Lean Six Sigma Project Report For Reliant Health Systems

Improvements opportunity- Define Phase

Problem Statement or Discussion of the process being examined 

Reliant Heath Systems is one of the independent, multi-specialty groups of physicians that are located in the United States of America (Yaduvanshi & Sharma, 2017).  In addition, Reliant Heath Systems is the first group that dealt with medical practices. Reliant Heath Systems is a healthcare provider that aims at providing positive outcomes and not just excellent health services. Reliant Heath Systems supports more than 250 doctors, 1700 employees in and across 20 locations. Reliant Heath Systems had been named under 2012 Top Workplace by Worse Ster Business Journal. Reliant Heath Systems accepts all main forms of health insurance in and across the world. Reliant Heath Systems is one of the regional healthcare providers that mainly focus on urgent care provided in its three hospital emergency rooms. Reliant Heath Systems was able to build an outstanding reputation for the quality of healthcare they actually provide (Weaver et al., 2013).

Reliant Health Systems experiences excellent reputation but observed the demand for its emergency room service decline over the last several years. In that way, revenue from the operating unit is down. The Financial Services Manager of Reliant Medical Group is of the opinion that their previous service provider was not well-equipped to handle the increasing levels of complexity of growing health systems (Watkins et al. 2014). As far as fee is concerned, it is needed to be broken out among different site and collection agency that works out well for meeting the changing objectives in the most appropriate way.  

After a year, Reliant Health Systems applied new process like credit reporting for applicable patient accounts where IC system produces some of the appreciated lifts in recoveries. In case of liquidation rates, it was noted one year after introducing the new process that include credit reporting of applicable accounts and considered and determined to be healthcare provider with an increase of 10.5% (Porter, Larsson & Lee, 2016). 

Parts per million Defective (PPM) are the number of defective units in one million units. PPM is used as a key measures when the number of defective products are produced is small and considered as the accurate measure of the defective rate and obtained or based on defective percentage.

Parts per million defective= Total number of defective units found in a sample/sample size)*1000000.

Defects per million opportunities (DPMO) are other way to measure number of defects. DPMO is a ratio of the number of defects or flaws in 1 million opportunities when an item contains more than one defect. In order to calculate DPMO, it is important to identify or known the total number of defect opportunities (Mason, Nicolay & Darzi, 2015).

Defects per million opportunities= Total number of defects found in a sample/ total number of defect opportunities in the sample*1000000.

Yield in Six sigma is one of the classic performance estimates that is calculated by using the equation (Yield= Output/ Input).

There are lots of process performance measures or metrics that need to be considered. It may take different form where some of them are equally equivalent at the same time. It is important for Reliant Health Systems for selecting the best ones as it widely depends upon the audiences and how the metrics will be used for driving improvement actions (Martens et al., 2014).

Identification of key measures used to evaluate the success of the project

The main scope of the project is to highlight the guidelines for preparing a Lean sigma green belt written certification report. In this report, proper emphasis will be given to the information that follows DMAIC Problem Solving Methodology that includes a description of the project, key point applicable in the problem solving process as well as detailed support of conclusions and recommendations (Laureani, Brady & Antony, 2013).

Current Performance Level 

In this particular section, different measuring tools and techniques are mentioned to give proper understanding of lean six sigma used in healthcare sector.

Six sigma is one of the proven as well as data-driven suites of improvement methodologies that actually based on a common philosophy as supported by measuring the tools used for process and product improvement. There are three main improvement methodologies that need to be evaluated by the management of Reliant Health systems before implementing one (Kozhimannil, Law & Virnig, 2013).

DMAIC- This is used for process improvement by way of reducing process variation as well as defects.

Design for six sigma is used for designing new process as well as products. In addition, Lean six sigma is used for improving in the process efficiency as well as speed (Koh et al., 2013).

DMAIC is one of the problem solving method that is treated as a roadmap that are used for any of the projects or quality improvements that need to be performed at Reliant health systems. It is a methodology that needs to be used when a product or process is in existence at any company but is not able to meet customer specification or not performing in an adequate way.

The first phase in DMAIC is defining the problem. The define phase is considered to be the first phase of six sigma improvement process. In this particular process, the leader of the project has the responsibility for creating a Project Charter and creating a high-level view of the process and understanding the needs of the customers in the process (Hussey, Wertheimer & Mehrotra, 2013).

The second phase in DMAIC is measuring or mapping out the current problem. In this particular phase, the main aim of the team is to focus on data collection and it needs to takes into account two goals. The first goal is determining the start point or baseline of the process. The second point is finding clues for understanding the root cause of the problems in the process.

The third phase in DMAC is improving or implementing with a solution. In this particular phase, the team needs to move on to solution development. In this, structured improvement effort is needed that lead to get innovative as well as elegant solutions at the same time (Ha et al., 2016).

The fourth phase in DMAIC is controlling over the identified problem. In this particular phase, the team mainly begins with documenting exactly on how they need to sustain improvements through pass of process improvement infrastructure on to the employees who actually work in the given process (Gijo & Antony, 2014).  

Discussing the scope of the project

Fishbone Diagram

Fishbone diagram allows team members for identifying, exploring as well as displaying details of all the possible causes related to an issue or condition after discovering the root cause. The diagram enables team members for focusing on the content of the problem and not on the history of the problem that differs to personal interests of team members. It mainly focuses the team in causes and not on symptoms. It can be used when the exact cause of an effect is not known (Folland, Goodman & Stano, 2016) 

Activity had been conducted where there is creating of fishbone diagram for solving a problem at Reliant Health Systems. The suggestions given are no shows from the consumers, staff turnover as well as computer or administrative issues and own situations.

 

Figure: Affinity Diagram of Reliant Health Systems

(Source: Drotar, 2014).

Affinity Chart- Safety problems in Reliant Health Systems
Security issues	Safety issues	Disaster planning	Negligence	Facilities	Personnel
IDs	Smoking	Hurricane	Confusion	Broken equipment	Interns
Weapons	Hot food	Power outrage	Misdiagnosis	Old	Residents
Violent people	Slips and falls	Shooter	Lack of standardization	Wait times	Unqualified
Drug seekers	Loose railing
Infant abduction	Poisoning	Fire	Infection	Transportation	Overworked
Illegal drugs	Falling

 
The affinity diagram needs to select an issue, problem or objective. It is required for ensure the reimbursement in a collaborative integrated care systems. In addition, it is important to understand the objectives as well as area of focus in the strategic plan. The knowledge need to be developed by use of six sigma projects (De Koeijer, Paauwe & Huijsman, 2014).

Figure: Pareto Diagram for Reliant Health Systems

(Source: Conway, Mostashari & Clancy, 2013)

A Pareto chart is one of the measuring charts that should be used by Reliant Health Systems as it help team member to focus on problems where it offers the greatest potential for improvement after identifying the problems in relative to frequency or size in a descending bar graph. This mainly helps in highlighting the issues in a cumulative way. It is the team that focuses on cause of the problem that have greatest impact at the same time.

There are various projects that need to be evaluated before selecting a suitable method for lean process improvement events for meeting the criteria at the same time. There are many other valuable projects as well as activities that are not suited to lean but are worth pursuing an innovation, service or product development as well as marketing at the same time (Chiarini & Bracci, 2013).

The target performance levels or project goals that need to be achieved by Reliant Health systems are as follows:

• Increased service capacity or revenue
• Decrease costs
• Reduce expenses
• Adding value for identifiable or targeted customers
• Waste reduction
• Improving an existing process or activity rather than creating a new whole activity
• There are advantages involved for building a cross-functional team for Reliant Health Systems
• Need to identify solutions and plans
• Identification of current state of the process as well as desired future state
• Advantages in process standardization

Value and impact considerations for prioritizing as well as selecting lean projects for solving the loopholes faced by Reliant Heath Systems

It is important to assume structural suitability and reason for selecting the project. The criteria that is essential to keep in mind while valuing or selecting the lean projects.

• Strategic plan relevancy
• Impacts bottom line
• Capacity expansion
• Contributes to annual growth target
• External customer impact
• Other identifiable value

Process or objective	Staff	Relevant to strategic plan	Impact bottom line	Contribute to growth target	Value added	Target date	Level of interest on preferences (5=high,1=low)
Clinical capacity
Call center
Error-free computer systems
Filling a staff vacancy

The performance target at Reliant Health systems is to meet the needs of the patients and provide them with healthy lifestyle. Some of the target are mentioned below that need to be achieved by Reliant Health Systems within a time span of 5 years.

• Providing high quality services
• Providing access to more people who ask for services
• Starting service delivery on prompt basis
• Matching work time at high reimbursement rates
• Positive customer experience
• Valuable clinical outcomes  

On analysis, it is found that there are some opportunities for streamlining the clinical work flow that is important for improving the quality of care. There are different structures that standardize the work process such as programmed logics, programmed forms as well as data validation and feedback at the same time. As far as lean paradox is concerned, it deals with bottleneck in programming as well as implements delays in most of the major projects. There is a need for correction to the problem identified for the department that includes prison parolees, rate of intakes triples, duration appeared unchanged as well as recording of standard versus actual time (Callahan & Roberts, 2017).

Current state of the process- Measure Phase

Lean six sigma need to be applied in the healthcare sector as it helps in describing the pioneering work at Reliant Heath Systems. The elements that are used in lean six sigma had been used in hospitals years. Several problems had been identified by the upper management of Reliant Heath Systems as the projects lacks strategic relevance, absence of systematic project tracking system and no uniform methods used for project management as well as control at the same time (Breslin, Hamilton & Paynter, 2014).

It is found that there had been shortening of service times, decreased range and variability, increased access to services as well as room for more intakes (Agarwal et al., 2016). Customer wait time considered to be main interest to Reliant Heath Systems but in the past they have been operating under the paradigm where the quality of healthcare is provided that is worth the wait. Reliant Heath Systems wanted to do something for counterpart the urgent or ready health care market plot but firstly they need to look at the level of performance. In addition, the information led Reliant Heath Systems for starting with ways for investigating the time where each patient waits to be seen in an emergency room. It is therefore important to understand the scope of lean six sigma project where the group need to develop a high level value stream map for the overall emergency room process for identifying some of the potential areas for admittance waiting time. As far as value stream map is concerned, it mainly helps in identifying number of improvement opportunities in and throughout the process where Reliant Heath Systems can directly act on quickly basis. The admission process had been a part of the process where the team members directly address the issues faced in the current project and tackle sub process at the same time It is the process that actually refers to the steps that goes through the patients who were admitted t the hospital in an emergency room (Bhat, Gijo & Jnanesh, 2014).

By use of IC system, Reliant Health Systems felt like they have true partners in the management in case of self-pay receivables. The Executive Director of Reliant Health Systems is of the opinion that he is pleased with both the financial performance and IC system ability for addressing the customary service elements in the collection process (Stanton et al., 2014).

The administrators of Reliant Heath Systems learned from a new aspect in health care that improvement can be attained by use of Lean six sigma for heath care. It is important to go through the literature and attend the conference where they the concepts is discussed and reviews some of the case studies that highlights lean six sigma use in healthcare (Sanders & Karr, 2015). Reliant Heath Systems had decided to make use of lean six sigma approach for investigating some of the reason on why the demand of Reliant Heath Systems emergency services has declined. In addition, the group of Reliant Heath Systems had contacted with the health care quality consulting form for investigating the situation after surveying former patients of Reliant Heath Systems for getting the voice of the customer. It is because the survey results will indicate the reason as to why Reliant Heath Systems has most of its market to the growing number of urgent care independent health care providers. The health care providers provide urgent care facilities that cost less as well as faster response alternatives to the traditional hospital emergency rooms. It is noted that these service providers treat minor injuries as well as refer the major cases to the hospital. One of the main key factors that is important to consider is the decision of the patient to go to an urgent care provider as it provides faster service because they have urgent care providers and guarantees the patient that they will be cured before the stipulated time frame. This is the main idea of these urgent care providers to get the business away from the hospital emergency rooms.

On analysis, it is noted that Reliant Health Systems had complex billing environment that actually spanned 6 different health systems in and across 20 distinct locations (Roberts, Wilson & Quezado, 2017). Far as internal healthcare billing software is concerned, it does not allow for optimal setup as well as processing of delinquent accounts by any chance. The previous agency of Reliant Health Systems remained conservative as well as safe that failed to render an acceptable level of return that fits within the needs and growing health systems.

It is recommended to Reliant Health Systems for improving their business process and it is listed as under:

• Delays and bottlenecks in communication
• Developing Electronic Health Record
• Automated communication
• Six months required for implementation purpose
• Need systems analysis as well as programming at the same time
• Reduced time for filling  up positions in 3 days
• It is harder to measure on compare to bringing clinical improvement
• Need technology as well as programming
• Need a year to implement
• Not reliant on technology as well as new grants management and financial staff members
• Dependent on completion of previous lean project for staff members that is used for tracking as well as allocation in the most appropriate way.
• Clinicians trained so that they become production within 3 days of hire
• Need use of Electronic Health Record
• Quick determination of ways for achieving the target
• Designing of new training program
• Implementing initial computer training within a time span of 1 month
• Developing online training modules such as fewer programs because of other staff commitments.

The Healthcare green belt certification program is recommended for anyone who is working or thinking to work in a healthcare industry. The present study revolves around case of a healthcare company such as Reliant Health Systems. For the professionals who work with healthcare, it is noted that the green belt certification will hold more weight than the general level six sigma green belt certification. Reliant Heath Systems had grown to a threshold that actually prevents the local-based collections providers from delivering the necessary levels of service. It is essential for Reliant Heath Systems to find a new partner who will be helping with Bad Debt accounts at the time of maintaining delicate as well as valuable healthcare provider to patient relationships. Reliant Heath Systems faces problems with increased bad debt levels because of rise of deductible levels as well as numerous healthcare insurance charges. Reliant Heath Systems needs a partner that will help in adding up value by coming up with creative solutions that had an impact on their medical group bottom line while not risking their delicate client relationships at the same time. The study need to generate a baseline statistical summary table for the output variable admission time that is from the baseline data within a time limit of 20 minutes admittance time goal. It is important to identify if the admittance wait time is large than a mean problem as well as variation problem. The project needs to discuss facts about some of the alternatives that should validate the integrity of the data for the admittance wait times. It is important to consider the fact of the existing wait time data that comes from the computer system logging of the time where the patient data is entered and present in ER bed after signaling doctors and nurses for keeping ready for treatment purpose (Lameijer et al., 2016).

The lean six sigma green belt healthcare certification considered to be the industry recognizable as well as fully accredited by the council of six sigma certification. Use of six sigma lean implementation, it will help Reliant Health Systems in getting ways for improving the patient outcomes at the time of driving down the cost of patient care. It is all about applying the concepts of continuous improvement for creating as well as sustaining a more productive, efficient and cost-effective industry such as Reliant Health Systems. Healthcare like other service operations needs systematic innovation efforts for remaining competitive, cost-efficient as well as up-to-date. It is important to gather facts on the methodologies used as well as presents with examples on how principles of lean six sigma can be combined in order to provide an effective framework for producing systematic innovation efforts in healthcare sector. Some of the benefits or advantages to the identified approach help in controlling the cost of healthcare, quality improvement as well as rendering better healthcare services at the same time.

It is recommended to partner with IC system as their bad debt medical collection provider named as Reliant Heath Systems realizes some new level of competencies as well as freedoms that were gained after adding up services like Credit Reporting in the toolkit. Reliant Heath Systems focus on collection by use of IC system as it allows health system for remaining focused and rendering world class medical care as well as not attempting for performing tasks that were not included in the core competency.

After applying new process like credit reporting for the applicable patient accounts, IC system actually produces some of the appreciated lifts at the time of recovery. As far as liquidation rates is concerned, it is looked for one year after introducing the new process that takes into account credit reporting of applicable accounted as mentioned by the healthcare provider in an effective way. The increase to the bottom line results are present in the portfolio that negatively impact client relationships and was able to make a noticeable improvement to the health system. At the time of looking at the situation, current healthcare environment gets a higher percentage of patient accounts for resolving the cause in and across healthcare organization.

It is important to consider appropriate projects as well as measurements where the project reduces emergency room and impatient expenses.

The main goal over here is to reduce expenses and not increase over the bed capacity. It needs to reduce hospital admissions as well as readmissions visits. Enables effective communication as well as shifted towards costly impatient to less expensive outpatient case management as well as care coordination at the same time (Assarlind, Gremyr & Bäckman, 2013).

It is important to plan a project for Reliant Health Systems that improve level of accuracy of counting consumers that is funded by other institutions (Ahmed, Manaf & Islam, 2013). There had been disagreement on the scope for the project that examines the entire reporting process at Reliant Health Systems. It is important for narrowing down the scope on one of the specific contract. There had been lack of alignment present between desires, shareholders interests as well as skills and participants. It is important to decide whether to select computer programming analysis or lean process improvement. Other attributes that need discussion is the cross-functional, multi-level lean or focused computer programming team (Arthur, 2016).

It is important to understand how lean process improvement operates in a given way. Rapid improvement events take place where almost 10 to 20 participants join. The benefits are concentrated as well as interrupted effort with the right participants for reviewing a process that knows the best. It helps in generating insights as well as commitment for improvement purpose. Cost required when human resources management participate in the events. Evolution actually shortens the events with the preliminary work at the same time (Anhang et al., 2014).

During Rapid Improvement Event, it is important to gather facts on current state, target state, gap analysis as well as brainstorm solutions and selecting the best solutions as well.

After Rapid Improvement Event, it is important to gather facts on implementing solutions, tracking the process, measuring results as well as reporting the results at the same time (Al-Abri & Al-Balushi, 2014). It is required to take into account that there were pockets of accounts that actually were being sufficiently worked because of limitations of the local collection servicer. As far as internal decisions are made, it is needed to find a new partner with various perspectives and solutions especially in the accounts receivables management area. Reliant Heath Systems is a growing health system where they desire to appoint a collection partner who will challenge them with a fresh as well as innovative set of tools for applying in the accounts. It is all about rising of self-pay receivables, increased copay amounts as well as growing level of complexity of government where it creates much more complex set of realities for Reliant Heath Systems. After knowing the prospect, it is understood that it is important to apply a new leverage input to patient accounts when it is called for in Reliant Heath Systems. It had actually no room for error as well as needed a partner that will help in safely managing relationships with the patient in the most appropriate way (Neufeld et al., 2013).

As a brand new business, it is important to monitor the fact that Reliant Health Systems need to have robust, easy to use as well as fully accessible staff members that schedules for the roster system in place of other activities (Albliwi, Antony & Lim, 2015). By implementing appropriate models on nursing care, the care assistance and general services at Reliant Health Systems needed a system that actually help in empowering ways for managing a pool of allied health and nurse specialists in the most appropriate way. It is important to take a control of the assignments as well as schedules of the clients in an effective way. Reliant Health Systems need to explain the working of scheduling tool through online medium as it has become one of the integral part of how it help in running the business in an overall manner. At Reliant Health Systems, they are looking for ways to put the systems as it help mangers for working at full efficiency and speed. The system actually underpins the ability for remaining organized irrespective of any situation (Albliwi et al., 2014). It is recommended to identify appropriate payer pr contract sources. It is important to identify value-added intake information. It is needed to reduce the data items or forms from 17 to 4. Main focus is essential on appropriate or desired treatment outcome measures. Reliant Health systems should have Bypass access team that is direct to designated clinicians as they will care the patients.

Conclusion 

At the end of the study, it is concluded that the template had been used as a guidelines for preparing a lean six sigma green belt written certification on the present project report. The current segment explains the lean six sigma application on behalf of Reliant Health Systems that operates in healthcare sector. The present study explains the DMAIC Problem solving methodology as it includes description of the projects, main key points as well as recommendations at the end. The project deployment in six sigma help in establishing executive support as well as leadership. It helps in identifying the project leader or champion and process owner at the same time. It needs to assemble the core project team with membership from cross-functional departments.  One of the ideal solutions is to combine both the approaches where team members can get benefit as lean six sigma is a structured approach, project-based deployment, organizational competency development ad well as linking strategy with selection of the project at the same time. The segment had been divided into several subsections where each section reveals some vital information and connects it with the case study healthcare company such as Reliant Health Systems. The first phase defines the several improvement opportunities for Reliant Health Systems after discussing the problem that need to be addressed on an urgent basis. The study identifies the six sigma projects where possible outcomes need to be identified and integrate visuals as well as summarizes the data by use of different charts and diagrams. Six sigma is one of the problems solving methodology. In addition, six sigma performances is one of the statistical terms for the process that actually produces fewer than 3.4 defects per million opportunities. This problem solving methodology brings improvement when the key outcome of the business or work process is improved dramatically. The deployment of six sigma considered to be the prescriptive rollout under the methodology used six sigma in and across companies with assigned practices, procedures and roles (Fuwad et al., 2015). Six sigma is used by organization as it uses six sigma methods and tools for improving the level of performance like customer satisfaction improvement, increased capacity and capability. It even reduces high of complexity as well as minimizes defects and errors at the same time. Lean help in providing a total system approach where the organizational structures and analysis tools are used for diagnosis purpose. Six sigma is one of the approaches that help in offering fewer standard solutions but renders a general analytic framework for solving the problem as well as organizational structure at the same time.  The information is used that are generated from the company report of Reliant Health Systems and check over the current performance at the same time. The information that is presented about Reliant Health Systems help the management to work at peed. Reliant Health Systems need to be accessible at the time when a client request for urgent help and respond quickly without any delay.

Reference List

Agarwal, S., Gallo, J. J., Parashar, A., Agarwal, K. K., Ellis, S. G., Khot, U. N., … & Kapadia, S. R. (2016). Impact of lean six sigma process improvement methodology on cardiac catheterization laboratory efficiency. Cardiovascular Revascularization Medicine, 17(2), 95-101.

Ahmed, S., Manaf, N. H., & Islam, R. (2013). Effects of Lean Six Sigma application in healthcare services: a literature review. Reviews on environmental health, 28(4), 189-194.

Al-Abri, R., & Al-Balushi, A. (2014). Patient satisfaction survey as a tool towards quality improvement. Oman medical journal, 29(1), 3.

Albliwi, S. A., Antony, J., & Lim, S. A. H. (2015). A systematic review of Lean Six Sigma for the manufacturing industry. Business Process Management Journal, 21(3), 665-691.

Albliwi, S., Antony, J., Abdul Halim Lim, S., & van der Wiele, T. (2014). Critical failure factors of Lean Six Sigma: a systematic literature review. International Journal of Quality & Reliability Management, 31(9), 1012-1030.

Anhang Price, R., Elliott, M. N., Zaslavsky, A. M., Hays, R. D., Lehrman, W. G., Rybowski, L., … & Cleary, P. D. (2014). Examining the role of patient experience surveys in measuring health care quality. Medical Care Research and Review, 71(5), 522-554.

Arthur, J. (2016). Lean Six Sigma for Hospitals: Improving Patient Safety, Patient Flow and the Bottom Line. McGraw Hill Professional.

Assarlind, M., Gremyr, I., & Bäckman, K. (2013). Multi-faceted views on a Lean Six Sigma application. International Journal of Quality & Reliability Management, 30(4), 387-402.

Bhat, S., Gijo, E. V., & Jnanesh, N. A. (2014). Application of Lean Six Sigma methodology in the registration process of a hospital. International Journal of Productivity and Performance Management, 63(5), 613-643.

Bhat, S., Gijo, E. V., & Jnanesh, N. A. (2016). Productivity and performance improvement in the medical records department of a hospital: An application of Lean Six Sigma. International Journal of Productivity and Performance Management, 65(1), 98-125.

Breslin, S. E., Hamilton, K. M., & Paynter, J. (2014). Deployment of lean six sigma in care coordination: an improved discharge process. Professional case management, 19(2), 77-83.

Callahan, C. D., & Roberts, T. S. (2017). Performance Measurement and Operations Improvement Using Lean Six Sigma. In Practical Psychology in Medical Rehabilitation (pp. 569-573). Springer International Publishing.

Carayon, P., Wetterneck, T. B., Rivera-Rodriguez, A. J., Hundt, A. S., Hoonakker, P., Holden, R., & Gurses, A. P. (2014). Human factors systems approach to healthcare quality and patient safety. Applied ergonomics, 45(1), 14-25.

Chiarini, A., & Bracci, E. (2013). Implementing lean six sigma in healthcare: issues from Italy. Public Money & Management, 33(5), 361-368.

Conway, P. H., Mostashari, F., & Clancy, C. (2013). The future of quality measurement for improvement and accountability. Jama, 309(21), 2215-2216.

De Koeijer, R. J., Paauwe, J., & Huijsman, R. (2014). Toward a conceptual framework for exploring multilevel relationships between Lean Management and Six Sigma, enabling HRM, strategic climate and outcomes in healthcare. The International Journal of Human Resource Management, 25(21), 2911-2925.

Drotar, D. (Ed.). (2014). Measuring health-related quality of life in children and adolescents: implications for research and practice. Psychology Press.

Drummond, M. F., Sculpher, M. J., Claxton, K., Stoddart, G. L., & Torrance, G. W. (2015). Methods for the economic evaluation of health care programmes. Oxford university press.

Folland, S., Goodman, A. C., & Stano, M. (2016). The Economics of Health and Health Care: Pearson International Edition. Routledge.

Fuwad, A., Ramasamy, R., Sebastian, A., Ashique, M., Mathew, R. J., & Yalla, U. T. (2015). The application of Lean Six Sigma to provide high quality, reliable health care. Journal of Pharmaceutical Research, 81-81.

Gijo, E. V., & Antony, J. (2014). Reducing patient waiting time in outpatient department using lean six sigma methodology. Quality and Reliability Engineering International, 30(8), 1481-1491.

Ha, C., McCoy, D. A., Taylor, C. B., Kirk, K. D., Fry, R. S., & Modi, J. R. (2016). Using Lean Six Sigma methodology to improve a mass immunizations process at the United States Naval Academy. Military medicine, 181(6), 582-588.

Hussey, P. S., Wertheimer, S., & Mehrotra, A. (2013). The Association Between Health Care Quality and CostA Systematic Review. Annals of internal medicine, 158(1), 27-34.

Koh, H. K., Brach, C., Harris, L. M., & Parchman, M. L. (2013). A proposed ‘health literate care model’would constitute a systems approach to improving patients’ engagement in care. Health Affairs, 32(2), 357-367.

Kozhimannil, K. B., Law, M. R., & Virnig, B. A. (2013). Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Health Affairs, 32(3), 527-535.

Lameijer, B. A., Lameijer, B. A., Does, R. J., Does, R. J., De Mast, J., & De Mast, J. (2016). Inter-industry generic Lean Six Sigma project definitions. International Journal of Lean Six Sigma, 7(4), 369-393.

Laureani, A., Brady, M., & Antony, J. (2013). Applications of lean six sigma in an Irish hospital. Leadership in Health Services, 26(4), 322-337.

Martens, L., Goode, G., Wold, J. F., Beck, L., Martin, G., Perings, C., … & Baggerman, L. (2014). Structured syncope care pathways based on lean six sigma methodology optimises resource use with shorter time to diagnosis and increased diagnostic yield. PloS one, 9(6), e100208.

Mason, S. E., Nicolay, C. R., & Darzi, A. (2015). The use of Lean and Six Sigma methodologies in surgery: A systematic review. The Surgeon, 13(2), 91-100.

McFadden, K. L., Lee, J. Y., & Gowen III, C. (2015). Factors in the path from lean to patient safety: Six sigma, goal specificity and responsiveness capability. The Quality Management Journal, 22(4), 37.

Neufeld, N. J., Hoyer, E. H., Cabahug, P., González-Fernández, M., Mehta, M., Walker, N. C., … & Mayer, R. S. (2013). A lean six sigma quality improvement project to increase discharge paperwork completeness for admission to a comprehensive integrated inpatient rehabilitation program. American Journal of Medical Quality, 28(4), 301-307.

Panat*, R., Dimitrova, V., Selvy Selvamuniandy, T., Ishiko, K., & Sun, D. (2014). The application of Lean Six Sigma to the configuration control in Intel’s manufacturing R&D environment. International Journal of Lean Six Sigma, 5(4), 444-459.

Porter, M. E., Larsson, S., & Lee, T. H. (2016). Standardizing patient outcomes measurement. New England Journal of Medicine, 374(6), 504-506.

Roberts, R. J., Wilson, A. E., & Quezado, Z. (2017). Using Lean Six Sigma methodology to improve quality of the anesthesia supply chain in a pediatric hospital. Anesthesia & Analgesia, 124(3), 922-924.

Sanders, J. H., & Karr, T. (2015). Improving ED specimen TAT using lean six sigma. International journal of health care quality assurance, 28(5), 428-440.

Stanton, P., Gough, R., Ballardie, R., Bartram, T., Bamber, G. J., & Sohal, A. (2014). Implementing lean management/Six Sigma in hospitals: beyond empowerment or work intensification?. The International Journal of Human Resource Management, 25(21), 2926-2940.

Valentine, M. A., Nembhard, I. M., & Edmondson, A. C. (2015). Measuring teamwork in health care settings: a review of survey instruments. Medical care, 53(4), e16-e30.

Watkins, E. Y., Kemeter, D. M., Spiess, A., Corrigan, E., Kateley, K., Wills, J. V., … & Bell, A. M. (2014). Performance excellence: using Lean Six Sigma tools to improve the US Army behavioral health surveillance process, boost team morale, and maximize value to customers and stakeholders. US Army Medical Department Journal, 91-96.

Weaver, S. J., Lubomksi, L. H., Wilson, R. F., Pfoh, E. R., Martinez, K. A., & Dy, S. M. (2013). Promoting a Culture of Safety as a Patient Safety StrategyA Systematic Review. Annals of internal medicine, 158(5_Part_2), 369-374.

Yaduvanshi, D., & Sharma, A. (2017). Lean Six Sigma in Health Operations: Challenges and Opportunities—‘Nirvana for Operational Efficiency in Hospitals in a Resource Limited Settings’. Journal of Health Management, 19(2), 203-213.