Description
Medical literature reports that Six-Sigma was applied at specific healthcare organizations. However, there
is a lack of studies that investigate the broader status of Six-Sigma in Lebanese healthcare systems. The
purpose of this paper is to explore the realities of factors critical (CSFs) to the success of a Six-Sigma
quality program to identify the nature of the quality program implemented in some of Lebanese hospitals in
Beirut. It also examines the impact of (CSFs) of a Six-Sigma quality program and its influence on
performance indicators.
2214-4625/$ – see front matter © 2014 Holy Spirit University of Kaslik. Hosting by Elsevier B.V. All rights reserved.http://dx.doi.org/10.1016/j.aebj.2014.07.001
ARAB ECONOMICS AND BUSINESS JOURNAL 9 (2014) 93–114
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* Corresponding author.
E-mail address: [email protected]; Tel: 71- 191207
Peer review under responsibility of xxxxx.
Conference Title
Factors critical to the success of Six-Sigma quality program and their
influence on performance indicators in some of Lebanese hospitals
Assrar Sabry*
Alexandria University, Egypt
A R T I C L E I N F O
Article history:
Received 24 February 14
Received in revised form 14 June 14
Accepted 14 Juillet14
Keywords:
Six-Sigma quality program
Critical success factors
Key performance indicators
Hospitals
CSFs
KPIs
A B S T R A C T
Medical literature reports that Six-Sigma was applied at specific healthcare organizations. However, there
is a lack of studies that investigate the broader status of Six-Sigma in Lebanese healthcare systems. The
purpose of this paper is to explore the realities of factors critical (CSFs) to the success of a Six-Sigma
quality program to identify the nature of the quality program implemented in some of Lebanese hospitals in
Beirut. It also examines the impact of (CSFs) of a Six-Sigma quality program and its influence on
performance indicators.
In order to achieve the objectives of the study, two questionnaires were used; ANOVA, Eta Squared, Pearson
Correlations were used to analyse the data collected from a sample of 101 respondents. Three hypotheses,
(H1), (H2) and (H3), were tested and partially accepted based on the results found.
The rest of the paper is organized as follows: First, an overview on the relevant literature reviews with
respect to the identified Six-Sigma factors. After that, the methodology and the data analysis of the results
are presented. The end of this paper is concluded with the discussion and suggestions for further research.
© 2013 xxxxxxxx. Hosting by Elsevier B.V. All rights reserved.
1. Introduction
The challenge in the Lebanese healthcare industries is how to balance
between quality and accessibility to the health care. The health care sector
in Lebanon falls under a private sector. Lebanon has a total of 130 hospitals
spread throughout the country of which 105 fall under the private sector
and 20 under the public sector (Health Care Sector in Lebanon: Syndicate
of Private Hospitals, 2012).
Based on the report prepared by (Rivers, 2010) and with
Association of the American Hospital in Lebanon, the service quality and
patients satisfaction are getting considerable attentions and these issues are
considered in their strategic planning process. Patients’ perceptions about
the services provided by particular health care organizations affect the
image and profitability of the hospital and it also significantly affects the
patient behaviour in terms of their loyalty. As mentioned by (Muhammad
and Ijaz, 2011), increased patients’ expectations about the service quality
had pushed the healthcare service providers to identify the key determinants
that are necessary to improve healthcare services that cause patients
satisfaction and yet also help the service providers to reduce time and
money involved in handling patient’s complaints. Quality has become a
major societal concern, as pointed out in latest reports such as The State of
Health Care Quality. Healthcare organizations have been looking for ways
to improve the bottom line and the quality of patient care. Some typical
© 2014 Holy Spirit University of Kaslik. Hosting by Elsevier B.V. All rights reserved.
Peer review under responsibility of Holy Spirit University of Kaslik.
94 ARAB ECONOMICS AND BUSINESS JOURNAL 9 (2014) 93–114
quality programs include the International Standards Organization (ISO)
9000 standards, the total quality management philosophy, Toyota
Production Systems (TPS), Lean manufacturing and recently the Six-Sigma
program. These quality standards and programs can be conveniently
borrowed to improve the performance of healthcare systems (Feng et al,
2008).
Quality of care can be defined by many ways depending on the
stakeholders involved in the industry. It can be different from the view of
the government, the shareholders, the clinical and non-clinical staff, the
patients and also the carers. Patient’s satisfaction has been used widely all
over the world to assess the quality of services rendered in healthcare
facilities. According to (Ismail and Alhashemi, 2011) the health managers
can identify the components of quality care such as the structure, process
and product of care by assessing the patient’s satisfaction. Joseph and
Kristina (2004) reported three approaches to quality improvement in the
healthcare industry to improve patient satisfaction by measuring the
patient’s perspective, improving patient outcomes and using Six-Sigma
approach.
Chakrabarty and Kay (2006) reported that defects found in a
service process incur a cost either to scrap or rework. Such service examples
include the need to re-contact a customer in order to verify either an order,
or providing an incorrect service, or providing a substandard service, or
even over servicing or providing more than what is required. The literature
review shows that empirical studies are limited to service industries, such
as healthcare systems. The financial benefits have the most concern, in
contrast to discussing gain in terms of process improvement. In addition, it
is important to note that the empirical studies emphasized the proper
identification of critical success factors (CSFs), critical to quality (CTQ)
characteristics, and key performance indicators (KPIs) much more than
testing the relation between these factors in the form of conceptual models.
All over the world healthcare is facing serious quality problems while costs
are exploding. The Institute of Medicine (IOM) produced two reports
demonstrating healthcare has serious safety and quality problems and is in
need of fundamental change. Care processes poorly designed and
characterized by unnecessary duplication of services, long waiting time and
delay. Costs are exploding and waste is identifying as an important
contributor to the increase in Healthcare expenditures. As a result,
healthcare consistently does not succeed in meeting patient’s needs
(Heuvel, Does and koning, 2006).
2. Structure
2.1. Research Problem
While there is substantial evidence on the use of six-sigma in many
manufacturing industries, there is limited empirical evidence demonstrating
the relationship between factors associated with a Six-Sigma quality
program and the performance of organizations in the health sector (Hilton
et al., 2008; Al Rashdi, 2011). Research on Six-Sigma has been anecdotal
in nature with minimal empirical findings (Dellifraine, Langabeer and
Nembhard, 2010). This research assists in filling another gap for Six-Sigma
quality program in this sector.
The problem statement of this study described in the following questions:
i. Determine empirically which of the critical success factors
(CSFs) of Six-Sigma quality program implementation exist in a
sample of Lebanese hospital. Since that there is no agreement
construct available in the literature to measure the key
performance indicators in the health sector, the current study
will empirically determine the key performance indicators that
are suitable to measure the performance in a sample.
ii. What are the ranking of the CSFs of six-sigma quality program
in the two groups (hospital department managers and
professionals) within the sample? In order to understand how
different the ranking of these factors from the actual ranking
presented by the (Hilton et al., 2008).
iii. What is the relationship between CSFs of Six-Sigma quality
program and the key performance indicators of the sample?
2.2. Research Question
The research objectives can be achieved by analyzing the results
obtained from posing the following specific research questions:
i. To what extent can the (CSFs) of Six-Sigma quality program
implementation explore the nature of the quality program
existing in a sample of Lebanese hospitals? and what is the
construct of the key performance indicators available in the
literature and suitable to measure the performance in a sample?
ii. To what extent will the ranking of the (CSFs) of Six-Sigma
quality program differ in the two groups of the sample: hospital
department managers and professionals from the actual
ranking?
iii. Which of the (CSFs) of Six-Sigma quality program
implementation are positively correlated with the construct of
the key performance indicators?
2.3. Research Objectives
i. Address the nature of the quality program in a sample of
Lebanese hospitals by describing which of the (CSFs) of Six-
Sigma quality program implementation are applied (Hilton et
al., 2008; Ismail et al., 2011; Wang and Hussain , 2011).
Providing an insight on the basic performance indicators that are
available in some previous literature, also, determining which of
them are used to measure the performance in a sample.
ii. Analyze the difference in the ranks of the (CSFs) of Six-Sigma
quality program between the actual ranks presented by the
(Hilton et al., 2008) and the ranks in the two groups of the
sample, the professionals and the hospital department managers.
iii. Provide an insight on the impact of the (CSFs) of Six-Sigma
quality program on the performance indicators (Dellifraine et
al., 2010) in a sample.
2.4. Research Importance
This research is important for the following reasons:
i. Based on (Ettinger, 2001) Six-Sigma principles and the
healthcare sector very well matched because of the healthcare
nature of very low or zero tolerance to mistakes and the high
potentials for reducing medical errors.
ii. Although the published literature contains many references on
quality and customer perceptions of the medical profession from
a clinical perspective, very little research has conducted into
ARAB ECONOMICS AND BUSINESS JOURNAL 9 (2014) 93–114 95
non-clinical aspects of the quality of medical care
(Hekmatpanah et al., 2008; Rivers, 2010).
iii. The reason behind the limitation of Six-Sigma in service
industries is that the features of service industries are not
uniform and therefore its application is limited to some specific
service sectors even within health care (Dileep and Rau, 2009).
iv. Based on the adoption of the previous studies on performance
measurement in hospitals on some measures, which differed
from one study to another. And the fact that there is no
agreement between these studies on the identification of specific
indicators to measure the performance in the healthcare sector,
the current study will include indicators from these studies and
will subject new indicators that can be more suitable for
application in the hospitals of the study sample.
3. Theoretical Background
Six Sigma is a powerful performance improvement tool that is changing the
face of modern healthcare delivery today. Six Sigma implemented in
diagnostic imaging processes, emergency room, and paramedic backup,
and laboratory, surgery room, and radiology, surgical site infections to
improve quality, performance and to improve the outcomes of their patients
(Sahbz, Taner, Kagan, Sasisoglu, Durmus, Tunca, Erabas, Kagan, Kagan,
and Enginyurt, 2014)
The term (Sigma) refers to a scale of quality measurement in any
processes such as manufacturing, and by using this scale. Six Sigma
equates to 3.4 defects per million opportunities (DPMO). There are
numerous definitions of Six Sigma in literature; it frequently defined as a
methodology for quality improvement with the goal of reducing the number
of defects to 3.4 units per million opportunities or 0.0003%. It is a statistics
based approach, which aims to isolate sources of errors and identify ways
to exclude them. Six Sigma has approved as an effective approach for
quality improvement in service sectors, especially at healthcare and
financial services (Schroeder, Linderman, Liedtke and Choo, 2008; Zhang,
Hill and Gilbreath, 2009). Aboelmaged, (2010), defined Six-Sigma as
standard deviations, which is a statistical representation of the variance in
a process based on data-driven approach to analyze the root causes of
processes problems and solving them.
In addition, Weinstein, Castellano, Petrick and Vokurka (2011)
reported that the higher the sigma the fewer the defects. With one sigma,
68.27% of products or services will meet customer requirements and there
will be 317,300 defects per million opportunities .Whereas three sigma,
99.73% of products or services will meet customer requirements and there
will be 2700 defects per million opportunities. With six-sigma, 99.99966%
of products or services will meet customer requirements and there will be
3.4 defects per million opportunities (DPMO). The focus of Six-Sigma is
not on counting the defects in processes, but the number of opportunities
within a process that could result in defects so that causes of quality
problems can be eliminated before they are transformed into defects. Tariq
and Ahmed-Khan (2011) analyzed the concept of Six-Sigma from different
attitudes. Six-Sigma is particular references to quality, defect, process
capability, variation and stability of operations. Six Sigma is an approach
that emphasis on reliability of data based on IT systems. Mohamed (2010)
clarifies emerging definitions of Six-Sigma through a comprehensive
review of Six-Sigma literature over 17 years, from 1992 to 2008 and found
SS defined as a philosophy that employs a well-structured continuous
improvement program, or defined as improvement strategy of processes
performance. Hekmatpanah, Sadroddin, Shahbaz, Mokhtari and Fadavinia
(2008); Wang (2011); Suhaiza et al., (2011), Khaidir, Habidin, Jamaludin,
Shazali, and Ali (2014), mentioned that many of the definitions of Six-
Sigma found in the literature review are very general and there is no
uniform agreement among them about certain factors or constructs related
to Six-Sigma.
3.1. Key Critical Success Factors (CSFs) of Six-Sigma quality
program
The healthcare organization is the place where defects and mistakes
cannot tolerate. A simple mistake can cost a human life so defects or
mistakes must eliminate in healthcare service processes. Six Sigma
approach is the best option in a healthcare environment for dealing with a
critical patient. Implementation of six-sigma approach can be reductions in
several aspects of healthcare such as patient waiting time in emergency
departments, lost charges for billing in patient financial services, delinquent
medical records, diagnostic result turnaround times, accounts receivable
days, patients’ length of stay, and medication errors (Selim, Noor, and
Rafikul, 2014) .
Leong and Teh (2013) proposed a model includes five CSF’s for
implementing SS quality program. First, top management commitment: is
important in handling the causes of process output variation. Second,
teamwork: is value-added to have teams in any problem solving actions.
Third, training and education: is necessary to design and plan for the Six
Sigma project development. Previous studies have found a positive
relationship between training and education, and the SS implementation.
Fourth, cultural change: the organizational administrators should collect
employees’ feedback, plan the cultural change through a proper SS
milestone, delegate jobs and empower staff in decision-making. Fifth,
organizational infrastructure: id needed to be in place prior to introduce Six
Sigma program in an organization.
Laureani and Antony (2012) aim to identify the most important factors
of CSF’s of SS quality program such as management commitment, cultural
change, linking Lean Six Sigma to business strategy and leadership styles.
They also identify the least important of CSF’s of SS quality program such
as linking Six Sigma to HR rewards and extending Lean Six Sigma to
supply chain. In addition, the results revealed that, although there are a
number of papers published on CSFs of Lean and Six Sigma, it found that
there is a dearth of literature on CSFs of Six Sigma implementation.
Ching-Chow (2004) investigates fifteen CSFs of Six-Sigma quality
program implementation and their importance degree for the different
industries in Taiwan. The result found factor ( training) is the first priority,
followed by such factors as top management involvement and commitment,
understanding methods, tools and techniques within Six-Sigma,
organization infrastructure. In addition, these industries should pay more
attention on five CSFs as follows: top management involvement and
commitment, cultural change, communication with all employees to
achieve congruence, linking Six-Sigma to business strategy, and linking
Six-Sigma to customers.
As mentioned by (Chakrabarty et al., 2006), the literature review shows
that top management commitment; education and training; culture change;
and financial benefits are the most important CSFs for the successful
application of SS in service sector. Other CSFs mentioned in some of the
literature reviews include customer focus; clear performance metrics; and
96 ARAB ECONOMICS AND BUSINESS JOURNAL 9 (2014) 93–114
organizational understanding of work processes. Schroeder et al. (2008)
found that SS focused on process improvement with DMAIC, training,
employee involvement and participation, team, customers, financial
performance metrics, suppliers, communication and solving problems
methods.
Rajamanoharan and Collier (2006) explored SS implementation issues
in services sector in Malaysia and used the process change management as
a framework. The results indicate that a low level of cultural readiness and
inadequate knowledge-sharing capability coupled with inadequate cross-
functional links inhibits the success of SS initiatives, and the learning
capacity are found to contribute positively to the SS implementations. In
the absence of a common shared knowledge database, the SS teams relied
on the cooperation of cross-functional staff for information. The erratic
cooperation from functional staff had a negative impact on the group’s
knowledge-sharing capability and the network relationship between
functions.
Fredendall, Robbins and Zu (2006) identify ten (CSFs) of Six-Sigma
quality program as follows : top management support, customer
relationship, supplier relationship, workforce management, quality
information, product/service design, process management, Six-Sigma role
structure, structured improvement procedure. Aboelmaged (2010) comes
out for identifying and highlighting the factors that have always been
subject to intensive literature (e.g. Buch and Tolentino, 2006; Chakrabarty
et al., 2007; Kumar, 2007; Kwak et al., 2006). They proposed the most cited
success factors in Six-Sigma literature. These are as follows: strong top
management involvement and commitment, selection of Six-Sigma
projects, changing organizational culture, aligning Six-Sigma projects to
corporate business objectives, cross-functional team working, effective
communication, infrastructure (both organizational and IT infrastructure),
training, linking Six-Sigma to business strategy, customer, human resource
management, suppliers, measurement, accountability, understanding tools
and techniques within Six-Sigma and project management skills.
Antony et al. (2007) mentioned that the main CSFs are as follows:
managing involvement and commitment, understanding of SS
methodology, linking it to a business strategy, linking it to customers,
project prioritization and selection, organizational infrastructure, cultural
change, project management skills, linking it to suppliers, training and
linking it to employees. Several studies such as (Pfeifer, Reissiger and
Canales, 2004; Szeto and Tsang, 2005; Salaheldin and Abdelwahab, 2009)
argued that the critical success factors (CSFs) of implementing Six-Sigma
involved three main factors. The most important factor is management
involvement and commitment, followed by linking Six-Sigma to business
strategy, customer expectations are critical point, and employees are one of
the stakeholders that have the real effect on the organization performance.
Dileep et al. (2009) ranked the top five ranks of CSFs as follows: first, (top
management, leadership and commitment) are essential for SS QMS
success and should act as key drivers in continuous improvements. Second,
(well implemented the system of customer satisfaction) to monitor
customer satisfaction levels, to receive customer feedback, and to resolve
customer concerns. Third, (education and training) required to provide
continuous courses to employees for equipping them with quality-related
knowledge and problem-solving skills. Fourth, (well-organized
information and analysis system) required to collect the performance
measures in order to monitor the quality of key business processes. Fifth,
(well-implemented process management system) required to identify,
improve, and monitor the key business processes that have a positive impact
on Six-Sigma quality management success.
Pulakanam and Voges, (2010) concentrated on identifying the critical
success factors in implementing Six Sigma. They found senior management
commitment, linking Six Sigma to business strategy and customers,
organizational readiness and project management skills have identified as
most important in the four surveys of their sample. The other less important
CSFs were management of cultural change, company-wide commitment,
integration of Six Sigma with financial accountability, understanding Six
Sigma methodology, training and education, project selection and
prioritization, project tracking and reviews, incentive programs, and linking
Six Sigma to employees and suppliers.
Weinstein et al. (2011) suggested the key CSFs of Six-Sigma that
emphasis on statistical measurement, structured training plans, problem-
solving techniques. However, according to (Frank and Young, 2004) the
key CSFs includes management commitment, organizational involvement,
project governance, project selection, planning, implementation
methodology, project management and control, cultural change, and
continuous training. Antony, Antony, Kumar and Cho, (2007) present an
empirical pilot study about the key (CSFs) in the UK service sector. The
questionnaires grouped under 13 (CSFs) which extracted from the
published literature of leading Six-Sigma practitioners and academics. The
results revealed the ranking of (CSFs) based on the mean ad thee standard
deviation of the data. These ranking as follows : business strategy 4.55,
followed by customer focus 4.40, project management skills 4.40,
management commitment and involvement 4.20, organizational
infrastructure 4.15, understanding of SS methodology 4.10, project
selection and prioritization 4.05. And then, integration of SS with financial
, accountability 3.70, management of cultural change 3.55, training and
education 3.25, project tracking and reviews 3.10, incentive program 2.90,
and company-wide commitment 2.80.
The study provided by (Brun, 2011) discussed the real life application
of Six Sigma in an Italian company. The results determined 12 CSF’s
ingredients for the effective implementation of Six Sigma program. These
factors are mmanagement involvement and commitment, cultural change,
communication, organizational infrastructure and culture, education and
training, linking Six Sigma to business strategy, linking Six Sigma to
customer, linking Six Sigma to human resources, linking Six Sigma to
suppliers, understanding tools and techniques within Six Sigma, project
management skills, and project prioritization and selection. Flynn, (2011)
presented top five success factors of Six-Sigma quality program and their
definition. These factors consist of first: support and deployment strategy,
which refers to commitment from top management, process owners,
customer focus and communication. Second: resources include allocation
of time, talent, equipment, training, technical support and the right people).
Third: data-driven decision making which involves statistical thinking and
project selection. Fourth: measurement and feedback, which emphasis on
the lessons learned. Fifth: effective control plan, and organizational which
refers to the impact of cultural acceptance, readiness and behavior toward
change and workforce management.
Taner (2013) reported paper to investigate the (CSFs) for the successful
introduction of Six Sigma in Turkish construction companies. The results
found the most important CSFs factors are involvement and commitment
of top management, linking quality initiatives to customer and linking
quality initiatives to supplier. Leadership and commitment of top
management, cross-functional teamwork and commitment of middle
ARAB ECONOMICS AND BUSINESS JOURNAL 9 (2014) 93–114 97
managers found to be the most CSFs for successful introduction of Six
Sigma, whereas lack of knowledge of the system to initiate and
complacency found to be hindering its implementation.
Wang (2011) examined the essential chances of achieving Six-Sigma
implementation goals in China’s banks. The results found factor (top
management commitment) considered as a significant contributor to the
effective implementation of Six-Sigma . Ismyrlis and Moschidis, (2013)
collected a list of 32 CSF of Six Sigma implementation which were
classified according to European Foundation for Quality Management
(EFQM) to the five enablers as follows : leadership, strategy, people,
partnerships and resources, and processes.
This result is corresponding with the results reported by (EL-Jardali,
2007) that mentioned the predictors of good quality results in Lebanese
hospitals were concentrated first on factor (leadership commitment). The
top management should change the culture and attitude of the people
working within the organization at all levels through increased and
sustained communication, motivation, education and teamwork.
Communication, motivation and education will encourage information
sharing within an organization, and this reciprocal sharing overcomes
functional barriers existing in an organization, as well as facilitating
knowledge flow. Meanwhile, teamwork means collaboration between
functions, between suppliers and customers, and between managers and
non-managers. The second factor: (training and development), to update the
employees and the managers with the necessary related knowledge, and to
achieve the organization’s plans through training programs. The third
factor: (continuously learned process) is supported by (Wang et al., 2011;
Rivers, 2010), they mentioned that maintaining high quality standards
through Six-Sigma is based on a continuous process through the use of the
process improvement tools.
Wang et al., (2004) provided an application guideline for the
assessment, improvement and control of quality in supply chain
management in different companies in Taiwan by using Six-Sigma
improvement methodology. They advocated that improvements in the
quality of all supply chain processes lead to cost reductions as well as
service enhancements. Garg, Narahari and Viswanadham (2004);
introduced Six-Sigma supply chains as a new notion to describe and
quantify supply chains with sharp and timely deliveries. They show that
based on using inventory optimization problem, the design of Six-Sigma
supply chains can deliver products within a customer specified delivery
window, with at most 3.4 missed deliveries per million.
Knowles et al. (2005) proposed a conceptual model that integrates the
Balanced Scorecard, BSC model (Supply Chain Reference model) and Six-
Sigma DMAIC methodology in strategic- and operational-level cycles.
This model supported by (Chappell et al., 2006; Kang et al., 2005). The
results concluded that Six-Sigma can be applied to supply chains by
following the DMAIC framework and employing a mixture of quantitative
and qualitative tools and suggested that it is difficult to implement Six-
Sigma methodology throughout the supply chain under some circumstances
related to stock holding policies and levels of demand. In addition , several
studies such as (Wang and Li, 2004; Knowles et al., 2005; Chappell and
Peck, 2006) studied how Six-Sigma methodology can effectively be
employed in supply chain management to measure, monitor and improve
the performance of the whole supply network .
Suhaiza et al., (2011) examined the relationship between the critical
factors for the implementation of Six-Sigma programs and perceived Six-
Sigma success of electronic companies in Malaysia. The results found
cultural change was the highest variable with the mean of 4.05, then linking
with supplier with the mean of 3.85 and company infrastructure was the
lowest mean 2.87. Factors (Management involvement and commitment)
and (linking Six-Sigma to supplier management) are strong positively
related to the success of Six-Sigma implementation.
(Sahbaz et al, 2014) mentioned that Six Sigma process produces 3.4
defective parts per million opportunities (DPMO). Six sigma is a method
that eliminates errors; it makes use of a structured methodology called
DMAIC to find the main causes behind problems and to reach near perfect
processes. DMAIC is useful to analyze and modify complicated time-
sensitive healthcare processes involving multiple specialists and treatment
areas by identifying and removing root causes of errors or complications
and thus minimizing healthcare process variability. Utilization of the
Failure Mode and Effect Analysis (FMEA) involved break down the
process into individual steps: potential failure modes (complications),
severity score, probability score, hazard score, criticality and detection.
Cagnazzo and Taticchi (2010); Suhaiza and Sivabalan (2011);
Attarwala, Kulkarni and Dwivedi (2011); Tariq et al., (2011) mentioned
that Six-Sigma methodology is an effective strategy to eliminate problems
within any organization that aims for better quality in its care. Within the
Six-Sigma strategy, there are two different methodologies: the problem
solving methodology that represented in DMAIC and preventative
methodology that known as the design for Six-Sigma (DFSS) which
consists of DMADV. Using root cause analysis as a tool of Six-Sigma can
lead to know the reasons about inconsistencies. These may be due to
variation in management processes, staff errors due to multitasking
requirements, lack of formal and unified processes, lack of accountability
due to unwritten policy to enforce, or lack of communication between
patient care units due to improper handling, preparation, and delivery of the
services. Jiju ,( 2004); Kwak et al., (2006) listed the most commonly used
tools and techniques in the service organizations such as brainstorming;
process mapping; affinity diagrams; root cause analysis; control charts;
benchmarking ; pareto analysis and change management tools.
Kang et al., (2005); Cagnazzo et al., (2010); Tariq et al., (2011)
introduced the key roles related to successful implementation of Six-Sigma
methodology for the executive leadership and other members of top
management. Champions have the responsibility for SS development inside
the organization; Black Belts apply SS methodology to specific projects;
Green Belts have a good methodological preparation. Project prioritization,
selection and project management skills are another critical success factors
(CSFs) of implementing Six-Sigma. Since Six-Sigma is a project driven
methodology, the prioritization and selection of the project is essential to
apply Six-Sigma successfully. Practicing this process in an effective way
will lead to achieve maximum financial benefits to the firms.
Khaidir et al. (2014) reported that (CSFs) in SS practices is important
in order to gain the goals and great performance. The CSFs in service
industry which include understanding the DMAIC methodology; project
management skills; project prioritization and selection; project tracking
and reviews, management commitment and involvement; company-wide
commitment; cultural change; linking SS to business strategy; integrating
SS with the financial infrastructure; organizational infrastructure; training
and education; incentive program; customer focus; linking SS to suppliers.
However, The CSFs of SS practices in healthcare industry are concentrated
on the following four factors: leadership, customer focus, structured
improvement procedure and focus in metric.
98 ARAB ECONOMICS AND BUSINESS JOURNAL 9 (2014) 93–114
Because this study aims to explore the critical success factors of Six-
Sigma quality program that implemented in some of Lebanese hospitals so
all common CSFs that mention in the literature and related to Six-Sigma
quality program will be measured in this study. The common CSFs are
nineteen factors , namely, executive commitment, adopting the philosophy,
benchmarking, training, closer customer relationships, closer supplier
relationships, open organization, employee empowerment, engagement and
morale, flexible operations, process improvement, measurement,
organizational structures, zero defects mentality, teams, planning and
values, audits, problem solving tools, design and engineering, and
production, this study has been tested and validated these factors.
3.2. Key Performance indicators (KPIs) in a hospital
Rodak, (2013) defined the key performance indicators as metrics
used to measure the hospitals’ performance in different categories,
including inpatient flow such as (inpatient raw mortality rate, bed turnover,
patient satisfaction, readmission rate, occupancy rate, average length of
stay, average cost per discharge, and surgical service.
Based on a framework mostly used in the health care research for
assessing quality of health care (Kalinichenko, Amado, and Santos, 2013)
categorized the performance indicators into three interrelated elements
which are structure, process and outcome. Structure refers to organizational
characteristics of the providers of care, including human, physical, and
financial resources and tools used in delivery of health care services,
presenting the inputs in health care provision. Process refers to the activities
that go on within and between health care practitioners and patients,
focusing on conformity to technical and ethical norms of good care. In
addition, finally, outcome refers to the impact of these activities on a
patient’s current and future health status.
Ismail et al. (2011) measured patient satisfaction levels and found time
with doctor was not to be a predictor of patient satisfaction. Communication
of the staff was the highest factor that influence patient satisfaction and the
predictor factors of total patient’s satisfaction were technical quality of
clinic staff, interpersonal aspect of clinic staff, availability/accessibility of
clinic and communication of clinic staff.
De Jager, Du Plooy, and Femi Ayadi, (2010) found that there is high
levels of patient satisfaction despite the limited human resources available.
Outpatients reported positive experiences with the medical staff,
specifically the doctors. While they had, negative experiences with the lack
of service orientation especially the nursing staff, unethical situations, and
frustrating inter-personal relationship difficulties. According to the
Commonwealth Fund’s International comparison of 7-world health, the U.
S .health care system ranks five dimensions of a high performance health
system. These dimensions include quality, access, efficiency, equity,
healthy lives to clarify how will hospitals and health systems lower costs
within settings of care, provide more patient-centered, and utilize cost-
effectiveness research. With an impeding expansion of medical enrollees,
effective care and cost management will be critical for program efficiency.
Bandyopadhyay and Coppens, (2005) listed four indicators that used by
singly or in combination to define the level of performance of a healthcare
organization. These indicators are service level, service cost, customer
satisfaction, and clinical excellence. Despite the challenges in using Six-
Sigma in the healthcare industry, many hospitals within the healthcare
industry are beginning to use Six-Sigma approach to improve patients’
satisfaction.
Jiju et al. (2007) mentioned that the KPI termed as a performance
metrics of Six-Sigma that used to help organizations define and evaluate
how successful they were in making progress toward long-term goals and
objectives. Performance indicators defined as statistics, which reflect,
directly or indirectly, the extent to which an anticipated outcome achieved
or the extent to which the quality of the processes can lead to that outcome.
KPIs help managers provide continuous quality system improvement,
identify areas of excellence, compare between the actual performance and
standards and monitor corrective action.
As reported by (Chakrabarty et al., 2007) the KPIs related to Six-Sigma
in service sector talks about financial benefits, others talks about customer
satisfaction and efficiency. However, the common literature mentioned that
the majority of the KPIs across services include efficiency, cost reduction,
time to-deliver, quality service, customer satisfaction, employee’s
satisfaction, financial benefits, reduced variation, and financial bottom
lines.
i. Efficiency: is one of the most important indicator in healthcare
systems which used to measure the clinical activities performed
based on these dimensions: reducing the length of stay, bed
occupancy rate, and admission per 1000 members (Nerenz and
Neil, 2001; John, 2010).
ii. Cost reduction: according to (Heuval, Does and Bisgaard, 2005;
Rivers, 2010) health care has opportunity to reduce costs by
eliminating wastes depending on three dimensions : reducing
errors, mistakes in a process, or reducing the time taken to
complete a task, or reducing a patient’s stay at a hospital to
provide opportunities for more admissions.
iii. Time-to-deliver: as mentioned by (Bandyopadhyay et al, 2005)
service time, waiting time, and cycle time are three dimensions
used to measure this indicator in the service sector. Service time
refers to the time required to serve a particular customer. Waiting
time refers to the time a customer waits in the system to have the
work completed .Cycle time refers to the total time including
service and waiting time
iv. Quality of the service: based on the previous studies mentioned
by (Hensley and Dobie, 2005) healthcare systems can depend on
the extent to which the service delivered, meets the customer’s
expectations as an adequate dimension to measure this indicator.
v. Customer satisfaction: as suggested by (Cowing, Davino-
Ramaya, Ramaya, and Szmerekovsky, 2009) healthcare
organizations found customer satisfaction is becoming an
important indicator for measuring its performance by using two
dimensions include patient satisfaction and perception of service
delivery by patient and clinician. These dimensions are
considered as subjective assessments based on the nature of
interactions with staff, the nature of communication with
clinicians, the degree of personalized care, the accessibility of
care, the responsiveness, and the timeliness of care. The health
care organization, the clinician (team of physicians, nurses,
medical assistants, and office staff), and the patients are
interrelated perspective on the needs associated with health care
performance to satisfy customers.
vi. Employee satisfaction: based on (Fogarty, Kim, Juon, Tappis,
Noh, Zainullah and Rozario, 2014), health-care worker
satisfaction and intention to stay on the job are highly dependent,
different groups of health-care workers in previous studies from
ARAB ECONOMICS AND BUSINESS JOURNAL 9 (2014) 93–114 99
other low-; middle- and high-income countries found that
retention rate of health-care workers is critical to measure
employees satisfaction for improving health system performance.
Being paid an appropriate salary, offered financial and moral
incentives to health-care workers were negatively related to
retention rate and intent to stay (??=?-0.326, P?
Medical literature reports that Six-Sigma was applied at specific healthcare organizations. However, there
is a lack of studies that investigate the broader status of Six-Sigma in Lebanese healthcare systems. The
purpose of this paper is to explore the realities of factors critical (CSFs) to the success of a Six-Sigma
quality program to identify the nature of the quality program implemented in some of Lebanese hospitals in
Beirut. It also examines the impact of (CSFs) of a Six-Sigma quality program and its influence on
performance indicators.
2214-4625/$ – see front matter © 2014 Holy Spirit University of Kaslik. Hosting by Elsevier B.V. All rights reserved.http://dx.doi.org/10.1016/j.aebj.2014.07.001
ARAB ECONOMICS AND BUSINESS JOURNAL 9 (2014) 93–114
Contents lists available at ScienceDirect
ScienceDirect
j our nal homepage: www. el sevi er. com/ l ocat e/ aebj
* Corresponding author.
E-mail address: [email protected]; Tel: 71- 191207
Peer review under responsibility of xxxxx.
Conference Title
Factors critical to the success of Six-Sigma quality program and their
influence on performance indicators in some of Lebanese hospitals
Assrar Sabry*
Alexandria University, Egypt
A R T I C L E I N F O
Article history:
Received 24 February 14
Received in revised form 14 June 14
Accepted 14 Juillet14
Keywords:
Six-Sigma quality program
Critical success factors
Key performance indicators
Hospitals
CSFs
KPIs
A B S T R A C T
Medical literature reports that Six-Sigma was applied at specific healthcare organizations. However, there
is a lack of studies that investigate the broader status of Six-Sigma in Lebanese healthcare systems. The
purpose of this paper is to explore the realities of factors critical (CSFs) to the success of a Six-Sigma
quality program to identify the nature of the quality program implemented in some of Lebanese hospitals in
Beirut. It also examines the impact of (CSFs) of a Six-Sigma quality program and its influence on
performance indicators.
In order to achieve the objectives of the study, two questionnaires were used; ANOVA, Eta Squared, Pearson
Correlations were used to analyse the data collected from a sample of 101 respondents. Three hypotheses,
(H1), (H2) and (H3), were tested and partially accepted based on the results found.
The rest of the paper is organized as follows: First, an overview on the relevant literature reviews with
respect to the identified Six-Sigma factors. After that, the methodology and the data analysis of the results
are presented. The end of this paper is concluded with the discussion and suggestions for further research.
© 2013 xxxxxxxx. Hosting by Elsevier B.V. All rights reserved.
1. Introduction
The challenge in the Lebanese healthcare industries is how to balance
between quality and accessibility to the health care. The health care sector
in Lebanon falls under a private sector. Lebanon has a total of 130 hospitals
spread throughout the country of which 105 fall under the private sector
and 20 under the public sector (Health Care Sector in Lebanon: Syndicate
of Private Hospitals, 2012).
Based on the report prepared by (Rivers, 2010) and with
Association of the American Hospital in Lebanon, the service quality and
patients satisfaction are getting considerable attentions and these issues are
considered in their strategic planning process. Patients’ perceptions about
the services provided by particular health care organizations affect the
image and profitability of the hospital and it also significantly affects the
patient behaviour in terms of their loyalty. As mentioned by (Muhammad
and Ijaz, 2011), increased patients’ expectations about the service quality
had pushed the healthcare service providers to identify the key determinants
that are necessary to improve healthcare services that cause patients
satisfaction and yet also help the service providers to reduce time and
money involved in handling patient’s complaints. Quality has become a
major societal concern, as pointed out in latest reports such as The State of
Health Care Quality. Healthcare organizations have been looking for ways
to improve the bottom line and the quality of patient care. Some typical
© 2014 Holy Spirit University of Kaslik. Hosting by Elsevier B.V. All rights reserved.
Peer review under responsibility of Holy Spirit University of Kaslik.
94 ARAB ECONOMICS AND BUSINESS JOURNAL 9 (2014) 93–114
quality programs include the International Standards Organization (ISO)
9000 standards, the total quality management philosophy, Toyota
Production Systems (TPS), Lean manufacturing and recently the Six-Sigma
program. These quality standards and programs can be conveniently
borrowed to improve the performance of healthcare systems (Feng et al,
2008).
Quality of care can be defined by many ways depending on the
stakeholders involved in the industry. It can be different from the view of
the government, the shareholders, the clinical and non-clinical staff, the
patients and also the carers. Patient’s satisfaction has been used widely all
over the world to assess the quality of services rendered in healthcare
facilities. According to (Ismail and Alhashemi, 2011) the health managers
can identify the components of quality care such as the structure, process
and product of care by assessing the patient’s satisfaction. Joseph and
Kristina (2004) reported three approaches to quality improvement in the
healthcare industry to improve patient satisfaction by measuring the
patient’s perspective, improving patient outcomes and using Six-Sigma
approach.
Chakrabarty and Kay (2006) reported that defects found in a
service process incur a cost either to scrap or rework. Such service examples
include the need to re-contact a customer in order to verify either an order,
or providing an incorrect service, or providing a substandard service, or
even over servicing or providing more than what is required. The literature
review shows that empirical studies are limited to service industries, such
as healthcare systems. The financial benefits have the most concern, in
contrast to discussing gain in terms of process improvement. In addition, it
is important to note that the empirical studies emphasized the proper
identification of critical success factors (CSFs), critical to quality (CTQ)
characteristics, and key performance indicators (KPIs) much more than
testing the relation between these factors in the form of conceptual models.
All over the world healthcare is facing serious quality problems while costs
are exploding. The Institute of Medicine (IOM) produced two reports
demonstrating healthcare has serious safety and quality problems and is in
need of fundamental change. Care processes poorly designed and
characterized by unnecessary duplication of services, long waiting time and
delay. Costs are exploding and waste is identifying as an important
contributor to the increase in Healthcare expenditures. As a result,
healthcare consistently does not succeed in meeting patient’s needs
(Heuvel, Does and koning, 2006).
2. Structure
2.1. Research Problem
While there is substantial evidence on the use of six-sigma in many
manufacturing industries, there is limited empirical evidence demonstrating
the relationship between factors associated with a Six-Sigma quality
program and the performance of organizations in the health sector (Hilton
et al., 2008; Al Rashdi, 2011). Research on Six-Sigma has been anecdotal
in nature with minimal empirical findings (Dellifraine, Langabeer and
Nembhard, 2010). This research assists in filling another gap for Six-Sigma
quality program in this sector.
The problem statement of this study described in the following questions:
i. Determine empirically which of the critical success factors
(CSFs) of Six-Sigma quality program implementation exist in a
sample of Lebanese hospital. Since that there is no agreement
construct available in the literature to measure the key
performance indicators in the health sector, the current study
will empirically determine the key performance indicators that
are suitable to measure the performance in a sample.
ii. What are the ranking of the CSFs of six-sigma quality program
in the two groups (hospital department managers and
professionals) within the sample? In order to understand how
different the ranking of these factors from the actual ranking
presented by the (Hilton et al., 2008).
iii. What is the relationship between CSFs of Six-Sigma quality
program and the key performance indicators of the sample?
2.2. Research Question
The research objectives can be achieved by analyzing the results
obtained from posing the following specific research questions:
i. To what extent can the (CSFs) of Six-Sigma quality program
implementation explore the nature of the quality program
existing in a sample of Lebanese hospitals? and what is the
construct of the key performance indicators available in the
literature and suitable to measure the performance in a sample?
ii. To what extent will the ranking of the (CSFs) of Six-Sigma
quality program differ in the two groups of the sample: hospital
department managers and professionals from the actual
ranking?
iii. Which of the (CSFs) of Six-Sigma quality program
implementation are positively correlated with the construct of
the key performance indicators?
2.3. Research Objectives
i. Address the nature of the quality program in a sample of
Lebanese hospitals by describing which of the (CSFs) of Six-
Sigma quality program implementation are applied (Hilton et
al., 2008; Ismail et al., 2011; Wang and Hussain , 2011).
Providing an insight on the basic performance indicators that are
available in some previous literature, also, determining which of
them are used to measure the performance in a sample.
ii. Analyze the difference in the ranks of the (CSFs) of Six-Sigma
quality program between the actual ranks presented by the
(Hilton et al., 2008) and the ranks in the two groups of the
sample, the professionals and the hospital department managers.
iii. Provide an insight on the impact of the (CSFs) of Six-Sigma
quality program on the performance indicators (Dellifraine et
al., 2010) in a sample.
2.4. Research Importance
This research is important for the following reasons:
i. Based on (Ettinger, 2001) Six-Sigma principles and the
healthcare sector very well matched because of the healthcare
nature of very low or zero tolerance to mistakes and the high
potentials for reducing medical errors.
ii. Although the published literature contains many references on
quality and customer perceptions of the medical profession from
a clinical perspective, very little research has conducted into
ARAB ECONOMICS AND BUSINESS JOURNAL 9 (2014) 93–114 95
non-clinical aspects of the quality of medical care
(Hekmatpanah et al., 2008; Rivers, 2010).
iii. The reason behind the limitation of Six-Sigma in service
industries is that the features of service industries are not
uniform and therefore its application is limited to some specific
service sectors even within health care (Dileep and Rau, 2009).
iv. Based on the adoption of the previous studies on performance
measurement in hospitals on some measures, which differed
from one study to another. And the fact that there is no
agreement between these studies on the identification of specific
indicators to measure the performance in the healthcare sector,
the current study will include indicators from these studies and
will subject new indicators that can be more suitable for
application in the hospitals of the study sample.
3. Theoretical Background
Six Sigma is a powerful performance improvement tool that is changing the
face of modern healthcare delivery today. Six Sigma implemented in
diagnostic imaging processes, emergency room, and paramedic backup,
and laboratory, surgery room, and radiology, surgical site infections to
improve quality, performance and to improve the outcomes of their patients
(Sahbz, Taner, Kagan, Sasisoglu, Durmus, Tunca, Erabas, Kagan, Kagan,
and Enginyurt, 2014)
The term (Sigma) refers to a scale of quality measurement in any
processes such as manufacturing, and by using this scale. Six Sigma
equates to 3.4 defects per million opportunities (DPMO). There are
numerous definitions of Six Sigma in literature; it frequently defined as a
methodology for quality improvement with the goal of reducing the number
of defects to 3.4 units per million opportunities or 0.0003%. It is a statistics
based approach, which aims to isolate sources of errors and identify ways
to exclude them. Six Sigma has approved as an effective approach for
quality improvement in service sectors, especially at healthcare and
financial services (Schroeder, Linderman, Liedtke and Choo, 2008; Zhang,
Hill and Gilbreath, 2009). Aboelmaged, (2010), defined Six-Sigma as
standard deviations, which is a statistical representation of the variance in
a process based on data-driven approach to analyze the root causes of
processes problems and solving them.
In addition, Weinstein, Castellano, Petrick and Vokurka (2011)
reported that the higher the sigma the fewer the defects. With one sigma,
68.27% of products or services will meet customer requirements and there
will be 317,300 defects per million opportunities .Whereas three sigma,
99.73% of products or services will meet customer requirements and there
will be 2700 defects per million opportunities. With six-sigma, 99.99966%
of products or services will meet customer requirements and there will be
3.4 defects per million opportunities (DPMO). The focus of Six-Sigma is
not on counting the defects in processes, but the number of opportunities
within a process that could result in defects so that causes of quality
problems can be eliminated before they are transformed into defects. Tariq
and Ahmed-Khan (2011) analyzed the concept of Six-Sigma from different
attitudes. Six-Sigma is particular references to quality, defect, process
capability, variation and stability of operations. Six Sigma is an approach
that emphasis on reliability of data based on IT systems. Mohamed (2010)
clarifies emerging definitions of Six-Sigma through a comprehensive
review of Six-Sigma literature over 17 years, from 1992 to 2008 and found
SS defined as a philosophy that employs a well-structured continuous
improvement program, or defined as improvement strategy of processes
performance. Hekmatpanah, Sadroddin, Shahbaz, Mokhtari and Fadavinia
(2008); Wang (2011); Suhaiza et al., (2011), Khaidir, Habidin, Jamaludin,
Shazali, and Ali (2014), mentioned that many of the definitions of Six-
Sigma found in the literature review are very general and there is no
uniform agreement among them about certain factors or constructs related
to Six-Sigma.
3.1. Key Critical Success Factors (CSFs) of Six-Sigma quality
program
The healthcare organization is the place where defects and mistakes
cannot tolerate. A simple mistake can cost a human life so defects or
mistakes must eliminate in healthcare service processes. Six Sigma
approach is the best option in a healthcare environment for dealing with a
critical patient. Implementation of six-sigma approach can be reductions in
several aspects of healthcare such as patient waiting time in emergency
departments, lost charges for billing in patient financial services, delinquent
medical records, diagnostic result turnaround times, accounts receivable
days, patients’ length of stay, and medication errors (Selim, Noor, and
Rafikul, 2014) .
Leong and Teh (2013) proposed a model includes five CSF’s for
implementing SS quality program. First, top management commitment: is
important in handling the causes of process output variation. Second,
teamwork: is value-added to have teams in any problem solving actions.
Third, training and education: is necessary to design and plan for the Six
Sigma project development. Previous studies have found a positive
relationship between training and education, and the SS implementation.
Fourth, cultural change: the organizational administrators should collect
employees’ feedback, plan the cultural change through a proper SS
milestone, delegate jobs and empower staff in decision-making. Fifth,
organizational infrastructure: id needed to be in place prior to introduce Six
Sigma program in an organization.
Laureani and Antony (2012) aim to identify the most important factors
of CSF’s of SS quality program such as management commitment, cultural
change, linking Lean Six Sigma to business strategy and leadership styles.
They also identify the least important of CSF’s of SS quality program such
as linking Six Sigma to HR rewards and extending Lean Six Sigma to
supply chain. In addition, the results revealed that, although there are a
number of papers published on CSFs of Lean and Six Sigma, it found that
there is a dearth of literature on CSFs of Six Sigma implementation.
Ching-Chow (2004) investigates fifteen CSFs of Six-Sigma quality
program implementation and their importance degree for the different
industries in Taiwan. The result found factor ( training) is the first priority,
followed by such factors as top management involvement and commitment,
understanding methods, tools and techniques within Six-Sigma,
organization infrastructure. In addition, these industries should pay more
attention on five CSFs as follows: top management involvement and
commitment, cultural change, communication with all employees to
achieve congruence, linking Six-Sigma to business strategy, and linking
Six-Sigma to customers.
As mentioned by (Chakrabarty et al., 2006), the literature review shows
that top management commitment; education and training; culture change;
and financial benefits are the most important CSFs for the successful
application of SS in service sector. Other CSFs mentioned in some of the
literature reviews include customer focus; clear performance metrics; and
96 ARAB ECONOMICS AND BUSINESS JOURNAL 9 (2014) 93–114
organizational understanding of work processes. Schroeder et al. (2008)
found that SS focused on process improvement with DMAIC, training,
employee involvement and participation, team, customers, financial
performance metrics, suppliers, communication and solving problems
methods.
Rajamanoharan and Collier (2006) explored SS implementation issues
in services sector in Malaysia and used the process change management as
a framework. The results indicate that a low level of cultural readiness and
inadequate knowledge-sharing capability coupled with inadequate cross-
functional links inhibits the success of SS initiatives, and the learning
capacity are found to contribute positively to the SS implementations. In
the absence of a common shared knowledge database, the SS teams relied
on the cooperation of cross-functional staff for information. The erratic
cooperation from functional staff had a negative impact on the group’s
knowledge-sharing capability and the network relationship between
functions.
Fredendall, Robbins and Zu (2006) identify ten (CSFs) of Six-Sigma
quality program as follows : top management support, customer
relationship, supplier relationship, workforce management, quality
information, product/service design, process management, Six-Sigma role
structure, structured improvement procedure. Aboelmaged (2010) comes
out for identifying and highlighting the factors that have always been
subject to intensive literature (e.g. Buch and Tolentino, 2006; Chakrabarty
et al., 2007; Kumar, 2007; Kwak et al., 2006). They proposed the most cited
success factors in Six-Sigma literature. These are as follows: strong top
management involvement and commitment, selection of Six-Sigma
projects, changing organizational culture, aligning Six-Sigma projects to
corporate business objectives, cross-functional team working, effective
communication, infrastructure (both organizational and IT infrastructure),
training, linking Six-Sigma to business strategy, customer, human resource
management, suppliers, measurement, accountability, understanding tools
and techniques within Six-Sigma and project management skills.
Antony et al. (2007) mentioned that the main CSFs are as follows:
managing involvement and commitment, understanding of SS
methodology, linking it to a business strategy, linking it to customers,
project prioritization and selection, organizational infrastructure, cultural
change, project management skills, linking it to suppliers, training and
linking it to employees. Several studies such as (Pfeifer, Reissiger and
Canales, 2004; Szeto and Tsang, 2005; Salaheldin and Abdelwahab, 2009)
argued that the critical success factors (CSFs) of implementing Six-Sigma
involved three main factors. The most important factor is management
involvement and commitment, followed by linking Six-Sigma to business
strategy, customer expectations are critical point, and employees are one of
the stakeholders that have the real effect on the organization performance.
Dileep et al. (2009) ranked the top five ranks of CSFs as follows: first, (top
management, leadership and commitment) are essential for SS QMS
success and should act as key drivers in continuous improvements. Second,
(well implemented the system of customer satisfaction) to monitor
customer satisfaction levels, to receive customer feedback, and to resolve
customer concerns. Third, (education and training) required to provide
continuous courses to employees for equipping them with quality-related
knowledge and problem-solving skills. Fourth, (well-organized
information and analysis system) required to collect the performance
measures in order to monitor the quality of key business processes. Fifth,
(well-implemented process management system) required to identify,
improve, and monitor the key business processes that have a positive impact
on Six-Sigma quality management success.
Pulakanam and Voges, (2010) concentrated on identifying the critical
success factors in implementing Six Sigma. They found senior management
commitment, linking Six Sigma to business strategy and customers,
organizational readiness and project management skills have identified as
most important in the four surveys of their sample. The other less important
CSFs were management of cultural change, company-wide commitment,
integration of Six Sigma with financial accountability, understanding Six
Sigma methodology, training and education, project selection and
prioritization, project tracking and reviews, incentive programs, and linking
Six Sigma to employees and suppliers.
Weinstein et al. (2011) suggested the key CSFs of Six-Sigma that
emphasis on statistical measurement, structured training plans, problem-
solving techniques. However, according to (Frank and Young, 2004) the
key CSFs includes management commitment, organizational involvement,
project governance, project selection, planning, implementation
methodology, project management and control, cultural change, and
continuous training. Antony, Antony, Kumar and Cho, (2007) present an
empirical pilot study about the key (CSFs) in the UK service sector. The
questionnaires grouped under 13 (CSFs) which extracted from the
published literature of leading Six-Sigma practitioners and academics. The
results revealed the ranking of (CSFs) based on the mean ad thee standard
deviation of the data. These ranking as follows : business strategy 4.55,
followed by customer focus 4.40, project management skills 4.40,
management commitment and involvement 4.20, organizational
infrastructure 4.15, understanding of SS methodology 4.10, project
selection and prioritization 4.05. And then, integration of SS with financial
, accountability 3.70, management of cultural change 3.55, training and
education 3.25, project tracking and reviews 3.10, incentive program 2.90,
and company-wide commitment 2.80.
The study provided by (Brun, 2011) discussed the real life application
of Six Sigma in an Italian company. The results determined 12 CSF’s
ingredients for the effective implementation of Six Sigma program. These
factors are mmanagement involvement and commitment, cultural change,
communication, organizational infrastructure and culture, education and
training, linking Six Sigma to business strategy, linking Six Sigma to
customer, linking Six Sigma to human resources, linking Six Sigma to
suppliers, understanding tools and techniques within Six Sigma, project
management skills, and project prioritization and selection. Flynn, (2011)
presented top five success factors of Six-Sigma quality program and their
definition. These factors consist of first: support and deployment strategy,
which refers to commitment from top management, process owners,
customer focus and communication. Second: resources include allocation
of time, talent, equipment, training, technical support and the right people).
Third: data-driven decision making which involves statistical thinking and
project selection. Fourth: measurement and feedback, which emphasis on
the lessons learned. Fifth: effective control plan, and organizational which
refers to the impact of cultural acceptance, readiness and behavior toward
change and workforce management.
Taner (2013) reported paper to investigate the (CSFs) for the successful
introduction of Six Sigma in Turkish construction companies. The results
found the most important CSFs factors are involvement and commitment
of top management, linking quality initiatives to customer and linking
quality initiatives to supplier. Leadership and commitment of top
management, cross-functional teamwork and commitment of middle
ARAB ECONOMICS AND BUSINESS JOURNAL 9 (2014) 93–114 97
managers found to be the most CSFs for successful introduction of Six
Sigma, whereas lack of knowledge of the system to initiate and
complacency found to be hindering its implementation.
Wang (2011) examined the essential chances of achieving Six-Sigma
implementation goals in China’s banks. The results found factor (top
management commitment) considered as a significant contributor to the
effective implementation of Six-Sigma . Ismyrlis and Moschidis, (2013)
collected a list of 32 CSF of Six Sigma implementation which were
classified according to European Foundation for Quality Management
(EFQM) to the five enablers as follows : leadership, strategy, people,
partnerships and resources, and processes.
This result is corresponding with the results reported by (EL-Jardali,
2007) that mentioned the predictors of good quality results in Lebanese
hospitals were concentrated first on factor (leadership commitment). The
top management should change the culture and attitude of the people
working within the organization at all levels through increased and
sustained communication, motivation, education and teamwork.
Communication, motivation and education will encourage information
sharing within an organization, and this reciprocal sharing overcomes
functional barriers existing in an organization, as well as facilitating
knowledge flow. Meanwhile, teamwork means collaboration between
functions, between suppliers and customers, and between managers and
non-managers. The second factor: (training and development), to update the
employees and the managers with the necessary related knowledge, and to
achieve the organization’s plans through training programs. The third
factor: (continuously learned process) is supported by (Wang et al., 2011;
Rivers, 2010), they mentioned that maintaining high quality standards
through Six-Sigma is based on a continuous process through the use of the
process improvement tools.
Wang et al., (2004) provided an application guideline for the
assessment, improvement and control of quality in supply chain
management in different companies in Taiwan by using Six-Sigma
improvement methodology. They advocated that improvements in the
quality of all supply chain processes lead to cost reductions as well as
service enhancements. Garg, Narahari and Viswanadham (2004);
introduced Six-Sigma supply chains as a new notion to describe and
quantify supply chains with sharp and timely deliveries. They show that
based on using inventory optimization problem, the design of Six-Sigma
supply chains can deliver products within a customer specified delivery
window, with at most 3.4 missed deliveries per million.
Knowles et al. (2005) proposed a conceptual model that integrates the
Balanced Scorecard, BSC model (Supply Chain Reference model) and Six-
Sigma DMAIC methodology in strategic- and operational-level cycles.
This model supported by (Chappell et al., 2006; Kang et al., 2005). The
results concluded that Six-Sigma can be applied to supply chains by
following the DMAIC framework and employing a mixture of quantitative
and qualitative tools and suggested that it is difficult to implement Six-
Sigma methodology throughout the supply chain under some circumstances
related to stock holding policies and levels of demand. In addition , several
studies such as (Wang and Li, 2004; Knowles et al., 2005; Chappell and
Peck, 2006) studied how Six-Sigma methodology can effectively be
employed in supply chain management to measure, monitor and improve
the performance of the whole supply network .
Suhaiza et al., (2011) examined the relationship between the critical
factors for the implementation of Six-Sigma programs and perceived Six-
Sigma success of electronic companies in Malaysia. The results found
cultural change was the highest variable with the mean of 4.05, then linking
with supplier with the mean of 3.85 and company infrastructure was the
lowest mean 2.87. Factors (Management involvement and commitment)
and (linking Six-Sigma to supplier management) are strong positively
related to the success of Six-Sigma implementation.
(Sahbaz et al, 2014) mentioned that Six Sigma process produces 3.4
defective parts per million opportunities (DPMO). Six sigma is a method
that eliminates errors; it makes use of a structured methodology called
DMAIC to find the main causes behind problems and to reach near perfect
processes. DMAIC is useful to analyze and modify complicated time-
sensitive healthcare processes involving multiple specialists and treatment
areas by identifying and removing root causes of errors or complications
and thus minimizing healthcare process variability. Utilization of the
Failure Mode and Effect Analysis (FMEA) involved break down the
process into individual steps: potential failure modes (complications),
severity score, probability score, hazard score, criticality and detection.
Cagnazzo and Taticchi (2010); Suhaiza and Sivabalan (2011);
Attarwala, Kulkarni and Dwivedi (2011); Tariq et al., (2011) mentioned
that Six-Sigma methodology is an effective strategy to eliminate problems
within any organization that aims for better quality in its care. Within the
Six-Sigma strategy, there are two different methodologies: the problem
solving methodology that represented in DMAIC and preventative
methodology that known as the design for Six-Sigma (DFSS) which
consists of DMADV. Using root cause analysis as a tool of Six-Sigma can
lead to know the reasons about inconsistencies. These may be due to
variation in management processes, staff errors due to multitasking
requirements, lack of formal and unified processes, lack of accountability
due to unwritten policy to enforce, or lack of communication between
patient care units due to improper handling, preparation, and delivery of the
services. Jiju ,( 2004); Kwak et al., (2006) listed the most commonly used
tools and techniques in the service organizations such as brainstorming;
process mapping; affinity diagrams; root cause analysis; control charts;
benchmarking ; pareto analysis and change management tools.
Kang et al., (2005); Cagnazzo et al., (2010); Tariq et al., (2011)
introduced the key roles related to successful implementation of Six-Sigma
methodology for the executive leadership and other members of top
management. Champions have the responsibility for SS development inside
the organization; Black Belts apply SS methodology to specific projects;
Green Belts have a good methodological preparation. Project prioritization,
selection and project management skills are another critical success factors
(CSFs) of implementing Six-Sigma. Since Six-Sigma is a project driven
methodology, the prioritization and selection of the project is essential to
apply Six-Sigma successfully. Practicing this process in an effective way
will lead to achieve maximum financial benefits to the firms.
Khaidir et al. (2014) reported that (CSFs) in SS practices is important
in order to gain the goals and great performance. The CSFs in service
industry which include understanding the DMAIC methodology; project
management skills; project prioritization and selection; project tracking
and reviews, management commitment and involvement; company-wide
commitment; cultural change; linking SS to business strategy; integrating
SS with the financial infrastructure; organizational infrastructure; training
and education; incentive program; customer focus; linking SS to suppliers.
However, The CSFs of SS practices in healthcare industry are concentrated
on the following four factors: leadership, customer focus, structured
improvement procedure and focus in metric.
98 ARAB ECONOMICS AND BUSINESS JOURNAL 9 (2014) 93–114
Because this study aims to explore the critical success factors of Six-
Sigma quality program that implemented in some of Lebanese hospitals so
all common CSFs that mention in the literature and related to Six-Sigma
quality program will be measured in this study. The common CSFs are
nineteen factors , namely, executive commitment, adopting the philosophy,
benchmarking, training, closer customer relationships, closer supplier
relationships, open organization, employee empowerment, engagement and
morale, flexible operations, process improvement, measurement,
organizational structures, zero defects mentality, teams, planning and
values, audits, problem solving tools, design and engineering, and
production, this study has been tested and validated these factors.
3.2. Key Performance indicators (KPIs) in a hospital
Rodak, (2013) defined the key performance indicators as metrics
used to measure the hospitals’ performance in different categories,
including inpatient flow such as (inpatient raw mortality rate, bed turnover,
patient satisfaction, readmission rate, occupancy rate, average length of
stay, average cost per discharge, and surgical service.
Based on a framework mostly used in the health care research for
assessing quality of health care (Kalinichenko, Amado, and Santos, 2013)
categorized the performance indicators into three interrelated elements
which are structure, process and outcome. Structure refers to organizational
characteristics of the providers of care, including human, physical, and
financial resources and tools used in delivery of health care services,
presenting the inputs in health care provision. Process refers to the activities
that go on within and between health care practitioners and patients,
focusing on conformity to technical and ethical norms of good care. In
addition, finally, outcome refers to the impact of these activities on a
patient’s current and future health status.
Ismail et al. (2011) measured patient satisfaction levels and found time
with doctor was not to be a predictor of patient satisfaction. Communication
of the staff was the highest factor that influence patient satisfaction and the
predictor factors of total patient’s satisfaction were technical quality of
clinic staff, interpersonal aspect of clinic staff, availability/accessibility of
clinic and communication of clinic staff.
De Jager, Du Plooy, and Femi Ayadi, (2010) found that there is high
levels of patient satisfaction despite the limited human resources available.
Outpatients reported positive experiences with the medical staff,
specifically the doctors. While they had, negative experiences with the lack
of service orientation especially the nursing staff, unethical situations, and
frustrating inter-personal relationship difficulties. According to the
Commonwealth Fund’s International comparison of 7-world health, the U.
S .health care system ranks five dimensions of a high performance health
system. These dimensions include quality, access, efficiency, equity,
healthy lives to clarify how will hospitals and health systems lower costs
within settings of care, provide more patient-centered, and utilize cost-
effectiveness research. With an impeding expansion of medical enrollees,
effective care and cost management will be critical for program efficiency.
Bandyopadhyay and Coppens, (2005) listed four indicators that used by
singly or in combination to define the level of performance of a healthcare
organization. These indicators are service level, service cost, customer
satisfaction, and clinical excellence. Despite the challenges in using Six-
Sigma in the healthcare industry, many hospitals within the healthcare
industry are beginning to use Six-Sigma approach to improve patients’
satisfaction.
Jiju et al. (2007) mentioned that the KPI termed as a performance
metrics of Six-Sigma that used to help organizations define and evaluate
how successful they were in making progress toward long-term goals and
objectives. Performance indicators defined as statistics, which reflect,
directly or indirectly, the extent to which an anticipated outcome achieved
or the extent to which the quality of the processes can lead to that outcome.
KPIs help managers provide continuous quality system improvement,
identify areas of excellence, compare between the actual performance and
standards and monitor corrective action.
As reported by (Chakrabarty et al., 2007) the KPIs related to Six-Sigma
in service sector talks about financial benefits, others talks about customer
satisfaction and efficiency. However, the common literature mentioned that
the majority of the KPIs across services include efficiency, cost reduction,
time to-deliver, quality service, customer satisfaction, employee’s
satisfaction, financial benefits, reduced variation, and financial bottom
lines.
i. Efficiency: is one of the most important indicator in healthcare
systems which used to measure the clinical activities performed
based on these dimensions: reducing the length of stay, bed
occupancy rate, and admission per 1000 members (Nerenz and
Neil, 2001; John, 2010).
ii. Cost reduction: according to (Heuval, Does and Bisgaard, 2005;
Rivers, 2010) health care has opportunity to reduce costs by
eliminating wastes depending on three dimensions : reducing
errors, mistakes in a process, or reducing the time taken to
complete a task, or reducing a patient’s stay at a hospital to
provide opportunities for more admissions.
iii. Time-to-deliver: as mentioned by (Bandyopadhyay et al, 2005)
service time, waiting time, and cycle time are three dimensions
used to measure this indicator in the service sector. Service time
refers to the time required to serve a particular customer. Waiting
time refers to the time a customer waits in the system to have the
work completed .Cycle time refers to the total time including
service and waiting time
iv. Quality of the service: based on the previous studies mentioned
by (Hensley and Dobie, 2005) healthcare systems can depend on
the extent to which the service delivered, meets the customer’s
expectations as an adequate dimension to measure this indicator.
v. Customer satisfaction: as suggested by (Cowing, Davino-
Ramaya, Ramaya, and Szmerekovsky, 2009) healthcare
organizations found customer satisfaction is becoming an
important indicator for measuring its performance by using two
dimensions include patient satisfaction and perception of service
delivery by patient and clinician. These dimensions are
considered as subjective assessments based on the nature of
interactions with staff, the nature of communication with
clinicians, the degree of personalized care, the accessibility of
care, the responsiveness, and the timeliness of care. The health
care organization, the clinician (team of physicians, nurses,
medical assistants, and office staff), and the patients are
interrelated perspective on the needs associated with health care
performance to satisfy customers.
vi. Employee satisfaction: based on (Fogarty, Kim, Juon, Tappis,
Noh, Zainullah and Rozario, 2014), health-care worker
satisfaction and intention to stay on the job are highly dependent,
different groups of health-care workers in previous studies from
ARAB ECONOMICS AND BUSINESS JOURNAL 9 (2014) 93–114 99
other low-; middle- and high-income countries found that
retention rate of health-care workers is critical to measure
employees satisfaction for improving health system performance.
Being paid an appropriate salary, offered financial and moral
incentives to health-care workers were negatively related to
retention rate and intent to stay (??=?-0.326, P?