Capella Univeristy Statistics Discussion

11/21/22, 1:27 PMDiscussion Participation Scoring Guide
Print
Discussion Participation Scoring Guide
Due Date: Weekly.
Percentage of Course Grade: 30%.
Discussion Participation Grading Rubric
Criteria
Non-performance
Basic
Proficient
Distinguished
Applies relevant course
Does not explain relevant
Explains relevant course concepts,
concepts, theories, or materials course concepts, theories, or theories, or materials.
correctly.
materials.
Applies relevant course
concepts, theories, or materials
correctly.
Analyzes course concepts, theories, or
materials correctly, using examples or
supporting evidence.
Collaborates with fellow
Does not collaborate with
learners, relating the discussion fellow learners.
to relevant course concepts.
Collaborates with fellow learners
without relating discussion to the
relevant course concepts.
Collaborates with fellow
learners, relating the discussion
to relevant course concepts.
Collaborates with fellow learners, relating
the discussion to relevant course concepts
and extending the dialogue.
Applies relevant professional,
personal, or other real-world
experiences.
Does not contribute
professional, personal, or
other real-world
experiences.
Contributes professional, personal, Applies relevant professional,
or other real-world experiences, but personal, or other real-world
lacks relevance.
experiences.
Applies relevant professional, personal, or
other real-world experiences to extend the
dialogue.
Supports position with
applicable knowledge.
Does not establish relevant
position.
Establishes relevant position.
Validates position with applicable
knowledge.
Supports position with
applicable knowledge.
Participation Guidelines
Actively participate in discussions. To do this you should create a substantive post for each of the discussion
topics. Each post should demonstrate your achievement of the participation criteria. In addition, you should also
respond to the posts of at least two of your fellow learners for each discussion question-unless the discussion
instructions state otherwise. These responses to other learners should also be substantive posts that contribute to the
conversation by asking questions, respectfully debating positions, and presenting supporting information relevant
to the topic. Also, respond to any follow-up questions the instructor directs to you in the discussion area.
To allow other learners time to respond, you are encouraged to post your initial responses in the discussion area by
midweek. Comment to other learners’ posts are due by Sunday at 11:59 p.m. (Central time zone).
https://courserooma.capella.edu/bbcswebdav/institution/DHA/DHA8042/190100/Scoring_Guides/discussion_participation_scoring_guide.html
1/1
Hey Tutor, there are two separate discussions that
you will present in separate word document. Each
word document will be single-spaced on one page,
hence you will be submitting two separate jobs. I
noticed that you don’t write the exact topic in your
solution. Please pay keen attention to the topics,
e.g. Discussion 1 Topic XXXXX, and Discussion 2
Topic XXXX. Please label them correctly this time. I
bolded the topics to get you out the confusion.
Please pay attention to the scoring guides also.
Discussion 1 Topic: Lean Management and Six
Sigma
Discuss with your peers concepts of lean management and Six Sigma that may
apply to improving quality and performance at a health care organization.
Discussion Topic 2: Leadership and the
Multidisciplinary Team Approach
Now that you have discussed lean management and the concepts of Six Sigma,
take a moment to discuss how leadership and the multidisciplinary team
approach are important to performance improvement. Consider how these
concepts can help projects become successful.
The resources below are from our assigned textbook,
but you can get it from other books to help you do the
two discussion topics. The resources are
•
•
Strategic Application of Six Sigma Concepts,”
Tactical Application of Lean Enterprise Theory,”
The current issue and full text archive of this journal is available at
www.emeraldinsight.com/0952-6862.htm
IJHCQA
26,3
Evaluating Lean in healthcare
Nicola Burgess
Warwick Business School, University of Warwick, Coventry, UK, and
220
Received 11 November 2010
Revised 6 May 2011
Accepted 29 May 2011
Zoe Radnor
Cardiff Business School, Cardiff University, Cardiff, UK, and
School of Business and Economics, Loughborough University,
Loughborough, UK
Abstract
Purpose – The purpose of this paper is to present findings relating to how Lean is implemented in
English hospitals.
Design/methodology/approach – Lean implementation snapshots in English hospitals were
conducted by content analysing all annual reports and web sites over two time periods, giving a
thorough analysis of Lean’s status in English healthcare.
Findings – The article identifies divergent approaches to Lean implementation in English hospitals.
These approaches are classified into a typology to facilitate an evaluation of how Lean is implemented.
The findings suggest that implementation tends to be isolated rather than system-wide. A second
dataset conveys Lean implementation trajectory across the time period. These data signal Lean’s
increasing use by English hospitals and shows progression towards an increasingly systemic
approach.
Practical implications – Data were collected using content analysis methods, which relies on how
“Lean” methods were articulated within the annual report and/or on the organisation’s web site, which
indicates approaches taken by hospital staff implementing Lean.
Originality/value – This research is the first to examine more closely “how” Lean is implemented in
English hospitals. The emergent typology could prove relevant to other public sector organizations
and service organisations more generally. The research also presents a first step to understanding
Lean thinking in the English NHS. This article empirically analyses Lean implementation in English
hospitals. It identifies divergent approaches that allow inferences about how far Lean is implemented
in an organisation. Data represent a baseline for further analysis so that Lean implementation can be
tracked.
Keywords Lean, Health care, Implementation, NHS England, National Health Service, United Kingdom
Paper type Research paper
Introduction
The English National Health Service (NHS) is a public sector organisation with a
longstanding objective to deliver high-quality healthcare free at the point of use.
Persistent NHS reform and calls for improved efficiency are considered prominent
drivers of process improvement methods such as Lean (Radnor et al., 2012; Radnor,
2010). During the last Labour government, Cole and Radnor (2010) report a gradual
shift towards increased governance and accountability, creating widespread pressure
to meet stringent performance targets. Performance in this regard is closely audited by
International Journal of Health Care
Quality Assurance
inspectorate bodies such as the Care Quality Commission (CQC) and the foundation
Vol. 26 No. 3, 2013
trust (FT) independent regulator, Monitor. Since 2004, the best performing NHS trusts
pp. 220-235
q Emerald Group Publishing Limited could apply to Monitor to become a new organisation known as a foundation trust,
0952-6862
which confers greater financial and operational freedom on trust managers. Ascension
DOI 10.1108/09526861311311418
to FT, however, involves extensive and rigorous assessment (NHS Choices, 2009),
representing a government drive towards devolved decision making (Monitor, 2009).
Calls for efficiency and performance targets led to process improvement methodologies
such as Lean, which is based on continuous improvement focusing on value, flow and
waste reduction. A recent literature review of business process improvement
methodologies found that 51 per cent of publications focused on Lean (35 per cent in
the health services) (Radnor, 2010). Further evidence of Lean implementation in
healthcare is proffered by reports in the main and grey literature (Brandao de Souza,
2009; Young and McCLean, 2008). Despite indications that Lean is prevalent in
healthcare, many authors regard Lean implementation to be pragmatic, patchy and
fragmented (Proudlove et al., 2008; Young and McCLean, 2008). To be effective at
delivering sustained and continuous service improvement, Lean implementation
should be aligned to organisational strategy, where Lean becomes part of the
organisational culture (Davies and Walley, 2000; Corbett, 2007; Ben-Tovim et al., 2007;
Hines et al., 2004; Hines et al., 2008). Here, we seek to evaluate empirically how Lean is
implemented in healthcare, specifically English hospitals, so that its impact can be
understood. We present three key findings: Lean implementation continues to be
popular in English hospital trusts; managers are implementing Lean in different ways
ranging from tentative exploration to systemic approaches; and hospital managers
have enhanced and elevated their approach to Lean implementation in line with an
organisation-wide programmes aligned to organisational strategy.
Background
Originating from the Toyota Motor Corporation in Japan, Lean (also referred to as the
Toyota Production System) was initially conceived as a radical alternative to
traditional mass production. This alternative manufacturing-method was conceived
when scarce resources and a financial crisis in Japan rendered mass production
practices (where products could be made cheaply in large quantities and stockpiled for
later sale) as infeasible (Cusumano, 1988; Holweg, 2006; Oliver, 2008; Seddon et al.,
2009). Womack et al. (1990) and Womack and Jones (1996) are widely credited as
popularising Lean in the West, coining the term “Lean Thinking” and articulating
Lean’s five core principles that guide its implementation. Lean is based on an
underlying assumption that organisations are made up of processes – linked activities
that have a specific order and space, with a beginning, an end and clearly defined
inputs and outputs (Davenport, 1993). Such processes can traverse and interlock with
other sub-processes or form the beginning/end of another procedure. Thus a process
perspective means moving away from traditional functions focused around
organisational activities towards creating value from the customer’s perspective
(Davenport, 1993). McNulty and Ferlie (2002, p. 20) elaborate: “a process perspective is
concerned with value creation rather than merely control of the value creation process”.
Lean is about making “value” flow at every step where value is what a customer would
pay for and waste is what a customer would not pay for. Lean, therefore, is primarily
about improving quality so that non-value adding activity (i.e. waste), which often
adds delay, requires extra resource (and ultimately attracts extra costs), should be
eliminated. Lean principles are promoted as a universal guide to its implementation
(Womack and Jones, 1996; Porter and Barker, 2005):
Evaluating Lean
in healthcare
221
IJHCQA
26,3
222
(1) Specify value from the customer’s perspective. Probably Lean’s most important
element is specifying and identifying value. As Womack and Jones (1996, p. 141)
state: “failure to specify value correctly before applying Lean techniques can easily
result in providing the wrong product or service in a highly efficient way.” In
healthcare, however, value is conceived as multifaceted and indeterminate.
Interpretations and perspectives vary widely. Young and McCLean (2008) define
value from a patient pathway perspective – the route patients take from entry into
hospital until s/he leaves; i.e. designing pathways around creating value to patients
at each step rather than considering patient-centred activities such as radiology,
pathology and ward care for example, as isolated processes or “functional silos”.
(2) Identify the value stream for each product/service provided and challenge all
wasted steps by mapping all processes involved in creating a product/service.
One might map the stroke patient pathway to identify value and non-value
adding activity. Process start and end points under consideration need to be
agreed in advance to keep the improvement focussed and manageable; for
example, the mapped process might start from stroke onset, hospital journey
(ambulance, walk-in patient or GP referral) and the process end-point in an
acute care setting context might be patient discharge. In practice, the mapping
activity is conducted by people who “touch” the patient pathway at different
points (call handler, paramedic, nurse, matron, specialist doctor, departmental
manager, etc.), later coming together to map the process. The outcome should be
an enhanced understanding of process aspects to challenge the steps not adding
value to the customer/patient.
(3) Make the product/service flow continuously and standardise processes around best
practice, which means redesigning the process and eliminating non-value adding
activity such as waiting for a bed, a specialist doctor or medication, for example.
(4) Introduce “pull” between all steps where continuous flow is impossible.
Recognising that it might not be possible to eliminate all non-value adding
steps immediately, this principle aims to eliminate waste as far as possible by
“pulling” the customer/patient to the next process step. For example, theatre
staff might telephone ward nurses to ask if there is a bed available for a patient
while s/he is in the recovery bay following surgery; this action presents an
attempt to push patients from one location to another. If there are no beds
available in the ward or no one available to answer the phone then the recovery
ward will soon become blocked consequently inhibiting theatre staff.
Conversely, a “pull” process would involve ward staff releasing beds to
patients in theatres based on their patient-demand knowledge.
(5) Manage towards perfection. Systematically eliminating waste to achieve an
ideal process where value is created at every step should become part of
organisation culture, where Lean becomes “the way we do things around here”,
so that non-value adding activity is continuously removed and the steps, time
and information needed to serve the customer/patient continually falls.
Toussaint and Gerard (2010) simplify these principles for healthcare as: focus on the
patient and design care around them; identify value for the patient and get rid of
everything else (waste); minimise time to treatment and through its course.
Lean thinking and healthcare
Transferring Lean to healthcare is relatively new. Brandao de Souza (2009) identifies
the first reference to Lean in UK healthcare by the NHS Modernisation Agency (2001).
Since then over 90 publications from ten countries refer to Lean in healthcare (Brandao
de Souza, 2009). Balle and Regnier (2007, p. 33) account for Lean’s popularity in
healthcare owing to a “double focus of Lean on customer satisfaction and employee
involvement [that] suits the culture of most care centres”. Similarly, Gary Kaplan,
Virginia Mason Medical Centre (VMMC) Chief Executive Officer (CEO), Seattle, cites
similarities between Lean and healthcare philosophies, primarily “putting the customer
first, a focus on quality and safety and a commitment to employees’ (Bohmer and
Ferlins, 2006, p. 4). However, according to Spear (2005, p. 91): “in healthcare, no
organisation has fully institutionalised to Toyota’s level, the ability to continuously
and systematically eliminate waste.” His contention is largely supported in the
literature, which identifies Lean implementation in healthcare as patchy and
fragmented (Young and McCLean, 2008; Proudlove et al., 2008; Balle and Regnier,
2007). Authors argue that a disjointed approach to Lean implementation delivers
pockets of best practice (Holweg and Pil, 2001; Radnor and Walley, 2008), which
potentially have a negative impact on the wider healthcare system (Towill and
Christopher, 2005; Waldman and Schargel, 2006). Some hospitals have become seminal
examples of Lean implementation, notably: VMMC in Seattle, USA; Flinders in
Australia and the Royal Bolton NHS Foundation Trust (RBH), UK (Bohmer and
Ferlins, 2006; Ben-Tovim et al., 2007; and Fillingham, 2008). Gubb (2009) notes the
Flinders Medical Centre achievements, which after two-and-a-half years was doing
15-20 per cent more work, with fewer safety incidents, on the same budget, using the
same infrastructure, staff and technology. Gubb (2009) also cites a reduced average
turnaround time in pathology from over 24 hours to two to three hours using less space
and fewer resources by staff at RBH. The RBH staff commitment to Lean, part of the
hospital’s long term strategy, is evidenced by its investment in Lean training across the
hospital aligned to career progression. David Fillingham (2008, p. 129), formerly Royal
Bolton’s CEO, explains:
[. . .] all 3,500 staff are to be trained to green level. Those wanting to progress to a first-line
supervisory role will be expected to achieve a bronze accreditation, while those in senior
management positions will be expected to achieve silver [. . .] “those who aspire to director
level or become part of the central Bolton Improving Care System (BICS) team [internal
improvement team] will be expected to train to the Gold standard.” The platinum level is
described as “a lofty aspiration” close to “sensei”.
Aim and method
Our research: explores how Lean is implemented in English hospitals; and provides
baseline data against which Lean implementation trends in healthcare can be tracked.
We contend that discernible approaches to Lean implementation exist in healthcare
and these approaches may progress over time towards an emerging culture where
Lean becomes “the way we do things around here”. We present data collected at two
points – 2007/2008 (T1) and 2009/2010 (T2). Our research design was guided by
Pettigrew and Whipp’s (1991) strategic change context-content-process model. The
“context” dimension refers to the “why” of change; “content” refers to “what”; and
“process” to “how”. The rationale for employing this model as a data-collection
Evaluating Lean
in healthcare
223
IJHCQA
26,3
224
framework is that Lean implementation requires change at both strategic and
operational levels (Hines et al., 2004, 2008). Our research adopts Pettigrew’s (1990,
p. 268) view: “theoretically sound and practically useful research on change should
explore change contexts, content and process together with their interconnections
through time. The aim is to catch reality “in flight”. The model is widely used to
analyse NHS change programmes (Pettigrew et al., 1992; Iles and Sutherland, 2001;
Stetler et al., 2007). The model’s basis is the contention that these three dimensions are
interrelated and any study in the NHS must consider all three dimensions. Figure 1
illustrates how the model guides data collection.
Data collection
Using content analysis (Weber, 1990), we examined all T1 and T2 annual reports from
English acute (excluding specialist) hospitals using a combined narrative analysis and
the key word in context (KWIC) approach (Grbich, 2007). Annual reports were chosen
as the main data source because trust managers are required to publish reports
covering the previous 12 months for Parliamentary purposes (Schedule 7, paragraph
25(4), National Health Service Act 2006). These reports are available to the public via
hospital web sites and generally adopt the standard structure (see the following list).
Guidance for annual report structure and content
.
directors’ report including a management commentary;
.
a remuneration report;
.
disclosures set out in the NHS Foundation Trust Code of Governance; and
.
other disclosures in the public interest.
The commentary (in the previous list) is usually written by the trust’s chairman and
chief executive and contains a narrative relating to highs, lows, strengths, weaknesses
and challenges (often financial or performance-oriented) faced by trust managers over
Figure 1.
Pettigrew and Whipp’s
(1991) Context-ContentProcess framework
the past year and provides an insight into the Lean implementation context. For
example:
.
indicating a successful/disappointing/difficult year;
.
attitude/drivers for service improvement;, e.g. a “turnaround trust” or one
claiming to be at the innovation and service improvement forefront;
.
financial circumstances: whether trust managers faced a historical debt or
healthy surplus;
.
key achievements and awards.
The content analysis method facilitated deriving key themes that serve as indicators
relating to the content and process of Lean implementation in the organisation. Based
on 20 annual reports, we found the following key words commonly associated with
Lean implementation:
.
“Lean” – as an application/awareness of Lean methods;
.
“productive” – implementing the national Productive Ward programme
commonly associated with Lean. Productive Ward (PW) is a national
programme based primarily on the “5S” tool for improving workplace
organisation and discipline (www.institute.nhs.uk);
.
“releas” – base form of the word “releasing” from the “releasing time to care”
initiative used synonymously with PW;
.
“waste” – reference to removing waste from processes;
.
“improvement” – highlighting activities related to service improvement that
may be connected to Lean;
.
‘rapid” and “kaizen” – rapid improvement events (also referred to as kaizen
events) as Lean implementation elements often used as a vehicle for
improvement projects and value stream mapping activities;
.
‘project” – identifying projects associated with Lean methods.
Our method identified trusts articulating Lean methods in their annual reports. The
search words were often embedded within service improvement/transformation
programmes, pathway redesign projects or small discrete projects that championed
Lean methods. Tables I and II present specimen data from one trust’s annual report.
Tables I and II clarify how data were collected, how categories are arrived at and the
rationale for the awarded category. Table I focuses on contextual data forming the
basis of more detailed research that considers the context’s influence on Lean. Table II
presents data collected to determine the approach to Lean implementation by the trust.
Limitations
We acknowledged that annual reports may be incomplete, biased and distorted, and it
may be that hospital managers are using but not mentioning Lean methods in their
report. To help counterbalance this issue, we extended our method to corresponding
trust web sites, which uncovered instances where trust staff cite Lean activities, for
example, in minutes, staff magazines or documents outlining a Lean consulting tender
or reporting an early, experimental project based on Lean methodology.
Evaluating Lean
in healthcare
225
Northern and Yorkshire region
Rural and costal
6,700
385,000
Context (internal)
Physical attributes
Area served
Population/location characteristics
Staff (FTE)
Catchment population
CQC – Service Quality
CQC – Resource use
Good
Excellent
Excellent
Fair
2008/2009
2006/2007
Good
Fair
T2
T1
1 May 2007
2007/2008
Yorkshire and the Humber
Context (external)
Strategic Health Authority (SHA)
Not coded
FT1
Large trust
Rural and coastal
Y&H
Categorical
interpretation
(continued)
In the UK, hospital trusts undergo a
rigorous assessment process to
achieve FT, which affords financial
and operational freedom to invest in
services they choose. FT1 means that
the organisation was a FT during T1;
FT2 infers that the organisation
attained FT status during T2
The Care Quality Commission (CQC)
conducted annual NHS-trust health
checks in England under two
categories: “service quality” and
“resources” between 2005-2009. These
scores provide useful contextual data
relating to how the trust is performing
operationally
Trust size and location. Several
hospital trust annual reports suggest
that area demographics have a direct
impact on services demand
SHA strategic direction may influence
Lean uptake in the region
Rationale
226
Trust performance
Foundation Trust (FT) authorisation
Data extracted
Table I.
Data collected under the
strategic change
“context” dimension for
Northern Lincolnshire
and Goole Hospitals NHS
Foundation Trust
Construct
IJHCQA
26,3
T1
Andrew North,
joined in April
1997 as CE
Data extracted
T2
Karen Jackson
Culture and strategy (from annual report summary by Chief Executive and Trust Chairman)
Notes from annual reports (T1: 2007/ “when reviewing our performance ‘in
2008)
the round’ we believe 2007/2008 to
have been a highly successful year’ for
the trust [. . .] It is testimony to my
colleagues that the Trust met and
exceeded our main financial and
performance targets meaning we have
money we can invest in the future
healthcare provision”
Notes from annual reports (T2: 2008/ “Throughout the year the trust has
2009)
built on the strong foundations
established in earlier years of both a
sound financial footing and high
quality services, and to give areal
emphasis to simultaneously
improving quality while driving value
for money”
Leadership
Chief Executive name and
background
Construct
The trust reports a successful year
meeting and exceeding targets. The
trust is coded as “successful” for T1
Another successful year denotes a
stable, strong performance
*This is not a picture that is portrayed
by most English Trusts! Other
categories include: financial difficulty;
crisis; recovery (financial turnaround)
among others
Successful
Has the CE changed recently, this may
impact on Lean implementation in the
trust
Rationale
Successful
New CE, stable
history
Categorical
interpretation
Evaluating Lean
in healthcare
227
Table I.
Table II.
Data collected under the
strategic change
“content” dimension for
Northern Lincolnshire
and Goole Hospitals NHS
Foundation Trust
Content
Areas identified under
transformation and impact
Categorical interpretation
T2: The centralised Histopathology service in
Lincoln has radically transformed its operations
through the implementation of LEAN thinking
and working practices. This has lead to greatly
improved productivity levels and quality of
service as evidenced by:
45 per cent Reduction in Turnaround Time
60 per cent Increase in Productivity
53 per cent Increase in Efficiency
98 per cent Reduction in Errors
Similar improvements have been made in
Cytology whereby the service far exceeds the
requirement to meet the national standard of a
maximum two week TaT for cervical cancer
screening. In Lincolnshire, all such tests are
reported in less than one week
T1: Lean assessments have been undertaken in a T1: Programme
number of areas both within pathology and into
the wider hospital community (theatres, surgery
and patient administration). Path links have
already benefited from a number of successful
projects in histology, blood sciences, and
microbiology and these same principles will now
be applied elsewhere in the trust using the newly
created “Lean Academy” (p. 33)
T2. Path Links has undertaken a major overhaul T2: Systemic
of its quality and governance arrangements
following the appointment of a Lean Specialist.
Targeting Lean implementation across the whole
of the organisation, the delivery of enhanced
levels of service quality and performance is the
overriding focus (p. 73)
Data extracted
Data collected supports the categorical
interpretation of the Lean approach
In T2, Lean and the Path Links programme
continues to thrive. The trust is categorised as
“systemic” as there is clear evidence that the
strategy is to implement Lean in the whole
organisation. Commitment to this endeavour is
shown by appointing a Lean specialist
Path Links is the name given to a programme
that clearly uses Lean methods. Several projects
are identified throughout the report alongside a
formal academy for Lean training
Rationale
228
Process
Elements of Lean and areas
identified as under
transformation.
Construct
IJHCQA
26,3
Validity and reliability
It is up to the investigators using content analysis to judge what method is appropriate.
However, to make valid inferences, classification procedures must be reliable
(consistent) (Weber, 1990) and thereby replicable. Transparency, the explicit process
used to collect data and key words for identifying Lean implementation and explicit
rationale for coding data are critical (Grbich, 2007) (see Tables I and II). We repeated
our data collection consistently, 300 hundred times at two points in time (152
individual hospital trust reports in 2008 and 142 in 2010 – reduced owing to hospital
mergers). This content analysis approach is intended to be a Lean implementation
“overview” or “snapshot” based on how Lean methods are articulated in the annual
report. In most cases, only small chunks of text in the annual reports referenced service
improvement activity and this text may or may not articulate or infer that Lean was
used. Thus, the extracts we analysed were treated as straightforward
Lean-implementation indicators and have not been subject to inter-rater reliability
tests. This may be perceived as a limitation; however, we feel that this weakness is
counter-balanced by the study’s high transparency levels and process repetition.
Findings
Our findings represent a snapshot of Lean implementation in English hospitals at two
points in time. During the operating year 2007/2008, 80 hospital trusts (53 per cent) in
our study cite Lean implementation in their annual reports and/or their corresponding
web sites. During the operating year 2009/2010, this figure rises to 111 trusts or 78 per
cent of the study population. Claims in the reports regarding Lean application and
implementation varied considerably – from trusts citing a few projects to those
announcing improvement programmes based on Lean principles. The Lean
implementation spectrum emerging from the dataset is presented as a typology in
the following list.
Approaches to Lean implementation – a typology
.
Tentative – Trust staff are contemplating Lean, tendering for external
management consultancy to help with implementation or piloting a small
isolated project.
.
Productive Ward Only (PW) – Trust staff are implementing Productive Ward
and or Productive Theatre but no other evidence of Lean implementation is
identified.
.
Few projects – Trust staff are using Lean principles and methods to underpin
projects relating to certain functions or pathways within the organisation.
.
Programme – Trust managers refer to Lean principles underpinning work
programmes expected to last between one and five years.
.
Systemic – Trust report refers to embedding Lean principles in the trust as a
whole so that it becomes “the way we do things around here”. A systemic
implementation also emphasises Lean training for all staff.
Figure 2 illustrates the distribution of Lean implementation approaches in English
hospital trusts during T1 and T2. The graph suggests that while a “few projects”
approach to Lean implementation is most prevalent in both T1 and T2, there has been
Evaluating Lean
in healthcare
229
IJHCQA
26,3
230
Figure 2.
Lean implementation in
English hospital trusts
a significant increase in the annual reports articulating a systemic approach to Lean
during T2.
The prevalence of a “few projects” approach was largely anticipated and supports
the literature, which claims that many hospital trusts are doing a few small projects
based on Lean methods but that this approach to implementation does not form an
integrated approach to service improvement (Radnor, 2010; Young and McCLean,
2008; Spear, 2005). What is particularly interesting, however, is the rise in hospital
trust managers articulating a more advanced implementation of Lean in their annual
reports (37 in T2 compared to 27 in T1 claiming to be taking a programme or systemic
approach). This finding leads us to consider the trajectory between approaches.
Figure 3 illustrates hospital trust movements from one implementation approach to
another. The central diagonal denotes trusts categorised as taking the same approach
in T2 as T1. To the right of the diagonal are trusts that increased their Lean
implementation and to the left are the hospitals that appear to have scaled down their
Lean implementation or stopped altogether.
Figure 3 shows 51 trusts (36 per cent) appearing to have maintained activity.
However, there is an early indication towards a more systemic and strategic approach
Figure 3.
Comparing approaches to
lean implementation
during T1 and T2
to Lean implementation in English hospital trusts. Seventy trusts (49 per cent) moved
to the right of the central diagonal, denoting a progression from localised approaches to
Lean implementation to one that is more system focused. Of 28 trusts identified as
taking a “few projects” approach in T1, 14 continued this approach in T2, five trusts
formalised the approach as a “programme”, and three appear to have aligned Lean to
organisational strategy, thereby warranting a systemic classification. Of those trusts
identified as taking a programme approach in T1, five progressed towards a systemic
organisation-wide approach in T2; five appear to have scaled down to a few projects or
PW and three appear to have stopped implementing Lean. In total 13 trusts appear to
have stalled Lean implementation during T2; i.e. Lean was not mentioned in the annual
report despite being reported in T1.
Discussion
Shah and Ward (2007, p. 791) state that Lean is “an integrated socio-technical system”
and should be considered to be a set of tools, techniques and practices (which can often
be easily emulated) combined with a cultural or social system (it takes time to change
organisational principles and routines). Figure 2 depicts only five hospitals taking a
systemic approach to Lean implementation in T1 rising to 15 in T2. “Productive Ward”
or “few projects” trusts could be viewed as taking short-term and localised approaches
to improvement, probably driven by national performance and efficiency targets;
i.e. focusing on the imminent pressures facing the organisation rather than a strategy
for long term improvement (Radnor and Walley, 2008). This approach reflects the
perception of Lean implementation in healthcare as fragmented, focussing on Lean’s
visible elements – tools and technology – but fails to address its less-visible strategic
elements and enabling factors relating to leadership and organisational readiness
(Radnor, 2010; Hines et al., 2008). One consequence is that initiatives such as the PW
are seen as Lean and so little effort is placed into sustainable activities such as
developing a structured, problem-solving culture (Radnor and Walley, 2008; Radnor
et al., 2012). Many authors express caution about a tools-based approach. Spear (2004)
suggests that where staff merely imitate the tools and not Lean principles then the
result is a rigid inflexible system. Indeed, David Fillingham, RBH’s former Chief
Executive, warns:
The risk in creatively adapting Lean initiatives to suit your own organisation is that their
essence can easily be lost. It can degenerate into just another quality drive, or worse still [. . .]
talking shops in which nothing gets done. The trick is to recognise the core elements of a Lean
approach and embody them in all you do (Health Service Journal, 2008).
Lean is often described as a journey containing landmarks in its implementation stages
(Bicheno, 2004; Hines et al., 2008). Some researchers suggest that developing and
implementing the tools facilitate a gradual cultural and behavioural change (Radnor
and Bucci, 2007). It could be argued that for some hospital trusts, PW and a “few
projects” approach represent the start or part of the Lean “journey”, suggesting that the
approaches to Lean implementation (see previous list) may potentially depict this
journey as organisational staff move at varying paces through each stage – from
isolated applications to daily problem-solving and improvement. Figure 3 offers some
support for this contention, where trajectory is portrayed by data analysis, which
might suggest that each category represents a journey landmark. For example, the
Evaluating Lean
in healthcare
231
IJHCQA
26,3
232
journey may consist of tentatively exploring Lean and its methods, followed by
experimentation with Lean tools and small projects before trust managers commit to a
service improvement programme based on Lean. The destination being where Lean
becomes aligned with organisational strategy and thus becomes part of daily working
life (Corbett, 2007).
The data however, do not suggest a linear transition from a tentative exploration
through each implementation stage. Thus, more detailed exploration is needed to fully
understand Lean implementation’s context, content and process in hospital trusts; in
line with how Pettigrew and Whipp (1991) intended their strategic change model to be
used. Pettigrew et al. (1992, p. 9) claim, “the analytical challenge is to connect the
content, context and process of change over time to explain the differential
achievement of change objectives”. Therefore, further research will gather and
combine these elements through ethnographic and case study analysis to overcome
content analysis limitations and to generate a more detailed understanding and
evaluation of Lean implementation in English hospitals. To illustrate the need to
explore context in greater detail, we examine one case. Figure 3 shows one trust
categorised as taking a systemic approach in T1, falling to “No Lean” (no evidence of
Lean implementation) in T2. Referring to the T1 and T2 data collected for this trust,
there is a clear commitment to implementing Lean based on their dedication to staff
training around Lean principles and descriptions of numerous projects based on Lean
methods. The trust’s CEO advocates Lean principles to achieve “organisational
transformation” within a supportive context:
We will foster a supportive culture in which we learn from mistakes, share best practice and
encourage staff to maximise their potential (Brighton and Sussex University Hospitals NHS
Trust, 2008, AR07/08:2).
In T2, trust managers report improved performance:
[. . .] a significant transitional year for the trust finances. With the support of the whole
organisation, and the local healthcare commissioners, the trust has delivered a surplus of £4.6
million.
Clearly, annual reports as analytical units, limit the degree to which any explanation
can be inferred, and thus without more detailed analysis one can only guess the
reasoning behind Lean’s disappearance in the trust. One explanation might be that
Lean was used towards a specific organisational goal and once achieved it was
dropped or no longer deemed noteworthy. A case study approach will facilitate a more
rigorous exploration of Lean implementation context, content and process to
understand its impact and why Lean might have stalled. Overall, 22 trusts appear to
have downgraded Lean implementation with 13 apparently stalling. Burgess and
Radnor (2010) report that Lean can stall, owing to manager mobility, quantifying the
benefits and value problems, and omnipresent financial pressures. In Brighton and
Sussex University Hospitals NHS Trust, Lean’s disappearance cannot be explained by
unstable management teams as the data reveal no issues. There is an indication,
however, that the Lean implementation-driver was related to finance, which leads us to
infer that either Lean was considered a tool rather than a strategy, or it could be that
Lean methods alongside other methods have become orthodox and thus no longer
receives attention in the trust’s annual report.
Conclusion
We present a snapshot using content analysis methods – an approach that: facilitates
synthesising large datasets across a reasonably large study population; and enables
change over time to be compared. Further analysis is needed to explore context
influence on Lean approaches and the sustainability or progression of that approach.
This will be carried out through case studies. We present and discuss three key
findings. First, Lean implementation continues to be popular in English hospital trusts;
furthermore, its implementation has become progressively widespread. Second,
hospital trust managers are implementing Lean in different ways ranging from a
tentative exploration in the form of learning from others (hospitals and organisations
in other sectors), through to a systemic approach aligned to strategy. Third, English
hospital managers increasingly enhance and elevate their Lean implementation
approaches in line with organisation-wide programmes and to the organisation’s
strategy. We develop a greater understanding of Lean implementation in hospitals,
which contributes to understanding how implementing an approach or practice into a
context for which it was not developed (i.e. from manufacturing). Our typology and
baseline data allowed us to track implementation movement and to investigate the
movement up and down the types. Further research using more detailed and in-depth
enquiry-methods, such as case studies to build theory (Eisenhardt, 1989), is necessary
to validate our findings. Sequential data collection, to generate time-series information,
will enable researchers to explore trends during Lean’s transition that starts with
tentative exploration, a tool or a few projects that develops into a programme and
eventually into a systemic approach.
References
Balle, M. and Regnier, A. (2007), “Lean as a learning system in a hospital ward”, Leadership in
Health Services, Vol. 20, pp. 33-41.
Ben-Tovim, D., Bassham, J., Bolch, D., Martin, M., Dogherty, M. and Szwarcbord, M. (2007),
“Lean thinking across a hospital: redesigning care at the Flinders Medical Centre”,
Australian Health Review, Vol. 37 No. 1, pp. 10-16.
Bicheno, J. (2004), The New Lean Toolbox: Towards Fast, Flexible Flow, 3rd ed., Picsie Books,
Buckingham.
Bohmer, R. and Ferlins, E.M. (2006), Virginia Mason Medical Center, Harvard Business School
Case 606-044, Harvard Business School, Boston, MA.
Brandao de Souza, L. (2009), “Trends and approaches in lean healthcare”, Leadership in Health
Services, Vol. 22 No. 2, pp. 121-39.
Brighton and Sussex University Hospitals NHS Trust (2008), Annual Report, available at: www.
bsuh.nhs.uk/about-us/trust-reports-and-policies/ (accessed 20 August 2009).
Burgess, N. and Radnor, Z. (2010), “Lean implementation in healthcare: complexities and
tensions’”, Proceedings of the 17th International Annual EurOMA Conference: Managing
Operations in Service Economies, Porto.
Cole, J. and Radnor, Z. (2010), “How healthy is the annual health check?”, International Journal of
Health Care Quality Assurance, Vol. 23 No. 6, pp. 537-53.
Corbett, S. (2007), “Beyond manufacturing: the evolution of lean production”, The McKinsey
Quarterly, Vol. 3, pp. 95-105.
Evaluating Lean
in healthcare
233
IJHCQA
26,3
234
Cusumano, M. (1988), “Manufacturing innovation: lessons from the Japanese auto industry”,
Sloan Management Review, Vol. 30 No. 1, pp. 29-39.
Davenport, T.H. (1993), Process Innovation, Harvard Business School Press, Boston, MA.
Davies, C.L. and Walley, P. (2000), “Clinical governance and operations management
methodologies”, International Journal of Health Care Quality Assurance, Vol. 13 No. 1,
pp. 21-6.
Eisenhardt, K.M. (1989), “Building theories from case study research”, The Academy of
Management Review, Vol. 14 No. 4, pp. 532-50.
Fillingham, D. (2008), Lean Healthcare: Improving the Patient’s Experience (Healthcare
Improvement), Kingsham Press, Chichester.
Grbich, C. (2007), Qualitative Data Analysis, 1st ed., Sage, Thousand Oaks, CA.
Gubb, J. (2009), “Have targets done more harm than good in the English NHS?”, British Medical
Journal, Vol. 338, pp. 442-3.
Health Service Journal (2008), “Making lean thinking work in the NHS”, available at: www.hsj.co.
uk/making-Lean-thinking-work-in-the-nhs/1894957.article (accessed 6 May 2011).
Hines, P., Found, P. and Harrison, R. (2008), Staying Lean: Thriving, Not Just Surviving, 1st ed.,
Lean Enterprise Research Centre, Cardiff University, Cardiff.
Hines, P., Holweg, M. and Rich, N. (2004), “Learning to evolve: a review of contemporary Lean
Thinking”, International Journal of Operations & Production Management, Vol. 24 No. 10,
pp. 994-1011.
Holweg, M. (2006), “The genealogy of Lean production”, Journal of Operations Management,
Vol. 26 No. 2, pp. 420-37.
Holweg, M. and Pil, F. (2001), “Successful build-to-order strategies start with the customer”,
Sloan Management Review, Vol. 43 No. 1, pp. 74-83.
Iles, V. and Sutherland, K. (2001), Managing Change in the NHS: A Review for Health Care
Managers, Professionals and Researchers, National Co-ordinating Centre for NHS Service
Delivery and Organisation R&D, London.
McNulty, E. and Ferlie, T. (2002), (2002) Reengineering Health Care: the Complexities of
Organizational Transformation, Oxford University Press, Oxford.
Monitor (2009), NHS Foundation Trust Financial Reporting Manual 2008/2009, available at:
www.monitor-nhsft.gov.uk (accessed 21 April 2011).
NHS Choices (2009), NHS Choices, available at: www.nhs.uk/chq/pages/1085.aspx (accessed
20 August 2009).
NHS Modernisation Agency (2001), “Ideal Design of Emergency Access (IDEA) Programme”,
available at http://wales.nhs.uk/sites3/w-docopen.cfm?orgid14530&id1458478&1936FC9F1143-E756-5CD3645843009ACA (accessed 21 August 2008).
Oliver, N. (2008), “Rational choice or leap of faith? The creation and defence of a management
orthodoxy”, The Learning Organization: An International Journal, Vol. 15, pp. 373-87.
Pettigrew, A. (1990), “Longitudinal field research on change: theory and practice”, Organization
Science, Vol. 1 No. 3, pp. 267-92.
Pettigrew, A. and Whipp, R. (1991), Managing Change for Competitive Success, Blackwell,
Oxford.
Pettigrew, A., Ferlie, E. and McKee, L. (1992), “Shaping strategic change – the case of the NHS in
the 1980s”, Public Money and Management, Vol. 12, pp. 27-31.
Porter, L. and Barker, B. (2005), Using Lean Principles to Increase the Efficiency of Service Delivery
in the Public Sector, Oakland Consulting PLC, Leeds.
Proudlove, N., Moxham, C. and Boaden, R. (2008), “Lessons for Lean in healthcare from using six
sigma in the NHS”, Public Money and Management, Vol. 28 No. 1, pp. 27-34.
Radnor, Z. (2010), Literature Review of Business Process Improvement Methodologies, Advanced
Institute of Management Research, London.
Radnor, Z. and Bucci, G. (2007), Evaluation of Pacesetter, Lean, Senior Leadership and
Operational Management within HMRC Processing, HMRC, London.
Radnor, Z. and Walley, P. (2008), “Learning to walk before we try to run: adapting lean for the
public sector”, Public Money and Management, Vol. 28, pp. 13-20.
Radnor, Z.J., Holweg, M. and Waring, J. (2012), “Lean in healthcare: the unfilled promise?”, Social
Science & Medicine, Vol. 74 No. 3, pp. 364-71.
Seddon, J., O’Donovan, B. and Zokaei, K. (2009), “Rethinking Lean service”, available at: www.
systemsthinking.co.uk/home.asp (accessed December 2009).
Shah, R. and Ward, P.T. (2007), “Defining and developing measures of lean production”, Journal
of Operations Management, Vol. 25, pp. 785-805.
Spear, S.J. (2004), “Learning to lead at Toyota”, Harvard Business Review, Vol. 83 No. 9, May,
pp. 78-91.
Spear, S.J. (2005), “Fixing health care from the inside”, Harvard Business Review, Vol. 83 11,
September, pp. 78-91.
Stetler, C., Ritchie, J., Rycroft-Malone, J., Schultz, A. and Charns, M. (2007), “Improving quality of
care through routine, successful implementation of evidence-based practice at the bedside:
an organizational case study protocol using the Pettigrew and Whipp model of strategic
change”, Implementation Science, Vol. 2 No. 3, pp. 1-13.
Toussaint, J. and Gerard, R. (2010), On the Mend, Lean Enterprise Institute, Cambridge, MA.
Towill, D. and Christopher, M. (2005), “An evolutionary approach to the architecture of effective
healthcare delivery systems”, Journal of Health Organisation Management, Vol. 19 No. 2,
pp. 130-47.
Waldman, J.D. and Schargel, F.P. (2006), “Twins in Trouble II: systems thinking in healthcare
and education”, Total Quality Management, Vol. 17, pp. 117-30.
Weber, R. (1990), Basic Content Analysis, 2nd ed., Sage, Newbury Park, CA.
Womack, J.P. and Jones, D.T. (1996), Lean Thinking, Simon and Schuster, New York, NY.
Womack, J.P., Jones, D.T. and Roos, D. (1990), The Machine that Changed the World, Macmillan,
New York, NY.
Young, T. and McCLean, S. (2008), “A critical look at Lean Thinking in healthcare”, Quality and
Safety in Health Care, Vol. 17, pp. 382-6.
About the authors
Nicola Burgess is a Research Fellow at the International Centre for Governance and Public
Management at Warwick Business School, University of Warwick. Nicola Burgess is the
corresponding author and can be contacted at: Nicola.Burgess@wbs.ac.uk
Zoe Radnor is a Professor of Operations Management at Cardiff Business School, Cardiff
University.
To purchase reprints of this article please e-mail: reprints@emeraldinsight.com
Or visit our web site for further details: www.emeraldinsight.com/reprints
Evaluating Lean
in healthcare
235
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.
Global Health Action
æ
ORIGINAL ARTICLE
Implementation of 5S management method for lean
healthcare at a health center in Senegal: a qualitative
study of staff perception
Shogo Kanamori1,2,3, Seydou Sow4, Marcia C. Castro5, Rui Matsuno6,
Akiko Tsuru3 and Masamine Jimba1*
1
Department of Community and Global Health, Graduate School of Medicine, University of Tokyo, Bunkyo-ku
Tokyo, Japan; 2Takemi Program in International Health, Harvard T. H. Chan School of Public Health, Harvard
University, Boston, MA, USA; 3IC Net Limited, Saitama, Japan; 4Agence Africaine de Santé Publique, Dakar,
Senegal; 5Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Harvard
University, Boston, MA, USA; 6Faculty of Medicine School of Health Sciences, Gunma University, Maebashi,
Gunma, Japan
Background: 5S is a lean method for workplace organization; it is an abbreviation representing five Japanese
words that can be translated as sort, set in order, shine, standardize, and sustain. The 5S management method
has been recognized recently as a potential solution for improving the quality of government healthcare
services in low- and middle-income countries.
Objective: To assess how the 5S management method creates changes in the workplace and in the process and
outcomes of healthcare services, and how it can be applicable in a resource-poor setting, based on data from
a pilot intervention of the 5S program implemented in a health facility in Senegal.
Design: In this qualitative study, we interviewed 21 health center staff members 1 year after the pilot
intervention. We asked them about their views on the changes brought on by the 5S program in their
workplace, daily routines, and services provided. We then transcribed interview records and organized the
narrative information by emerging themes using thematic analysis in the coding process.
Results: Study participants indicated that, despite resource constraints and other demotivating factors present
at the health center, the 5S program created changes in the work environment, including fewer unwanted
items, improved orderliness, and improved labeling and directional indicators of service units. These efforts
engendered changes in the quality of services (e.g. making services more efficient, patient-centered, and safe),
and in the attitude and behavior of staff and patients.
Conclusions: The pilot intervention of the 5S management method was perceived to have improved the quality
of healthcare services and staff motivation in a resource-poor healthcare facility with a disorderly work
environment in Senegal. Quantitative and qualitative research based on a larger-scale intervention would
be needed to elaborate and validate these findings and to identify the cost-effectiveness of such intervention
in low- and middle-income countries.
Keywords: 5S; lean; healthcare; quality improvement; intervention programs; work environment; qualitative study
*Correspondence to: Masamine Jimba, Department of Community and Global Health, Graduate School
of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan, Email: mjimba@m.
u-tokyo.ac.jp
Received: 12 January 2015; Revised: 13 March 2015; Accepted: 13 March 2015; Published: 7 April 2015
S stands for five Japanese words, Seiri, Seiton,
Seisou, Seiketsu, and Shitsuke, which broadly refer
to maintaining cleanliness. These five words, often
translated in English as sort, set in order, shine, standardize, and sustain, represent a set of practices for improving workplace organization and productivity (14).
The 5S management method is recognized as the foundation of lean healthcare approaches, which maximize
5
value-added levels by removing all factors that do not
generate values (5). It evolved in manufacturing enterprises in Japan, and it was introduced to the manufacturing sector in the West in the 1980s (2). It has
now been applied to the healthcare sector as a systematic
method of organizing and standardizing the workplace
for lean healthcare (6), and it has been recognized as a
low-cost, technologically undemanding approach that
Global Health Action 2015. # 2015 Shogo Kanamori et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to
remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.
1
Citation: Glob Health Action 2015, 8: 27256 – http://dx.doi.org/10.3402/gha.v8.27256
(page number not for citation purpose)
Shogo Kanamori et al.
serves as a starting point for the improvement of healthcare services (3, 69).
The 5S management method has been suggested
recently as a method for quality improvement of government healthcare services, particularly in low- and middleincome countries. The governments of Sri Lanka and
Tanzania have officially adopted 5S as a national strategy
for healthcare service quality improvement (10, 11). In
Senegal, 5S was introduced to the healthcare sector under
a pilot intervention program of the Japan International
Cooperation Agency (JICA) in 2007 (12). Based on
experiences gained through the pilot intervention, the
JICA-assisted Project for Reinforcement of the Health
System in Senegal (Projet d’Appui au Renforcement
du Système de Santé au Sénégal, or PARSS) was initiated
in 2011. It aimed at establishing a 5S intervention model
to address common chronic problems in the work
environment of health centers, such as a lack of orderliness with documents and supplies, deficient labeling and
directional indicators of service units, and precarious
overall cleanliness (13). The implementation of PARSS
resulted in the inclusion of 5S in the national strategy
for improving the quality of healthcare services (13, 14).
The impact of the application of the 5S management
method in the healthcare sector has been documented
in the United States (1518), India (19), Jordan (20), and
Sri Lanka (21), although other lean tools and methods
were often combined with the 5S management method.
Observed changes as a result of these interventions included improved working processes and increased physical space (16, 1820), elimination of safety violations
and improved compliance with regulations (15), improved
clinical indicators of safety (21), and increased time with
patients and improved patient satisfaction (17).
Despite these findings, little is known about the
specifics of how the 5S management method changes
the quality of healthcare services. Furthermore, no study
has focused on its application in a resource-poor setting.
Several studies targeted hospitals in low- and middleincome countries and identified measurable changes
resulting from the 5S management method, such as
improved process flows, increased capacity, and shorter
stays for all patient classes at an emergency department
(19); potential reductions in the drug-dispensing cycle
time at an inpatient pharmacy (20); and reductions in
the infection rate post Caesarean section and in the
stillbirth rate (21). However, they did not note explicitly
that the studied facilities faced resource constraints.
To address these issues, we conducted a qualitative
study to explore how the 5S management method pilot
intervention created changes in the workplace and in
the process and outcomes of healthcare services. We also
explored if the method was applicable in a healthcare
facility facing resource constraints. This article provides
insights into the potential applicability of the 5S manage-
2
(page number not for citation purpose)
ment method to government healthcare facilities in
low- and middle-income countries.
Methods
Target facility
The health center where the qualitative study was
conducted is located in the Tambacounda region, which
is 462 km away from Dakar, the capital of Senegal. At
the kick-off meeting of PARSS, conducted in May 2011
in Tambacounda, project stakeholders reached the consensus to select it as the facility at which to start the 5S
management method before expansion of the method
to other health centers. The reason behind this selection
was primarily associated with ease of physical access by
the project stakeholders who would participate in the
pilot intervention. At the time of the study, the health
center had 78 staff members and a range of service units
and offices, including outpatient consultation, maternity,
dental, pediatric, immunization, laboratory, social counseling, health education, and nutrition programs; a
pharmacy; inpatient wards; and administrative offices.
The health center is located in a poverty-stricken area
that is characterized by comparatively lower healthcare
service and economic indicators than other areas of
Senegal; the percentage receiving antenatal care from a
skilled provider is 79% in Tambacounda, whereas the
country average is 93%, and 52.9% of the population in
Tambacounda fall in the first economic quintile of the
country average (22).
Pilot 5S intervention
The implementation of the 5S management method pilot
intervention (hereinafter referred to as the 5S program)
was conducted under the JICA-assisted project, PARSS,
and involved three phases: 1) training and planning for the
application of the 5S management method, 2) 5S practices
at each unit, and 3) progress monitoring. The ultimate
objectives of PARSS were to standardize activities involved in these three phases and to integrate those into the
health system’s administrative process to be managed by
government officials at the national and regional levels.
However, because this was the initial experimental intervention, all activities were facilitated by PARSS team
members consisting of foreign experts on 5S and Senegalese
government officials who had prior experiences in 5S
practice elsewhere. Prior to initiating the activities, PARSS
team members visited all the locations in the health center
to obtain insights into the baseline situation.
Phase 1 consisted of a 1-day workshop for training
and planning for the application of the 5S management
method; it was conducted in July 2011 at the health
center with the support of PARSS team members. Sixtytwo staff members of the health center, representing
all the clinical, administrative, and support staff available
Citation: Glob Health Action 2015, 8: 27256 – http://dx.doi.org/10.3402/gha.v8.27256
Implementation of 5S at health center in Senegal
on the day of the event, attended the program. None of
the staff had prior exposure to 5S practice. The workshop
program consisted of lectures and practical sessions. In
the lecture session, a series of presentations were made on
the principles of 5S and its applications in a healthcare
facility. During the practical sessions, several service units
and offices were bundled into the same category according to physical arrangement and proximity, and the
health center premises were divided into nine locations:
1) administration office; 2) primary healthcare supervisor’s office and social worker’s office; 3) laboratory,
drug store, and ticket counter; 4) dental unit; 5) health
education unit; 6) pediatric unit, expanded program on
immunization (EPI) unit, elderly support office, and
nutrition center; 7) outpatient medical clinic; 8) supply
manager’s office and outside areas; and 9) maternity
unit. Staff members were divided into nine groups, each
assigned to one of the nine locations closely related to
their job duties. Participants visited their assigned areas,
conducted situation analyses, and developed action plans
for improvements in accordance with the 5S criteria.
The subsistence allowance was paid to all participants
in accordance with the rules and conditions determined
by the government of Senegal.
Phase 2 was launched 1 week after Phase 1 (July and
August 2011). During Phase 2, 5S practices were implemented at each of the nine locations. Nine days were
devoted to this process, which included 1 day at each
of the previously established locations. PARSS team
members visited the implementation location and provided guidance to the health center staff members in the
establishment of 5S practices at the beginning of the day.
Staff members subsequently conducted 5S practices for
35 consecutive hours under the supervision and onsite
guidance of PARSS team members. The activities varied
between locations; however, typical ones included cleaning the internal and external spaces, eliminating unwanted items, placing labels and indications, and setting
and sorting documents and records. The cost involved
in the physical reorganization under the 5S program was
nominal; some stationeries and inexpensive tools were
purchased with PARSS funds to facilitate 5S practices.
No financial incentive was given to the health center staff
members during this phase.
During Phase 3, PARSS team members conducted two
separate 1-day meetings at the health center to assess
the progress of 5S and to provide feedback that could
generate further improvements. The first meeting, conducted 1 week after Phase 2, was attended by 43 people,
comprising 14 health center staff members, 14 government officials, and 15 external experts and volunteers
of JICA. Participation of staff members was limited to
those with supervisory functions, including representatives of the nine locations, who were expected to learn the
assessment procedure to continue supervising the 5S
practice. The participants visited each of the nine
locations where the 5S management method had been
implemented and assessed the progress. Each participant
filled out a ballot that was designed to rank the nine
locations from first to ninth in order of their perceived
achievement level of the 5S management method. By
calculating the means of the ranks for each location,
well-performing units were recognized and given prizes
of inexpensive items such as office supplies. The participants then held a session to share their observations
and to provide advice to the health center staff members
on areas for further improvements. Forty-seven people,
comprising 14 health center staff members, 21 government officials, and 12 external experts and volunteers
of JICA, attended a second meeting in December 2011,
3 months after the first progress-monitoring meeting. The
participants assessed the 5S application status in each
of the nine locations using an evaluation sheet developed
by PARSS team members, and provided feedback for
further improvements. The subsistence allowance was
paid to the health center staff members who participated
in the meetings, but not to those working at the locations
that were assessed.
Individual interview
We conducted data collection for this study in November
2012. To obtain detailed information about staff members’ personal feelings, perceptions, and opinions, we
chose face-to-face individual interviews. An external
evaluator (the second author [SS], a male Senegalese
researcher who holds a PhD in social science and is
fluent in English and French), who was not involved in
the 5S program and not known to the staff members of
the health center, was recruited to conduct the semistructured interviews. An interview guide was developed
in French. To ensure clarity of questions and to gain
preliminary insights into a range of potential responses
from interviewees, the interview guide was tested with
staff members from a different health center in Senegal.
We identified interview participants from the staff members
of the health center who had participated in both Phase
1 (training and planning) and Phase 2 (5S practice at
each unit) of the 5S program based on their availability.
During the given period for the interviews, we were
able to reach 21 staff members; all of them agreed to
participate in the interviews. Participants consisted of 11
men and 10 women (median age: 34 years; range: 25 to 56
years), and they consisted of 9 paramedical staff members, 11 community workers, and 1 support staff member.
All the interviews were conducted in French. To guarantee privacy, interviews were conducted in a compartment
of the health center where conversations were not audible
to other staff members. To avoid bias, each participant
was informed before the interview that their responses
would be used for research purposes only and would
Citation: Glob Health Action 2015, 8: 27256 – http://dx.doi.org/10.3402/gha.v8.27256
3
(page number not for citation purpose)
Shogo Kanamori et al.
never be used to evaluate the performance of any health
center staff members or PARSS team members. The
participants did not receive any financial incentives for
their participation in the interviews. During the interviews, the participants were asked questions pertaining to
changes brought on by the 5S program in the following
areas: 1) visible or physical areas of the health center, 2)
services provided to patients, 3) their own daily routines,
and 4) the work of other health center staff members.
Participants were initially asked, in each of these four
areas, to indicate a dichotomous answer of ‘Yes’ or ‘No’
to the question as to whether or not they perceived
changes after the introduction of the 5S program. They
were then asked to elaborate on the nature of the changes
they observed. Participants were also prompted to make
suggestions for improving the quality of services at the
health center. Interview sessions lasted between 20 and
40 min until respondents’ answers were saturated. We
digitally recorded the interviews with the permission of
participants.
Data analysis
All interviews were translated from French to English and
transcribed to English by the second author (SS, who
conducted the interviews). The translated texts were
reviewed several times in light of the original interview
recordings to ensure that all the information and nuances
were adequately converted. The transcribed texts were
imported into MAXQDA software, Version 10, and a deidentified data set was prepared to allow thematic analysis
(23). The lead author (SK) closely read each transcript
several times to become thoroughly familiar with the
content and coded the texts to categorize the narrative
data into themes. Two of the co-authors (SS and RM)
reviewed the coded transcriptions and the themes identified by the first author. All authors discussed disputes and
revised the coding categories and themes until consensus
was reached. Contradictory views and negative opinions
about the 5S program were particularly noted. During this
coding process, the identities of the participants were
masked to the authors.
Ethical considerations
We obtained ethical clearance from the National Ethical
Committee for Medical Research of the Ministry of Health
and Social Action of Senegal and the Research Ethics
Committee of the University of Tokyo. Participation in
the study was voluntary, and we assured participants
of anonymity. In addition, we obtained written consent
from each interview participant before each interview. We
informed participants that they could withdraw from the
study at any point without any risk of sanctions. We used
numbers and codes on both the recorded interviews and
transcripts to guarantee confidentiality. Furthermore, all
problems and constraints identified at the health center
4
(page number not for citation purpose)
under this study were promptly shared with key officials
of the Ministry of Health and Social Action.
Results
From 21 participants’ answers to quantitative questions,
we found that a majority perceived that the 5S program
brought on changes in each of the following areas:
1) visible or physical areas of the health center (all
respondents said ‘Yes’), 2) services provided to patients
(Yes 19; No1; Don’t know 1), 3) their own daily
routines (all respondents said ‘Yes’), and 4) the work
of other health center staff members (Yes 17, No 2,
Don’t know2).
We analyzed and classified participants’ narrative
responses, and developed a thematic framework that
included domains and key themes that were defined
based on the responses. We identified four domains that
characterized participants’ perspectives of the impact of
the 5S program: work environment, attitude and behavior
of staff, attitude and behavior of patients, and quality
of services. We further subdivided the quality of the
service domain into three subdomains: efficiency, patientcenteredness, and safety. Within each domain and subdomain, we identified the key themes (Table 1).
Impact on work environment
Participants’ responses pertaining to the work environment domain were represented by key themes, including
fewer unwanted items, improved hygiene and cleanliness,
improved orderliness of items, and improved labeling
and directional indicators of service units (Table 1).
Narratives of the participants included: ‘We can easily
find drugs to be offered to patients as all the unnecessary
items were thrown away’ (Participant L: aged 5054,
male); ‘For instance, at the maternity ward, we no longer
confront [the] odor problem . . .. So, we unanimously
recognize that 5S have considerably improved our working environment’ (Participant J: aged 3034, female); and
‘Yes, I observed that the ticket sellers are more organized,
particularly the way they store the money; notes and
coins are separated by category’ (Participant B: aged
3539, male). Because this domain reflects the commonly
recognized primary objectives of the 5S program, changes
in the work environment reported by participants were
direct results of the application of the 5S management
method.
Impact on attitude and behavior of staff
Participants described perceived changes in their own
and others’ attitude and behavior after the 5S program
implementation. A few participants admitted an increase
in their awareness about the principles of 5S; some
indicated changes in their attention toward how other
people perceived their offices. One participant said, ‘I can
say that I am personally motivated to come to work. I am
Citation: Glob Health Action 2015, 8: 27256 – http://dx.doi.org/10.3402/gha.v8.27256
Implementation of 5S at health center in Senegal
Table 1. Key themes identified by staff members about the
impact of the 5S program
Domains and
sub-domains
Work environment
Key themes
–
Fewer unwanted items
–
Improved hygiene and cleanliness
–
Improved orderliness of items
–
Improved labeling and directional
indicators of service units
Attitude and behavior of staff
Increased awareness of 5S
–
Improved collaboration among staff
–
members
Increased reuse of items
–
5S practices extended outside work
Attitude and behavior –
Voluntary participation in maintaining
of patients
cleanliness of the facility
Quality of services
Efficiency
–
Reduction in time searching for items
–
Improved ability of staff to move
Patient
–
around in the office
Reduction in waiting time for patients
centeredness
–
Better directions for patients
Safety
–
Improved sterilization processes
not proud of the past situation where I received visitors
in my office with the mess that prevailed’ (Participant
P: aged 5559, male). Another participant answered,
‘Nowadays, the first thing I do in the morning is to free
my workplace from garbage and unnecessary items. In
fact, I don’t want other staff members to find a mess on
my working place or desk’ (Participant A: aged 4549,
female).
A few participants indicated that the 5S program
brought a culture of recycling and reusing items to the
health center. One participant commented about the
other office staff members, ‘They don’t throw away items
as they did before the 5S program. They first think if
items are reusable or not. Currently, they recycle many
things that used to be usually thrown away’ (Participant
D: aged 2529, female).
Some participants mentioned that collaboration among
staff members increased, particularly in educating other
staff members on the practice of 5S. Others indicated that
they came to practice 5S outside the workplace, such as
in their home, because of their exposure to the advantages
of the 5S management method in the workplace.
Impact on attitude and behavior of patients
Some participants noted attitude and behavioral changes
in patients after the 5S program was implemented. They
stated that the clean environment encouraged patients to
maintain the cleanliness of the health center. A participant
working at the medical wards reported, ‘The cleanliness
of the rooms makes the patients themselves cleaner. We
put mops in the rooms and it is not uncommon to see a
patient or caretaker cleaning by himself. All this is because
of the clean environment’ (Participant Q: aged 4044,
male).
Impact on quality of services
Participants’ responses indicated changes in the quality
of services, particularly in the three subdomains of
efficiency, patient-centeredness, and safety, among the
six dimensions of healthcare quality proposed by the US
Institute of Medicine (24).
Efficiency
Almost all the participants mentioned that the 5S
program facilitated the identification of items, and hence
reduced time spent searching for an item. This efficiencyrelated measure was raised primarily in the context of
the improved orderliness of items in the work environment. A participant in the maternity unit highlighted
its impact on service efficiency: ‘Previously we had some
difficulties in finding patients’ files following family
planning. Since the implementation of the 5S program,
we have better organized the workplace by separating
out things and clearly indicating the storage sites of
documents and files. Nowadays, the family planning
consultation is running smoothly. We have also labeled
the content of cupboards and shelves; this made it easy to
locate documents’ (Participant M: aged 2529, female).
A few participants mentioned that the ability of the
staff to quickly move around the health unit improved
in the office following the 5S program. Those responses
were mostly attributed to the reduction of unwanted
items that had previously prevented staff members from
moving around smoothly.
Patient-centeredness
About one-half of the participants mentioned reductions
in waiting times for patients due to the 5S program. This
impact was attributed to improved efficiency at work.
One participant remarked, ‘Because documents and files
are now in order, we save time ourselves and the patients
do not wait so long, unlike before the 5S program’
(Participant D: aged 2529, female).
About one-half of the participants indicated that it was
easier for patients to locate their destination within the
health center premises because of the improved labeling
and directional indicators of service units. Participants
noticed that even slightly literate patients could easily
identify the locations to visit because of the improved
labeling and directional indicators of service units. In
addition, indications of the occupancy of service units
better directed patients, as noted by one participant: ‘A
sign on the door indicating that the room is occupied
was introduced by the 5S program. [Now] patients do not
Citation: Glob Health Action 2015, 8: 27256 – http://dx.doi.org/10.3402/gha.v8.27256
5
(page number not for citation purpose)
Shogo Kanamori et al.
keep on knocking on the door all the time’ (Participant
K: aged 3539, male).
quality of services and the changes in the attitude and
behavior of staff and patients.
Safety
The improvement in the sterilization processes was also
attributed to the improved orderliness of items. A participant working at the maternity unit noted, ‘Our working
tools are better organized, and the safety has improved
because of the systematic sterilization of the medical
equipment deriving from the 5S program’ (Participant I:
aged 2529, female).
Necessary measures to improve the quality of
services at the health center
We coded all 21 interviewees’ suggestions about the
necessary measures to improve the quality of services at
the health center into 12 categories. Greater physical and
material resources were the most frequently mentioned
(12 participants), followed by financial incentives for
staff members (7), eliminating staff shortages (4), physical
arrangements of service units (3), more cleanliness/5S
activities (2), and staff training (2). Other measures
mentioned included security issues, staff supervision, a
drug management system, responsiveness to patients,
employment modality, and punctuality.
Among these measures suggested, the limited amount
of financial incentives was particularly recognized as a
demotivating factor for staff members, as noted by a
participant: ‘In order to motivate the staff, the amount
of incentives should be improved’ (Participant G: aged
2529, female). In addition, one participant highlighted
the same issue by sharing a negative opinion regarding
insufficient incentives given to the health staff members
who participated in the 5S program: ‘People complain
about PARSS because it asked us to do 5S but did not
give substantial incentives . . .. Recently, we worked with
two projects that paid decent subsidies to the community
health workers who were involved. You know, the
majority of healthcare providers here are community
workers, and their wages are very low’ (Participant M:
aged 2529, female). A few participants also suggested
Mechanisms of emerging changes
We identified and illustrated the root causes of the
perceived changes in the quality of services through a
context analysis of the coded transcripts (Fig. 1). The 5S
program initially changed the work environment because
of fewer unwanted items, improved orderliness of items,
and improved labeling and directional indicators of service
units. These efforts engendered changes in the quality
of services*specifically, making them more efficient,
patient-centered, and safe*because of reductions in
the time spent searching for items, improved ability to
move around in the office, reductions in waiting times
for patients, better directions for patients, and improved
sterilization processes.
We found that the attitude and behavior changes of
staff and patients derived from changes in the work
environment and were positively affected by their participation in the 5S program. However, from analysis of
participants’ responses under this study, causal relationships were not identified between the improvements in the
Work environment
Quality of services
Efficiency
Reduction in time searching
for items
Fewer unwanted items
Improved ability of staff to
move around in the office
Patient-centeredness
Reduction in waiting time
for patients
5S Program
Improved orderliness of
items
Better directions for patients
Safety
Improved labeling and
directional indicators of
service units
Improved sterilization
process
Fig. 1. Root cause analysis on perceived changes in the quality of services.
6
(page number not for citation purpose)
Citation: Glob Health Action 2015, 8: 27256 – http://dx.doi.org/10.3402/gha.v8.27256
Implementation of 5S at health center in Senegal
better measures to further improve or sustain 5S practice:
‘We need more space for the pharmacy to make 5S
practice more visible’ (Participant S: aged 4549, male);
and ‘A routine supervision is also necessary to maintain
the good practice of 5S’ (Participant J: 2529, female).
Discussion
Through analysis of the interviews, we highlighted a
range of changes engendered by the pilot intervention
of the 5S management method. We identified that the
5S management method improved the quality of services,
and the improvements were rooted in three dimensions:
efficiency, patient-centeredness, and safety. Our finding
indicated that the improvements in the quality of services
were caused by changes in the work environment, including fewer unwanted items, improved orderliness of
items, and improved labeling and directional indicators
of service units. As with previous studies, no negative
impact was perceived about the 5S management method;
this could be because it was perceived by nature as a
‘common-sense approach’ (9).
We also identified changes in the attitude and behavior
of staff related to the application of the 5S management
method. In particular, staff members indicated increased
willingness to come to work and efforts toward maintaining a better work environment. From these findings, we
suggest that application of the 5S management method
contributed to the increase in staff motivation through
changes in attitudes and behaviors. Despite the perceived
effectiveness of the 5S management method, this study
was not designed to assess if the increase in motivation
had resulted from the improved status of the work environment, or from the experiences of staff members while
participating in the implementation process. Because
the 5S management method is an approach that by nature
necessitates staff participation in its implementation
process, it may not be significantly important for 5S
practitioners to identify the degree of contribution of
each of these two factors to the motivation increase.
Nevertheless, for those designing intervention programs,
it might be useful to know if the staff members’
participation in improvement processes could affect
staff motivation.
To the best of our knowledge, this is the first study to
focus on the application of the 5S management method to
a resource-poor facility. Despite the resource constraints
faced by the health center, the interviewees suggested that
the 5S program led to an improvement in the quality
of services. This result, along with the nature of the 5S
program as a low-cost and technologically undemanding
approach (9), implies that the 5S management method
is particularly suitable for improving service quality in
resource-poor settings.
The results of our study also implied that the increase
in the staff motivation could be brought on by the
application of the 5S management method in a resourcepoor healthcare facility. Several measures suggested by
interviewees for improvement of the quality of services
at the health center were directly associated with the
motivational factors identified by Willis-Shattuck et al.
(25), such as financial incentives, career development,
hospital infrastructure, and resource availability. These
results indicate that the working conditions at the health
center were far from ideal in motivating staff; nevertheless, interviewees indicated that the 5S program led to
an increase in staff motivation despite constraints.
The results of several earlier studies indicated associations between the work environment and motivation of
health workers in low- and middle-income countries;
however, the focus was primarily on the physical infrastructure of healthcare facilities, which is costly (25).
Factors related to or efforts toward the orderliness or
cleanliness of the workplace, which is attainable at low cost
and with little need for technology, were not examined in
previous studies. Our study results therefore suggest that
improvement of the work environment by the application
of the 5S management method possibly could serve as
a new approach for motivating staff, particularly in a
healthcare facility where resource constraints and other
demotivating factors prevail.
In addition, our examination of the implementation
process and results of the pilot 5S intervention at the
health center contributed to filling knowledge gaps but, at
the same time, highlighted areas of further studies and
policy implications in the applicability of the 5S management method to healthcare facilities in low- and middleincome countries. First, it was identified that, when the 5S
management method is applied to a resource-poor
healthcare facility as represented by the health center of
our study, its context and roles might be different from
those that are usually applied to hospitals in the United
States or other healthcare facilities in resource-rich
settings. Regardless of workplace settings or situations,
the same description is used to depict the 5S management
method as the starting point for quality improvement
efforts (68). However, where they stand at the starting
point could differ depending on the situations of healthcare facilities. Apparently, significant differences would be
observed between private hospitals in high-income countries and government healthcare facilities in resource-poor
countries as represented by the health center of our study.
During the site visits before the pilot intervention, PARSS
team members recognized that the work environment at
the health center was extremely disorderly; documents
and records were piled up or stored in disorganized
ways, broken equipment and other unwanted items were
kept everywhere unattended, and garbage was scattered
around in external spaces. They even found some patient
registers dated from 1979 inside a cabinet.
Citation: Glob Health Action 2015, 8: 27256 – http://dx.doi.org/10.3402/gha.v8.27256
7
(page number not for citation purpose)
Shogo Kanamori et al.
Our study highlighted the potential root causes of
the perceived changes in the quality of services engendered by the 5S program (e.g. reduction in time searching
for items due to improved orderliness of items, as illustrated in Fig. 1). Considering the initial situation of the
health center, these results could alternatively be interpreted as meaning that the extremely disorderly work
environment had been a potential bottleneck in providing
adequate services. Although variations may exist, we
assume that such a work environment is by no means
unique to the health center of our study, but can represent
many government healthcare facilities managed in a
traditional fashion in resource-poor countries. This implies
the need to further explore the validity of introducing the
5S management method to those countries, particularly
to see if the 5S management method can contribute to
removing the bottleneck in providing adequate services at
healthcare facilities facing similar challenges.
Second, our study highlighted another area of interest
regarding how the 5S management method could contribute to the effective implementation of other quality
improvement efforts in such settings. A report based on a
case of government hospitals in Tanzania indicated that
initial efforts to improve healthcare service quality via a
combination of infection control guidelines and continuous quality improvementtotal quality management
(CQI-TQM) resulted in little progress, and that improvements were seen only after the introduction of the 5S
management method (26). To address these issues, the
results of our study could be used to develop hypotheses
or research questions for further studies as well as to
narrow the scope of quantitative studies on the impacts
of 5S implementation in such settings.
Third, our study identified a policy implication of its
applicability, especially when the 5S management method
is applied as a government quality improvement initiative
in low- and middle-income countries. As earlier mentioned, the 5S management method has been recognized
as a low-cost approach (9). During the pilot intervention
at the health center, the cost involved in the physical
reorganization was nominal, although some expenses
accrued from the organization of the training and meetings. Thus, when the 5S management method is implemented in a single facility, the cost would not be very high
or not be much higher than other activities typically
conducted in low- and middle-income countries. However, if the goal is to integrate the method into the health
system management procedures, additional administrative costs will be incurred in managing an intervention
program at a large scale and in ensuring its sustainability.
The cost-effectiveness of such an initiative could be
of interest among policy makers. This is also another
area of further studies that could present policy options
to government health authorities in those countries.
8
(page number not for citation purpose)
This qualitative study was designed to identify possible
impacts of the 5S management method from the service
provider’s perspectives. Needless to say, patients’ viewpoints are also important. We conducted a separate
quantitative study to assess the impact of the 5S management method on patient satisfaction. It was conducted
at several other health centers where the 5S program
was later implemented under PARSS (27).
Several limitations were involved in our study. The
interviews were conducted with participants available
within the predetermined period of our fieldwork, and
additional data collection was not possible. Although
study participants were selected indifferently according to
their availability during the given timeframe of the study,
their responses might not reflect the opinions of all of
the staff members of the health center in this study.
Last, although an external evaluator (who had not been
involved in the intervention and not been known to the
participants) was assigned to conduct the interviews, it
was not possible to perfectly mask the fact that the data
collection was conducted by PARSS, which might have
affected their way of giving responses during interviews.
It is likely that most of the participants’ statements
reflected true information or what they actually perceived;
however, exaggerated expressions might have been shared
on some occasions.
Conclusions
The pilot intervention of the 5S management method
was perceived to have improved the quality of healthcare
services in a resource-poor facility in Senegal. In addition,
the improvement of the work environment by the application of the 5S management method was observed
to have motivated staff in a healthcare facility where
resource constraints and other demotivating factors prevail. Although our results cannot be generalized to other
health facilities, they provide a viewpoint for assessing the
applicability of the 5S management method, particularly
to government healthcare facilities in resource-poor settings where a disorderly work environment serves as a
potential bottleneck in providing adequate healthcare
services. Quantitative and qualitative research based on
a larger-scale intervention would be needed to elaborate
and validate these findings as well as to identify the costeffectiveness of their integration into health systems’
management procedures. The findings of the research
can then be used to develop and present policy options,
particularly to government health authorities in low- and
middle-income countries and representatives of donor
agencies that provide support in such fields.
Authors’ Contributions
SK designed the study, reviewed the literature, analyzed
data, and drafted and revised the manuscript. SS conducted interviews, transcribed the audio-recorded con-
Citation: Glob Health Action 2015, 8: 27256 – http://dx.doi.org/10.3402/gha.v8.27256
Implementation of 5S at health center in Senegal
versations, and analyzed the data. MCC reviewed and
provided major inputs to the manuscript. RM assisted in
designing, implementing, and monitoring the 5S program
at the health center in this study. AT reviewed the
manuscript and contributed to its revision. MJ provided
overall guidance to the conception and design of the
study, and helped revise the manuscript. All authors read
and approved the final manuscript.
Acknowledgements
The authors acknowledge the contribution of the staff members of
the health center in this study who kindly agreed to participate in the
interviews. The authors also thank the members of the Project for
Reinforcement of the Health System in Senegal, who provided
technical and administrative support for implementation of the 5S
program at the health center.
Conflict of Interests and Funding
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article. The study was funded by Japan International
Cooperation Agency (JICA) through its technical cooperation project, the Project for the Reinforcement of Health
System in Senegal.
References
1. Gapp R, Fisher R, Kobayashi K. Implementing 5S within a
Japanese context: an integrated management system. Manage
Decis 2008; 46: 56579.
2. Hirano H. 5S for operators: 5 pillars of the visual workplace.
Portland, OR: Productivity Press; 1996.
3. Hirano H. JIT implementation manual – The complete guide
to just-in-time manufacturing: Volume 2 – Waste and the 5S’s.
Boca Raton: CRC Press; 2009.
4. Ho SK, Cicmil S, Fung CK. The Japanese 5-S practice and
TQM training. Train Qual 1995; 3: 1924.
5. Womak J, Jones D, Roos D. The machine that changed the
world. New York, NY: Rawson Associates; 1990.
6. Jackson TL. 5S for healthcare. New York, NY: Productivity
Press; 2009.
7. Manos A, Sattler M, Alukal G. Make healthcare lean. Qual
Prog 2006; 39: 2430.
8. Hadfield D. Lean healthcare*implementing 5S in lean or Six
Sigma projects. Chelsea: MCS Media, Inc; 2006.
9. Imai M. Gemba Kaizen: a commonsense approach to a
continuous improvement strategy. New York, NY: McGraw
Hill; 2012.
10. Jayantha W, Sridharan S, Kanamori S. National guidelines for
improvement of quality and safety of healthcare institutions
(Quality Series No.1: For Line Ministry and Provincial Hospitals).
Colombo: Ministry of Health, Sri Lanka; 2010.
11. Ministry of Health and Social Welfare. Implementation guideline for 5S-CQI-TQM approaches in Tanzania: foundation of all
quality improvement programme. Dar es Salaam: The United
Republic of Tanzania; 2009.
12. Japan International Cooperation Agency. 5S-KAIZEN-TQM:
good practice collection. Tokyo: JICA; 2010.
13. Ministère de la Santé et de l’Action Sociale. Manuel illustratif
des 5S: pour l’amélioration de la qualité des soins et des services
dans un centre de santé [Illustrative manual of 5S for improvement of the healthcare services in health centers]. Dakar:
Republic of Senegal; 2013. French.
14. Ministère de la Santé et de l’Action Sociale. Guide du formateur
sur la pratique des 5S dans un centre de santé [Trainer’s guide
on 5S practice at health center]. Dakar: Republic of Senegal;
2013. French.
15. Ikuma LH, Nahmens I. Making safety an integral part of 5S in
healthcare. Work 2014; 47: 24351.
16. Rutledge J, Xu M, Simpson J. Application of the Toyota
Production System improves core laboratory operations. Am J
Clin Pathol 2010; 133: 2431.
17. Waldhausen JH, Avansino JR, Libby A, Sawin RS. Application
of lean methods improves surgical clinic experience. J Pediatr
Surg 2010; 45: 14205.
18. Farrokhi FR, Gunther M, Williams B, Blackmore CC. Application of lean methodology for improved quality and efficiency in
operating room instrument availability. J Healthc Qual 2013.
doi: 10.1111/jhq.12053. [Epub ahead of print].
19. Chadha R, Singh A, Kalra J. Lean and queuing integration for
the transformation of health care processes: a lean health care
model. Clin Govern Int J 2012; 17: 1919.
20. Al-Araidah O, Momani A, Khasawneh M, Momani M.
Lead-time reduction utilizing lean tools applied to healthcare:
the inpatient pharmacy at a local hospital. J Healthc Qual 2010;
32: 5966.
21. Withanachchi N, Karandagoda W, Handa Y. A performance
improvement programme at a public hospital in Sri Lanka: an
introduction. J Health Organ Manag 2004; 18: 3619.
22. Agence Nationale de la Statistique et de la Démographie
(ANSD) [Sénégal], ICF International. Enquête Démographique
et de Santé à Indicateurs Multiples au Sénégal (EDS-MICS)
2010-2011 [The 2010-11 Senegal Demographic and Health and
Multiple Indicator Clustor Survey (DHS-MICS)]. Calverton,
Maryland: ANSD and ICF International; 2012. French.
23. Braun V, Clarke V. Using thematic analysis in psychology. Qual
Res Psychol 2006; 3: 77101.
24. Institute of Medicine (US). Crossing the quality chasm: a new
health system for the 21st century. Washington, DC: National
Academies Press; 2001.
25. Willis-Shattuck M, Bidwell P, Thomas S, Wyness L, Blaauw D,
Ditlopo P. Motivation and retention of health workers in
developing countries: a systematic review. BMC Health Serv
Res 2008; 8: 247.
26. Matsubara C, Ikeda N, Ishijima H, Handa Y. Technologies
for global health. Lancet 2012; 380: 17389; author reply 1739.
27. Kanamori S, Castro MC, Sow S, Matsuno R, Cissokho A,
Jimba M. Introducing the Japanese 5S management method
to 10 health centers in Senegal: implementation and evaluation
of a pilot project. 2015. (unpublished).
Citation: Glob Health Action 2015, 8: 27256 – http://dx.doi.org/10.3402/gha.v8.27256
9
(page number not for citation purpose)