefits, and motivations for LSS in healthcare. This work includes directions for managers and healthcare professionals in healthcare organisations to embark on a focused LSS journey aligned with the strategic objectives. This study is perhaps one of the most comprehensive SLRs covering a vital agenda of LSS in healthcare. This study provides all the deliverables of LSS for its successful deployment in healthcare.

Multi-objective programming and Six Sigma approaches for a competitive pharmaceutical supply chain with the value chain and product lifecycle

This study examines two pharmaceutical supply chains (PSCs) under the product life cycle and marketing strategies for the first time. Nash equilibrium between PSCs is based on marketing mix factors (i.e., price, the value provided by the value chain, availability, and promotion) at different periods of product life (i.e., introduction, growth, and maturity). Considering the previous step's outputs, environmental protection, and sustainable development, this study provides a multi-objective mixed-integer nonlinear programming model (MOMINLP) for the design of PSCs to minimize environmental pollution and maximize profit, consumer health level, and brand equity. At this stage of the network design, disruption issues in the manufacturer, distributor, and retailer are considered. Based on the value from the value chain in different periods of product life, different scenarios are considered. Optimizing the supply chain network design (SCND) under uncertainty through the reliability and Six Sigma concepts is examined. The proposed approach is validated with a real-case study in Iran. The results show that the brand equity, pollution created, and supply chain profits decrease with increasing optimization levels. However, the level of consumer health rises with increasing levels of optimization. Based on the obtained results, the total profit of the two supply chains at the optimization level 3σ is 3.6% more than the profit at the optimization level 6σ. The total environmental pollution of the two supply chains at the optimization level 3σ is 1.9% less than the environmental pollution at the optimization level 1.285σ. The total consumer health level of the two supply chains at the optimization level 3σ is 3.3% more than the consumer health level at the optimization level 1.285σ. The total brand equity of the two supply chains at the optimization level 3σ is 2.5% more than the brand equity at the optimization level 6σ. It seems that the optimization level 3σ for the two pharmaceutical supply chains is more appropriate than the other optimization levels.

The evolution and future of lean Six Sigma 4.0

Purpose

This purpose of this study is to provide an overview of the current state of research on Lean Six Sigma (LSS) and Industry 4.0 and the key aspects of the relationships between them. The research analyses LSS's evolution and discusses the future role of LSS 4.0 in an increasingly digitalized world. We present the benefits and motivations of integrating LSS and Industry 4.0 as well as the critical success factors and challenges within this emerging area of research.

Design/methodology/approach

A systematic literature review methodology was established to identify, select and evaluate published research.

Findings

There is a synergistic nature between LSS and Industry 4.0. Companies having a strong LSS culture can ease the transition to Industry 4.0 while Industry 4.0 technologies can provide superior performance for companies who are using LSS methodology.

Research limitations/implications

One limitation of this research was that as this area is a nascent area, the researchers were limited in their literature review and research. A more comprehensive longitudinal study would yield more data. There is an opportunity for further study and analysis.

Practical implications

This study reviews the evolution of LSS and its integration with Industry 4.0. Organisations can use this study to understand the benefits and motivating factors for integrating LSS and Industry 4.0, the Critical Success Factors and challenges to such integration.

Originality/value

This is the first systematic literature review on LSS 4.0 and can provide insight for practitioners, organisations and future research directions.

Diffusion of a Lifelog-Based Digital Healthcare Platform for Future Precision Medicine: Data Provision and Verification Study

We propose a method for data provision, validation, and service expansion for the spread of a lifelog-based digital healthcare platform. The platform is an operational cloud-based platform, implemented in 2020, that has launched a tool that can validate and de-identify personal information in a data acquisition system dedicated to a center. The data acquired by the platform can be processed into products of statistical analysis and artificial intelligence (AI)-based deep learning modules. Application programming interfaces (APIs) have been developed to open data and can be linked in a programmatic manner. As a standardized policy, a series of procedures were performed from data collection to external sharing. The proposed platform collected 321.42 GB of data for 146 types of data. The reliability and consistency of the data were evaluated by an information system audit institution, with a defects ratio of approximately 0.03%. We presented definitions and examples of APIs developed in 17 functional units for data opening. In addition, the suitability of the de-identification tool was confirmed by evaluating the reduced risk of re-identification using quasi-identifiers. We presented specific methods for data verification, personal information de-identification, and service provision to ensure the sustainability of future digital healthcare platforms for precision medicine. The platform can contribute to the diffusion of the platform by linking data with external organizations and research environments in safe zones based on data reliability.

Smart City E-Governance Through Intelligent ICT Framework

The concept of Smart Cities was developed during the first decade of 21st century and the govt. of India has started the smart city mission since June, 2015. Smart city e-governance is an integral part of this paper and the deliverables are quite helpful for citizen centric services. The ‘smartness’ of a city is linked to the provision of city centric services, high quality of life and the proper utilization of available resources in tandem with the government, which helps through investments in citizens, transport and modern communication infrastructure (ICT) for sustainable economic development. This article aims at explaining the Smart City project design architecture, describing how city data is collected, transmitted, stored and processed using smart IoT devices, Machine Learning (ML) and Deep Learning (DL) techniques.

Modeling critical success factors for sustainable LSS implementation in hospitals: an empirical study

Purpose

The objective of this paper is to investigate, assess and develop a hierarchical model to evaluate the interrelationship of critical success factors (CSFs) that influence the deployment of Sustainable LSS framework in hospitals. Further, developed model has been validated to investigate its applicability in hospitals towards sustainable LSS implementation.

Design/methodology/approach

“Interpretive Structural Modeling” (ISM) has been utilized to develop a convenient hierarchy and contextual relationship of key CSFs throughout the implementation pathway in Indian healthcare industry through systematic literature review and expert opinion, which is ensured by a taxonomy of CSFs using MICMAC (“Matrice d' Impacts Croisés-Multiplication Appliquée á un Classement”) and questionnaire-based survey to empirically validate the model through utilizing “Structural Equation Modelling” (SEM).

Findings

In this study, 17 keys CSFs to sustainable LSS implementation in healthcare industry have been investigated, and modeled. “Social and environmental responsibility,” “Financial return and project success stories,” “Top management involvement and leadership to implement Sustainable LSS,” “Availability of required resources, and their efficient utilization” are found to be the most essential CSFs for successful sustainable LSS implementation in healthcare industry. Further, classification of CSFs has been done for better interpretation of their nature using MICMAC approach. Moreover, the applicability of the proposed model has been empirically assessed utilizing SEM.

Research limitations/implications

The scrutiny of data reveals that the initial inputs from experts throughout the ISM pathway could trigger biased inputs into the study and generalization of the results into others, it might be viable that this propounded model might trigger distinct outcomes for contrasting types of healthcare organizations.

Practical implications

This model on sustainable LSS would support the decision-makers, practitioners and researchers to predict key CSFs through deployment and support the existing academic research on sustainable LSS. Accordingly, the focus on the CSFs of the sustainable LSS can be prioritized to diminish waste, and enhance patient satisfaction and safety.

Originality/value

This paper is an original contribution of analysis of CSFs in Indian healthcare industry utilizing an integrated ISM-MICMAC and SEM approach.

Prioritization of critical success factors for sustainable Lean Six Sigma implementation in Indian healthcare organizations using best-worst-method

Purpose

Recent years have seen an increased demand for healthcare services, presenting a need to improve service quality through the deployment of sustainable Lean Six Sigma (LSS). This study aims to identify critical success factors (CSFs) of sustainable LSS and prioritize them based on their intensity of importance for the effective implementation of sustainable LSS in the healthcare environment.

Design/methodology/approach

The present study identified 33 leading CSFs through a comprehensive literature review and expert experience and classified them into six major categories based on organizational functions. The primacy of these CSFs is established using the best-worst-method (BWM) approach. The significant advantage of this approach is that the decision-maker identifies both the best and worst criteria among alternatives prior to pairwise comparisons, leading to fewer pairwise comparisons and saving time, energy and resources. It also provides more reliable and consistent rankings.

Findings

The findings of the present study highlight the economic and managerial (E&M) CSFs as the most significant CSFs among the major category criteria of sustainable LSS-CSFs, followed by organizational (O), knowledge and learning (K&L), technological (T), social and environmental (S&E), and external factors (EF). Similarly, management involvement and leadership to implement sustainable LSS (E&M1), structured LSS deployment training and education (K&L2), and availability of required resources and their efficient utilization (O2) are ranked as the topmost CSFs among sub-category criteria of sustainable LSS-CSFs.

Practical implications

The prioritization of sustainable LSS-CSFs determined in this study can provide healthcare managers, researchers and decision-makers with a better understanding of the influence on effective deployment of sustainable LSS, resulting in improved service quality in hospitals.

Originality/value

This paper is an original contribution to the analysis of CSFs in an Indian healthcare institute, utilizing the BMW method for ranking the sustainable LSS-CSFs. The advantage of utilizing and distinguishing the performance of this approach compared to other MCDA approaches in terms of (1) least pairwise comparison and violation, (2) consistency (3) slightest deviation and (4) conformity.

Application of Six Sigma methodology to enhance the productivity and performance of a hotel in the UAE

Purpose

The hotel industry is one of the primary sectors contributing to every country's economy by promoting and reinforcing tourism. The pandemic situation across the globe is forcing the hospitality industry to adopt a suitable operational excellence (OPEX) methodology and its associated tools to deliver quality service at an affordable cost. However, there is limited evidence of applying one of the prominent OPEX methodologies, such as Six Sigma (SS), to enhance the hospitality industry's productivity and performance. Thus, the purpose of the study is to explore the application of the SS methodology to reduce the cycle time of a pantry workstation in a United Arab Emirates (UAE) hotel sector.

Design/methodology/approach

The research adopted a case study approach using DMAIC (define-measure-analyse-improve-control) phases to improve the performance of the minibar updating process attached to the hotel rooms. In addition, the study effectively used several tools, including normality tests, control charts, capability analysis, cause and effect diagram, failure mode effects analysis (FMEA), value stream mapping (VSM) and GEMBA, to validate the root causes and draw robust inferences.

Findings

The average cycle time and standard deviation of the pantry process were drastically reduced. Further, the analysis showed that the process capability index was substantially improved. Consequently, a notable improvement in the process performance was witnessed, which has resulted in a profit of $50,000 per annum in the hotel.

Practical implications

The article provides a structured and disciplined approach of SS in a hotel which can be used as a benchmarking document by the academicians, practitioners and policymakers for OPEX within the hospitality industry. Further, it paves the way to develop a road map for applying SS in the hospitality sector.

Originality/value

As per the authors' knowledge, to date, no case study has been reported in top tier refereed journals regarding the application of SS in the hotel sector. Thus, the current case study bridges this gap and reiterates that SS can be effectively used with meticulous planning and deployment in the hospitality industry.

Hospitalizations for acute gout: process mapping the inpatient journey and identifying predictors of admission

Objective

To identify predictors of admission following emergency attendances for gout flares, and describe barriers to optimal inpatient gout care.

Methods

Emergency department (ED) attendances and hospital admissions with primary diagnoses of gout were analyzed at two UK-based hospitals between 1st January 2017 and 31st December 2020. Demographic and clinical predictors of ED disposition (admission or discharge) and re-attendance for gout flares were identified using logistic regression and survival models, respectively. Case-note reviews (n=59), stakeholder meetings and process mapping were performed to capture detailed information on gout management and identify strategies to optimize care.

Results

Of 1,220 emergency attendances for gout flares, 23.5% required hospitalization (median length of stay: 3.6 days). Recurrent attendances for flares occurred in 10.4% of patients during the study period. In multivariate logistic regression models, significant predictors of admission from ED were older age, overnight ED arrival time, higher serum urate, higher CRP and higher total white cell count at presentation. Detailed case-note reviews showed that only 22.6% of patients with pre-existing gout were receiving urate-lowering therapy (ULT) at presentation. Initial diagnostic uncertainty was common, yet rheumatology input and synovial aspirates were rarely obtained. By six months post-discharge, 43.6% were receiving ULT; however, few patients had treat-to-target dose optimization, and only 9.1% achieved a urate ≤360 micromol/L.

Conclusion

We identified multiple predictors of hospitalization for acute gout. Prescription of ULT and treat-to-target optimization following hospitalization remain inadequate, and must be improved if admissions are to be prevented.

Strategies for successful deployment and sustainment of Lean Six Sigma in healthcare sector in India: a multi-level perspective

Purpose

This study aims to present Lean Six Sigma (LSS) deployment and sustainment strategies for the healthcare sector from a multi-level perspective. The objective is to present LSS implementation insights to enable policymakers, practitioners and academicians to test and develop an LSS framework for healthcare sectors.

Design/methodology/approach

The strategies identified are the result of a multi-method research design involving literature review, action research (AR) and Delphi study. Further, the AR portion of the study involved more than 10 years of projects focused on the deployment of LSS in the healthcare sector.

Findings

The strategies include a holistic view from the multi-level perspective, considering the Top Management Level, Middle Management Level and Operational Level. The authors ascertained 27 strategies across the three levels of organizational structure for the effective deployment of LSS. Further, the authors present a customized LSS “pocket guide” from the healthcare perspective for quick reference.

Research limitations/implications

The strategies delineated in this study are based on the Indian healthcare section only; thus, further research in additional geographic contexts is needed. Also, further research is necessary to provide additional empirical validation of the effects of the identified strategies on LSS program outcomes and to verify that the strategies operate at the proposed organizational levels. Future research should also focus on identifying the interrelationships between strategies within and across levels, developing a “road map” for LSS implementation in hospitals and designing the LSS curriculum for medical schools and other medical training programs.

Practical implications

Observations of this study can contribute to developing a holistic framework for successful LSS implementation in the healthcare sector for academicians, practitioners and policymakers. This, in turn, ensures an enhanced value proposition, improved quality of life and reduced healthcare operational costs. Thus, it ensures a win-win situation among all the stakeholders of the healthcare sector.

Originality/value

The strategies put forth will enable the LSS researchers, academicians and, more particularly, practitioners to delve deeper into specific enablers and safeguard the LSS deployment from backlash. The research has two significant benefits. Firstly, it enhances the understanding of LSS from the healthcare perspective. Secondly, it provides direction for future studies with specific components for hospitals’ LSS framework, which can be further tested, refined and improved.

Lean six sigma in the healthcare sector: A systematic literature review

Healthcare is a very important sector as our lives depend on it. During the novel corona virus pandemic, it was evident that our healthcare organizations still lack in terms of efficiency and productivity. Especially in the developing nations, the problems were much bigger. Lean Six Sigma (LSS) is a methodology which when implemented in an organization, helps to increase the process capability and the efficiency, by reducing the defects and wastes. The present study systematically reviews the research studies conducted on LSS in the healthcare sector. It was found that comparatively less studies are focused on improving the medical processes, most of the studies targeted the management processes. Moreover, lesser number of studies were being conducted for developing nations, but now it seems that the focus of research scholars has shifted towards the developing nations also. But it was observed that the studies in these nations were majorly empirical in nature, very few studies were conceptual or exploratory. There is a need for guiding healthcare professionals on creating a continuous improvement environment, which sustains the improvements achieved after LSS implementation.

Operation Note Transformation: The Application of Lean Six Sigma to Improve the Process of Documenting the Operation Note in a Private Hospital Setting

Clinical documentation is a key safety and quality risk, particularly at transitions of care where there is a higher risk of information being miscommunicated or lost. A surgical operation note (ON) is an essential medicolegal document to ensure continuity of patient care between the surgical operating team and other colleagues, which should be completed immediately following surgery. Incomplete operating surgeon documentation of the ON, in a legible and timely manner, impacts the quality of information available to nurses to deliver post-operative care. In the project site, a private hospital in Dublin, Ireland, the accuracy of completion of the ON across all surgical specialties was 20%. This project sought to improve the accuracy, legibility, and completeness of the ON in the Operating Room. A multidisciplinary team of staff utilised the Lean Six Sigma (LSS) methodology, specifically the Define/Measure/Analyse/Design/Verify (DMADV) framework, to design a new digital process application for documenting the ON. Post-introduction of the new design, 100% of the ONs were completed digitally with a corresponding cost saving of EUR 10,000 annually. The time to complete the ON was reduced by 30% due to the designed digital platform and mandatory fields, ensuring 100% of the document is legible. As a result, this project significantly improved the quality and timely production of the ON within a digital solution. The success of the newly designed ON process demonstrates the effectiveness of the DMADV in establishing a co-designed, value-adding process for post-operative surgical notes.

Managing the resource allocation for the COVID-19 pandemic in healthcare institutions: a pluralistic perspective

Purpose

As COVID-19 outbreak has created a global crisis, treating patients with minimum resources and traditional methods has become a hectic task. In this technological era, the rapid growth of coronavirus has affected the countries in lightspeed manner. Therefore, the present study proposes a model to analyse the resource allocation for the COVID-19 pandemic from a pluralistic perspective.

Design/methodology/approach

The present study has combined data analytics with the K-mean clustering and probability queueing theory (PQT) and analysed the evolution of COVID-19 all over the world from the data obtained from public repositories. By using K-mean clustering, partitioning of patients’ records along with their status of hospitalization can be mapped and clustered. After K-mean analysis, cluster functions are trained and modelled along with eigen vectors and eigen functions.

Findings

After successful iterative training, the model is programmed using R functions and given as input to Bayesian filter for predictive model analysis. Through the proposed model, disposal rate; PPE (personal protective equipment) utilization and recycle rate for different countries were calculated.

Research limitations/implications

Using probabilistic queueing theory and clustering, the study was able to predict the resource allocation for patients. Also, the study has tried to model the failure quotient ratio upon unsuccessful delivery rate in crisis condition.

Practical implications

The study has gathered epidemiological and clinical data from various government websites and research laboratories. Using these data, the study has identified the COVID-19 impact in various countries. Further, effective decision-making for resource allocation in pluralistic setting has being evaluated for the practitioner's reference.

Originality/value

Further, the proposed model is a two-stage approach for vulnerability mapping in a pandemic situation in a healthcare setting for resource allocation and utilization.

Critical parameters influencing the quality of metal castings: a systematic literature review

Purpose

Casting is one of the well-known manufacturing processes to make durable parts of goods and machinery. However, the quality of the casting parts depends on the proper choice of process variables related to properties of the materials used in making a mold and the product itself; hence, variables related to product/process designs are taken into consideration. Understanding casting techniques considering significant process variables is critical to achieving better quality castings and helps to improve the productivity of the casting processes. This study aims to understand the computational models developed for achieving better quality castings using various casting techniques.

Design/methodology/approach

A systematic literature review is conducted in the field of casting considering the period 2000–2020. The keyword co-occurrence network and word cloud from the bibliometric analysis and text mining of the articles reveal that optimization and simulation models are extensively developed for various casting techniques, including sand casting, investment casting, die casting and squeeze casting, to improve quality aspects of the casting's product. This study further investigates the optimization and simulation models and has identified various process variables involved in each casting technique that are significantly affecting the outcomes of the processes in terms of defects, mechanical properties, yield, dimensional accuracy and emissions.

Findings

This study has drawn out the need for developing smart casting environments with data-driven modeling that will enable dynamic fine-tuning of the casting processes and help in achieving desired outcomes in today's competitive markets. This study highlights the possible technology interventions across the metal casting processes, which can further enhance the quality of the metal casting products and productivity of the casting processes, which show the future scope of this field.

Research limitations/implications

This paper investigates the body of literature on the contributions of various researchers in producing high-quality casting parts and performs bibliometric analysis on the articles. However, research articles from high-quality journals are considered for the literature analysis in identifying the critical parameters influencing quality of metal castings.

Originality/value

The systematic literature review reveals the analytical models developed using simulation and optimization techniques and the important quality characteristics of the casting products. Further, the study also explores critical influencing parameters involved in every casting process that significantly affects the quality characteristics of the metal castings.

An evaluation of Lean and Six Sigma methodologies in the national health service

Purpose

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).

Design/methodology/approach

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.

Findings

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.

Originality/value

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.

Application of DMAIC Cycle and Modeling as Tools for Health Technology Assessment in a University Hospital

Background

The Health Technology Assessment (HTA) is used to evaluate health services, manage healthcare processes more efficiently, and compare medical technologies. The aim of this paper is to carry out an HTA study that compares two pharmacological therapies and provides the clinicians with two models to predict the length of hospital stay (LOS) of patients undergoing oral cavity cancer surgery on the bone tissue.

Methods

The six Sigma method was used as a tool of HTA; it is a technique of quality management and process improvement that combines the use of statistics with a five-step procedure: “Define, Measure, Analyze, Improve, Control” referred to in the acronym DMAIC. Subsequently, multiple linear regression has been used to create two models. Two groups of patients were analyzed: 45 were treated with ceftriaxone while 48 were treated with the combination of cefazolin and clindamycin.

Results

A reduction of the overall mean LOS of patients undergoing oral cavity cancer surgery on bone was observed of 40.9% in the group treated with ceftriaxone. Its reduction was observed in all the variables of the ceftriaxone group. The best results are obtained in younger patients (−54.1%) and in patients with low oral hygiene (−52.4%) treated. The regression results showed that the best LOS predictors for cefazolin/clindamycin are ASA score and flap while for ceftriaxone, in addition to these two, oral hygiene and lymphadenectomy are the best predictors. In addition, the adjusted R squared showed that the variables considered explain most of the variance of LOS.

Conclusion

SS methodology, used as an HTA tool, allowed us to understand the performance of the antibiotics and provided variables that mostly influence postoperative LOS. The obtained models can improve the outcome of patients, reducing the postoperative LOS and the relative costs, consequently increasing patient safety, and improving the quality of care provided.

Voice of the customer as a tool for service quality analysis in public transport

Purpose

The purpose of this paper is to explore the voice of the customer (VOC) of public transport (PT) users and non-users and to identify the role VOC plays in PT service quality analysis and improvement practices.

Design/methodology/approach

This research is based on quantitative and qualitative data collection. Quantitative data were collected through two questionnaires; the first is based on ranking data: 192 responses and the second on the Kano model: 46 responses. The qualitative data was obtained through 10 semi-structured interviews with senior management from seven bus companies in the UK.

Findings

Findings indicate that VOC differs between PT users and non-users and compared with the perspectives of PT Providers. The research also revealed that VOC plays a crucial role in PT service quality improvement (QI).

Practical implications

The findings can be used by PT service providers to better understand the VOC of PT users and non-users, which will assist in strategic and QI decision-making. Furthermore, an in-depth study of VOC in PT is provided, which progresses the academic field on this topic and advances research in this area.

Originality/value

This research brings new insight into the most important quality attributes for PT users and non-users. Moreover, the paper fundamentally contributes to the literature, which until now had severely limited input pertaining to the role of VOC in PT and little knowledge of service QI tools and practices in this sector.

Entropy-Based Lean, Energy and Six Sigma Approach to Achieve Sustainability in Manufacturing System

This work proposes a Value Stream Mapping (VSM) to be used in manufacturing industry that combines Lean, Energy and Six-Sigma methodologies. Lean's VSM tool is amended to energy VSM so that the value-added and non-value-added approach can be used to determine the energy use and waste. In order to identify the maximum rejection or rework at a workstation, an entropy-based mathematical model is developed and a Lean-Energy-Six Sigma Value Stream Mapping (LESSVSM) is presented. The model can be used in manufacturing at product level where temperature and energy can be measured from input to output. The model has been implemented on a manufacturing system containing four workstations. The proposed LESSVSM model will help to industry to become more sustainable as it can minimize energy and waste in the case of rework and rejection. This study presents a systematic approach which researchers and practitioners can apply for sustainable manufacturing.

Developing a practical methodology to improve the health-care services: studying a neonatal intensive care unit case in Oman

Purpose

This study aims to develop a practical methodology to identify possible areas of improvements as well as exploring how to improve the health-care staff flow within a selected department in a hospital.

Design/methodology/approach

It focuses on showing how to properly study and analyze the health-care services and processes practiced at a selected department within a hospital. For this, several techniques like non-value-adding activities, time motion study, spaghetti diagram, layout analysis, etc. are used.

Findings

To test the proposed methodology, a neonatal intensive care unit (NICU) of a hospital in Oman was considered as a case study. The study revealed that this unit has several potential improvements capabilities. Further, this study also discussed possible areas of improvements of this case unit and suggested how such improvements can be implemented.

Originality/value

Several possible improvements are suggested and are discussed with the hospital authority, which can be clarified as the re-layout of the NICU rooms, reorganization of the store to improve the staff flow, increase the work efficiency, introduction of Help Us Support Healing policy, etc., which can enhance the entire operational system at the studied NICU.

Impact of Lean, Six Sigma and environmental sustainability on the performance of SMEs

Purpose

This paper aims to explore the impact of lean, Six Sigma and environmental sustainability on the performance of small and medium enterprises (SMEs) in Pakistan. The firm performance has been measured in terms of operational, business and environmental performance.

Design/methodology/approach

A survey-based methodology is adopted for collecting data from the main cities of Punjab, Pakistan. SMEs related to different industries such as service, manufacturing, automotive and retail were targeted. The data gathered were ordinal, and Spearman's correlation test was used as the data analysis technique.

Findings

The findings indicated that the three management styles positively impacted the environmental performance of SMEs. Moreover, no significant relationship was found between the three management styles and the SMEs' business and operational performance.

Research limitations/implications

To counter the inefficient and wasteful practices of SMEs and their detrimental impact on overall firm performance, SMEs have to refocus and reconfigure their management strategies. It is implied to use lean, Six Sigma and environmental sustainability practices to achieve this goal.

Originality/value

The study empirically investigates the impact of lean, Six Sigma and environmental sustainability on the performance of SMEs in Pakistan, which is the first study to be conducted in the Pakistani context.

Analysis and Evaluation of Reviews on Lean and Six Sigma in Health Care

BACKGROUND AND OBJECTIVES

Health care is a complex industry in which professionals are facing the challenge of balancing lower costs with better health and quality of care. To remain competitive, health care organizations have promoted the use of Lean and Six Sigma in various settings. More than 300 refereed English-language articles about Lean and/or Six Sigma in health care are found in the literature, and many reviews have been published on this subject.

METHODS

This article characterizes the literature by evaluating and classifying 22 reviews, based on year of publication, country, taxonomy, health care setting, outcome, tools, and enabling factors, in order to identify gaps in the literature and set new directions for research.

RESULTS

Findings indicate that 90% of reviews are characterized by restrictive inclusion criteria that result in the inclusion of only 3% to 66% of the literature at the corresponding time. Furthermore, there is no full comprehensive literature review available on Lean and Six Sigma in health care. Other gaps in the literature include more studies with better research design, broader applications in various health care settings and various countries, sustainability assessment and long-term effects, and evidence of failed Lean and Six Sigma implementations.

CONCLUSION

This study provides an updated starting point for future research to researchers and practitioners in the field.

Application of Six Sigma methodology in an Indian chemical company

Purpose

The aim of this paper is to deploy Six Sigma (SS) methodology for addressing the customer complaints pertaining to Chemical-X in an Indian chemical company.

Design/methodology/approach

The study followed a structured Define, Measure, Analyze, Improve, Control (DMAIC) approach to address the customer complaints. The complaints have been classified into different categories along with a project charter in the define phase. In the measure phase, measurement system analysis (MSA) and supplier, input, process, output and control (SIPOC) have been applied. In the analyze and improve phase, why–why analysis, process capability study, how–how analysis, Gage repeatability and reproducibility and Taguchi design have been applied to optimize the manufacturing process parameters for Chemical-X. Lastly, in the control phase, validation of 20 batches has been piloted to validate the optimized parameters.

Findings

The findings of this study highlight the optimization and prioritization of the process parameters. It shows that humidity has the least impact on the manufacturing of Chemical-X, whereas shift type has the maximum impact. The experimental output indicates that the 1st Shift, the holding time after grinding should be twenty-four hours, and the temperature after grinding should be 40 °C to reduce the customer complaints concerning lumps formation in Chemical-X.

Research limitations/implications

The study is performed for a single product (Chemical-X). It has focused only from the manufacturing process view and not from the transportation, suppliers and downstream supply chain view.

Originality/value

A systematic and data-driven approach of the SS methodology ensured that the customer complaints due to lumps formation reduced from 5% (approx.) to 1% (approx.) which resulted in the cost saving of INR 4 million (approx.) annually.

The relationship between quality and governance mechanisms

Purpose

Recent literature has highlighted the importance of quality and governance in supply networks. Usually, the relationships between the actors are complex, comprising both formal and informal interactions. Despite recent advances in quality and governance in supply networks, extant literature highlights the lack of quality in healthcare supply-chain networks in relation to governance mechanisms. This paper aims to investigate the role of governance mechanisms and their influence on the quality of healthcare supply networks, and assumes that governance instruments can support quality performance.

Design/methodology/approach

A multiple-case research approach was employed. Six organisations in the Brazilian healthcare sector were analysed (four operate only with renal replacement therapy, one is a material supplier, and one operates with renal replacement therapy and collective procurement).

Findings

Findings showed that there is no formalised supply network structure in these organisations. A possible consequence of this is that the supply-network governance is dominated by informal relationships. In the quality dimension, managers' awareness is limited, but there are mechanisms in place to control the quality of the materials.

Practical implications

Healthcare managers can actively invest in the social aspects of the relationship between buyer and supplier, such as trust and commitment, thus increasing responsiveness in patient care. However, this informal procedure can lead to problems with tracking and reliability, ultimately leading to quality problems. Therefore, it is recommended that formal and informal governance instruments be used jointly to improve service quality.

Originality/value

This study suggests that the integration of formal and informal mechanisms of governance can improve the quality of supply networks. Additionally, if the administrative process is purely formal, network relationships and their efficiency will be impaired.

Integrating DMAIC approach of Lean Six Sigma and theory of constraints toward quality improvement in healthcare

Healthcare is a unique service industry and it deals with complex tasks. To overcome complex tasks, healthcare organizations need to implement DMAIC (Define, Measure, Analyze, Improve, Control) approach of Lean Six Sigma (LSS) to improve quality performance. Application of DMAIC in a healthcare organization provides guidelines on how to handle a quality service system toward patient satisfaction. This approach also helps healthcare service providers to reduce waste, variation and work imbalance in the service processes. This chapter discusses five phases of DMAIC approach and its integration with the theory of constraints (TOC) for continuous improvements in healthcare performance. The integration of TOC and DMAIC approach would enhance healthcare performance by reducing medical costs, medical errors, administration errors and defects. Moreover, this integration can improve performance in healthcare service processes where it is not possible to reduce bottlenecks.

How operations matters in healthcare standardization

Purpose

Process management approaches all pursue standardization, of which evidence-based medicine (EBM) is the most common form in healthcare. While EBM addresses improvement in clinical performance, it is unclear whether EBM also enhances operational performance. Conversely, operational process standardization (OPS) does not necessarily yield better clinical performance. The authors have therefore looked at the relationship between clinical practise standardization (CPS) and OPS and the way in which they jointly affect operational performance. The paper aims to discuss this issue.

Design/methodology/approach

The authors conducted a comparative case study analysis of a cataract surgery treatment at five Belgium hospital sites. Data collection involved 218 h of observations of 274 cataract surgeries. Both qualitative and quantitative methods were used.

Findings

Findings suggest that CPS does not automatically lead to improved resource or throughput efficiency. This can be explained by the low level of OPS across the five units, notwithstanding CPS. The results indicate that a wide range of variables on different levels (patient, physician and organization) affect OPS.

Research limitations/implications

Considering one type of care treatment in which clinical outcome variations are small complicates translating the findings to unstructured and complex care treatments.

Originality/value

With the introduction of OPS as a complementary view of CPS, the study clearly shows the potential of OPS to support CPS in practice. Operations matters in healthcare standardization, but only when it is managed in a deliberate way on a hospital and policy level.

Lean Six Sigma approach to reduce LOS through a diagnostic-therapeutic-assistance path at A.O.R.N. A. Cardarelli

Purpose

The rise of the mean age incremented the occurrence of femur fractures with respect to the past, leading thus to serious consequences, as regards morbidity and socio-economic impact. The direction of the A.O.R.N. Cardarelli of Naples has introduced a DTAP whose aim was the reduction of LOS. The paper aims to discuss this issue.

Design/methodology/approach

The aim of this paper is to analyze the introduction of DTAP, employing Lean Thinking and Six Sigma methodology based on the DMAIC cycle. To evaluate the effectiveness of DTAP, two groups of patients have been observed for 14 months (before and after the implementation of DTAP).

Findings

Statistical tests were performed on the groups and graphics were provided to visualize the decrease of LOS (29.9 per cent). The overall population was also divided in subgroups according to six variables potentially influencing LOS.

Research limitations/implications

Authors considered six variables of influences; yet, others could be taken into account in the future.

Practical implications

The decrease of costs due to the management of elderly patients with femur fracture, the optimization of care processes in hospitals and a faster recovery for patients is the tangible contribute of DTAP.

Originality/value

The implementation of DTAP allowed the hospital to obtain a significant reduction of LOS with a consequently decrease of costs alleviating the hospital and the society from the socio-economic burden and the morbidity of this pathology.

Performance measurement for supply chain management and quality management integration

Purpose

The purpose of this paper is to present a conceptual framework for performance measurement (PM) for the integration of supply chain management (SCM) and quality management (QM).

Design/methodology/approach

A systematic literature review on SCM and QM was conducted to develop key performance measures related to six areas of integration between QM and SCM: leadership; continuous improvement and innovation; sustainability performance; stakeholders; information system; and management and strategic planning.

Findings

Supported by the literature concerning to supply chain quality management (SCQM) integration, a set of nine propositions about performance measures, that contribute to the integration of SCQM, were developed.

Originality/value

This study contributes to QM practices within a supply chain environment from an integrated perspective. Additionally, the propositions have significant implications from both managerial and theoretical perspectives. This study also extends the concept of supply chain quality integration by focusing on key aspects of PM that may help to improve the overall performance of the supply chain.