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Six sigma in health-care service: a case study on COVID 19 patients’

satisfaction
Article in International Journal of Lean Six Sigma · May 2021

DOI: 10.1108/IJLSS-11-2020-0189
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Six sigma in
Six sigma in healthcare service: a health-care
case study on COVID 19 service
patients’ satisfaction
AQ:1 Kaja Bantha Navas Raja Mohamed
Department of Mechanical, Sathyabama Institute of Science and Technology,
AQ:2 Chennai, India Received 6 November 2020
Revised 16 February 2021
8 March 2021
AQ: 3 Palaninatha Raja M. 9 March 2021
Department of Mechatronics, Thiagarajar College of Engineering, Madurai, India Accepted 9 March 2021
SharmilaParveen S.
Department of Business Administration, Nazareth College of Arts and Science,
Chennai, India
John Rajan A.
Department of Mechanical, Vellore Institute of Technology, Vellore, India, and
Ranjitham Anderson
Madras Medical Mission, Chennai, India
Abstract
Purpose – The purpose of this paper is to determine the major influencing factors for the COVID 19
patients’ satisfaction with a six sigma framework model and to explore the successful deployment of six
AQ: 4 sigma in the health-care sector.
Design/methodology/approach – The study is based on a descriptive research design conducted in
Chennai, India between May to July 2020 wherein 1,000 COVID 19 patients were studied. The convenience
sampling method is used by the researcher for data collection. In this research paper, define-measure-analysis-
improve-control methodology has been applied and factors such as assurance, process standardization,
AQ: 5 infrastructure, waiting time, cost were analyzed using QFD, regression analysis and Monte Carlo simulation.
Findings – The applied six sigma model indicated that process standardization contributed the most
toward the variation in COVID 19 patients’ satisfaction. Assurance by doctors is the second important factor.
The interpersonal quality is important, which indicates a higher level of psychological needs in COVID 19
patients. Waiting time is another important factor influencing COVID 19 patients’ satisfaction. One of the
unexpected findings is that cost is insignificant in influencing COVID 19 patients’ satisfaction.
Originality/value – Six Sigma focuses on process variation improvement that encourages data analysis
and problem-solving statistical techniques and evaluates the ability of a process to perform defect-free. Six
sigma focused toward COVID 19 patients’ satisfaction has not been carried out, which this paper has done.
Keywords Six sigma, Regression, DMAIC, QFD, COVID 19
Paper type Research paper
1. Introduction
In recent years, the health-care system has been facing various difficulties, not only in India International Journal of Lean Six
Sigma
but also in many developed countries. The most critical issue is that the operating costs keep © Emerald Publishing Limited
2040-4166
increasing. US health care spending grew 4.6% in 2019, reaching $3.8tn or $11,582 per DOI 10.1108/IJLSS-11-2020-0189
ID: bhardwaj.singh Time: 19:42 I Path: //mumnasprod/home$/Bhardwaj.Singh$/EM-IJLS210027

IJLSS person. As a share of the nation’s Gross Domestic Product, health spending accounted for
17.7% (National Health care Expenditure Data, 2019). Brue G (2006) listed various health-
care system problems such as billing defects, defective patient records, patient satisfaction,
food service, doctors utilization, operating room utilization, medical and surgical capacity,
surgery success rate, accuracy of lab result, rapid emergency room treatment, bed
availability, laboratory and radiology cycle time, antibiotic administration, cleaning process
accuracy, admission delay and discharge delay. Health-care system continues to produce
care that varies in quality. This leads to high rates of medical errors – resulting in deaths,
permanent disability, unnecessary suffering, patient’s dissatisfaction and inefficient
processes. The Institute of Medicine reported that medical mistakes in the USA cause as
many as 98,000 hospital deaths per year (Crago, 2000). Verma et al. (2021) reported that the
average economy is down from 1.62 to 5.45 and S&P 500 stock index is highly influenced
due to COVID 19. From this point, it is clearly inferred that quality in the health-care system
is more important for particularly COVID risk time.
2. Theoretical background
The evaluation of quality efforts in hospitals reflects four broad concepts, namely, quality
assurance, quality improvement, quality management and six sigma (Woodard, 2006). In
the health-care system, quality evolution and its strategies are discussed in Table 1. T1
3. Theoretical background
Antony (2006) attempts to explain the usefulness of six sigma in service segments such as
health care, banking, finance, public utilities and transportation industries. Brue (2006)
stressed the importance of six sigma in health-care service and identified potential areas
where six sigma may be used, for example, patients waiting time, billing defects, defective
patients records, patient satisfaction, food service, doctors utilization, operating room
utilization, surgery success rate, medical and surgical capacity, surgery success rate,
accuracy of lab result, rapid emergency room treatment, surgery success rate, accuracy of
lab result, rapid emergency room treatment, bed availability, laboratory and radiology cycle
time, antibiotic administration, cleaning process accuracy, admission delay and discharge
delay. From the paper, it is clearly inferred that six sigma can be approached to near perfect
process in the health-care system. Pexton (2005) presented the case study about the six
sigma’s define-measure-analysis-improve-control (DMAIC) implementation process of
Charleston Area Medical Center, USA. Six sigma team found that critical factors
surrounding the administration of antibiotics (post-operative surgical infection is a major
problem). The project mode approach has a significant impact on patients’ safety. From the
Time of
initiation Quality effort Strategy
1950 Quality Identify errors in clinical care and to eliminate these errors
assurance
1980 Quality Decrease variations to reduce error, as well as improve clinical and non-
improvement clinical processes
Table 1. 1990 Quality Use managerial concepts centered on quality improvement to achieve
Evaluation of quality management technical quality and customer satisfaction
efforts in health-care Late 1990 Six sigma Achieve defect free processes and reduce variance through six sigma
system improvement projects

paper, it is clearly inferred that six sigma is the best solution for the medical error reducing Six sigma in
process. DeYong and Sehwail (2003) presented a case study about the six sigma health-care
implementation process of Mount Carmel Health systems, OH. In Mount Carmel Health, six
sigma projects have included accurate medicare processing time in central scheduling,
service
clinical documentation, bottlenecks in the emergency department, Patients waiting time,
reducing cycle time in various inpatient and outpatient diagnostic areas. The project mode
approach has significantly reflected on financial results and employee retention was
achieved. Scheckner et al. (2003) described the use of DMAIC methodology for improving
acute anticoagulation service in a community hospital, New Jersey. Six sigma project was
used to replace the weight-based protocol heparin treatment in to low molecular weight
heparin treatment. The project mode approach has a significant impact on staff productivity
and patients’ safety. From the paper, it is clearly inferred that six sigma is a process that can
be used in meeting the needs and expectations of the patients in health-care organizations
along with profitability. All over the world, six sigma has been successfully implemented in
T2 various hospitals’ departments. Some of them are listed in Table 2.
Palani Natha Raja et al. (2007), developed a health service quality framework with service
quality dimensions.
Arafeh et al. (2014) have applied six sigma for patients’ waiting time reduction up to 50%
in an outside pharmacy located in a cancer treatment hospital. Discrete event simulation
model, sensitivity analysis and design of experiments played a major role in the study. Bhat
et al. (2014) have applied the six sigma DMAIC methodology and improved the Health
Information Department of a Medical College hospital registration process in India. Rohini
and Mallikarjun (2011) developed operation theatre process improvement through six sigma
DMAIC methodology in India. Godley and Jenkins (2019) reduced waiting time in the
vascular interventional radiology department through six sigma. Similarly, Jayasinha (2016)
has applied six sigma and decreased turnaround time in Pediatrics Clinic and Agarwal et al.
(2016) experimented and improved cardiac catheterization laboratory efficiency through six
sigma. Hundal et al. (2021) investigated the application and impact of COVID 19 lean six
sigma in the health-care environment. They have directly linked lean six sigma tools with
tools, applications, benefits and challenges for the purpose of health-care supply chain
resilience. Sarkar and Sana (2019) developed a disease decision supports system (DDSS) for
disease prediction using hybrid data mining techniques. The DDSS working as an e-doctor
to detect diseases. Sarkar and Sana (2020) stressed the importance of an improved and
Sl. no Authors Study location Parameters
1 Trakulsunti et al. (2020) Inpatient pharmacy of a Dispensing errors

teaching hospital in Thailand
2 Chang et al. (2020) surgical rooms and sickbeds in Time efficiency with surgical room
Taiwan process
3 Edward et al. (2017) academic children’s hospital in Operating efficiency
Loma Linda, CA
4 Prajapati and Suman (2019) Rural Hospitals, India Length of stay for neonatal jaundice
patients
5 Sayeed et al. (2018) Level I Trauma Center, Detroit Hip fracture care pathway
Medical Center, Detroit, MI time reduction
6 Elbireer et al. (2013) Ugandan laboratories Laboratory data entry quality Table 2.
7 Al Kuwaiti and Subbarayalu Hospital-acquired infection Infection rate Six sigma in health-
(2017) (HAI), Saudi Arabia care system

IJLSS secured health-care system with respect to a database of patient’s electronic medical records
with big data environment. Tolga Taner et al. (2007) have done five different case studies in
the health-care field with respect to decreasing unnecessary laboratory tests, improving MRI
image quality, decreasing waiting time before surgery, reducing catheter infection and
decreasing excess length of stay in hospital by the DMAIC methodology for improvement.
Furterer (2018) has applied and demonstrated six sigma DMAIC methodology in the
emergency department with a focus on the patients’ length of stay. Allen et al. (2009) applied
six sigma in the field of patient discharge streamline in community hospital using DMAIC.
They found that physician preparation writing for discharge order writing is a greater
impact. Al-Zain et al. (2019) implemented lean six sigma in the field of patient waiting time
in a Kuwaiti private hospital at obstetrics and gynaecology department. Improta et al. (2019)
demonstrated the efficacy and efficiency of the novel protocol for track surgery in the
Complex Operative Unit of Orthopaedic and Traumatology of the University Hospital with
the help of DMAIC methodology. Ricciardi et al. (2020) have improved length of
stay 19.9% and standard deviation 17.1% in fast track surgery through six sigma
DMAIC methodology. Mostadam et al. (2014) have analyzed patient satisfaction with respect
to reduction of process prosthetic treatment in an Imam Khomeini, Dental Center, Iran.
3.1 Gaps in literature

Countries all over the world are spending huge amounts for COVID 19 treatment and
controlling. Six sigma focuses world class performance and concentrates mainly on process
variation improvement that encourages data analysis and problem-solving statistical
techniques and evaluates the ability of a process to perform defect free. There are no studies
about the COVID 19 patients’ satisfaction. So far, research studies have been carried out
using six sigma and patient satisfaction but six sigma focused toward COVID 19 patients’
satisfaction has not been carried out, which we have done.
4. Methods and analysis

Six sigma has two methodologies. DMAIC methodology is an improvement system for
existing processes falling below specification and looking for incremental performance.
DMADV (Define-measure-analysis-design-verify) methodology is an improvement system
used to develop new processes or products at six sigma quality. COVID 19 patient
satisfaction process is falling below specification and looking for incremental so that
DMAIC methodology as chosen (Evans and Henderson, 2004). DMAIC methodology for
COVID 19 patients’ satisfaction is shown in Figure 1. F1
4.1 Define
Scoping and determining the right operational area are the preliminary steps in the defined
phase. The SIPOC tool was carried out in the defined phase. Scoping and determining the
right operational area are the preliminary steps in the defined phase. SIPOC tool was carried
out in the defined phase. SIPOC Diagram for COVID 19 Patients’ treatment process is shown
in Figure 2. F2
4.2 Measure
Totally 1,000 COVID 19 patients’ data were analyzed from May 2020 to July 2020. Without AQ: 7
causing any ethical issue, we carried out the survey among the patients who were affected
and treated successfully for COVID 19 in Chennai, India. We found that 98 patients (9.80%)
are dissatisfied in the selected health-care services.

Phases:
Objectives:
Six sigma in
Identify scope
and project boundaries
Tools: SIPOC, Process map Output: health-care
DEFINE
Draw the process map Understand the
service
process
Objectives:
Measure CTQs Tools: CTQ, Sigma calculation Output:
MEASURE Measure current Identify the

Patients’ satisfaction level current
Performance
level
Objectives:
Develop QFD Tools: QFD Output:
matrix for patients’ identify the
ANALYSE Satisfaction prioritize
patients’
requirements
Objectives:
Formulate the Multiple Tools: SPSS Output:

IMPROVE Regression Model for identify the
Patients’ relationship
satisfaction patients’
satisfaction
Formulate the Response Minitab and
Surface Regression prioritize
Model for patient
Patients’ requirements
satisfaction
Objectives:
Run Manocarlo Tools: Crystal Ball Output: Figure 1.
CONTROL simulation identify the DMAIC methodology
with sensitivity main drivers
analysis for patients’ for COVID-19
for patients’ satisfaction patients’ satisfaction
Satisfaction model model
Suppliers Inputs Process Flow Outputs Customers
Referring Physicians Defect free

COVID Patients’
Hospitals, Nurses services, Figure 2.
Treatment Patients
Insurers, Receptionist Satisfied SIPOC diagram for
Industries. Lab technicians Patients COVID-19 patients’
treatment process
Lab Instruments
Total no of respondents = 1,000.

Customers that were dissatisfied even on one critical to quality (CTQ) = 98.
No of opportunities (as per technical dimensions)= 6.
Defects per Unit (DPU) = 98/1,000.
Defects per Opportunities (DPO) = 98/(1,000 * 6).

IJLSS Defects per Million Opportunities (DPMO) = (98 * 1,000,000)/(1,000 * 6)

= 16,333.33.
Current sigma level = 3.63.
From the sigma calculation, the current patients’ satisfaction performance level is in 3.63
sigma means industrial average competitive level. Every sigma level increases, variations
will reduce. In the six sigma level the variation is close to zero. World class performance
companies such as Motorola, general electrical, dow chemicals and Mumbai dabbawala are
achieved six sigma levels.
4.3 Analysis
4.3.1 Critical to quality. It is very important for any organization to clearly understand the
specific customer needs, these tangibly defined needs are called CTQ. CTQs represent the
product or service characteristics that are defined by the customers (Mast and Koning,
2007). The main objective is to identify the key drivers of COVID 19 patients’ satisfaction. If AQ: 6
the service does not meet CTQ, it will be considered a defect. A block diagram of the CTQ
identification process is shown in Figure 3. F3
We have identified the following CTQs:
CTQ1 General infrastructure ( X1 ).
CTQ2 Food quality during treatment ( X2 ).
CTQ3 Cross-functional collaboration ( X3 ).
CTQ4 Social camps ( X4 ).
CTQ5 Assurance by doctors ( X5).
CTQ6 Assurance by technicians ( X6).
CTQ7 Assurance by administrative staff ( X7 ).
CTQ8 Waiting time for treatment ( X8 ).
CTQ9Turnaround time between request and response( X9).
CTQ10 Process standardization ( X10 ).
CTQ11 Process management route guidance ( X11 ).
CTQ12 Cost for treatment ( X12 ).
4.3.2 Quality functional deployment. The goal of the analyze phase is to identify the key
drivers of the patients’ satisfaction model. The following steps were carried out in the
analysis phase by using QFD:
Identification of service quality dimensions.
Preparation of questionnaire.
Check the COVID 19 patients’ voice statement

(From the primary survey)
Organize the customer needs
Figure 3.
CTQs identification
process Complete the needs list

Collection of feedback from stakeholders such as doctors, patients and technicians. Six sigma in
Patient requirements prioritization using QFD. health-care
service
Shastree et al. (2006) identified eight major service quality dimensions for the educational
model. Similarly, we have identified equivalent dimensions, namely, infrastructural
requirements, working standard, overall working culture of the hospital, opportunities
provided by the hospital, interaction with other hospitals, exposure to global standard,
doctors and technician development and policy of fairness.
4.3.3 Questionnaire development. The patients’ questionnaire was drawn up in English
and Tamil (regional language). Seven point Likert-type scale is used, to determine the levels
of agreement with each statement (Camilleri and O’Callaghan, 1998). In addition, the
participants were asked for their overall views of their experience, satisfaction with the
COVID 19 treatment service. In total, 68% male COVID patients and 32% female COVID
patients have visible in the patient-specific characteristics of the sample.
4.3.4 Covid patients’ requirements prioritization using QFD. The patients’ requirements
differ from one person to another. Some patients need general infrastructure-related and
some patients need assurance-related satisfaction. There is a need for the identification of
prioritized patient requirements. So we have chosen the tool as QFD. QFD methodology for
F4 COVID 19 patients’ satisfaction is shown in Figure 4.
4.3.5 The whats. In QFD analysis, the process starts with the construction of the house of
quality, which requires the identification of the patients’ requirements. These describe the
service characteristics. The detailed dimensions of all of these requirements and their
T3 T4 ratings are given in Tables 3 and 4. Patient voices or the whats were ranked using simple
averages based on the responses of participants. The patient requirements are ranked on 1
to 10 scale. This ranking is used also as a row weighting such that 10 represent the most
important patient need and the greatest weight is assigned to it. 1 represents the least
important patient need.
Phases:
Rank patient Outputs:
The Whats
Voices using simple Identify patient
(Patients’ requirements)
average based method requirements
The Hows translate patient requirements in to Outputs:

technical Identify
(Technical requirements)
requirements technical
requirements
Categorize the whats and the hows Outputs:

Develop QFD
Matrix Rank the technical requirements Identify Figure 4.
prioritized patients QFD methodology for
requirements
COVID-19 patients’
satisfaction
Tools: Stockholders Feedback, Brainstorming, Parasuraman SERQUAL Model

IJLSS Important
Dimensions Sub-dimensions (voice of the patient) rating
Infrastructural (A0) Hospital building and premises 9

requirements (A) (A1) Availability of various laboratories 8
(A2) Quality of the accredited equipment available 10
(A3) Ambulance facility 4
(A4) Canteen facility 4
Working standard (B) (B0) Qualification of doctor’s and technician’s 5
(B1) ** Doctor’s and technician’s skill 5
(B2) Method and quality of diagnosing 9
(B3) Research work and publication by the doctors 6
Overall working culture of (C0) Respect for each one another 5
hospital (C) (C1) **Attitude of doctors toward patient 5
(C2) **Attitude of patient toward doctors 5
(C3) Direction and promptness from top management 9
(C4) Support of administrative staff to patient and doctors 8
Opportunities provided by (D0) No of patient diagnosed by social camps 10
hospital (D)
Interaction with other (E0) No of consultancy projects undertaken by hospital 5
hospital (E) (E1) Involvement of doctors to other hospitals in treatment process 5
(E2) Interaction with benchmarking hospitals 6
Exposure to global (F0) Visit to advanced multinational hospitals 4
standard (F) (F1) Access to electronic health care including telemedicine, 8
hospital information system (HIS)
Policy of fairness (G) (G0) Transparency in diagnosis and treatment 7
(G1) Timely assessment and declaration of results 7
(G2) Fees charged to patient and variation in the same 5
Doctor’s and technicians (H0) Number of training programs conducted for the doctor’s 5
development (H) development 4
Table 3. (H1) Number of doctors sent for higher learning institutions 4
Patients’ (H2) No of technicians underwent skill training
requirements and
important rating Note: ** Interpersonal dimension
Dimensions Voice of the COVID-19 patients
Tangible (X1) General infrastructure

(X2) Food quality during treatment
(X3) Cross functional collaboration
(X4) Social camps
Assurance (X5) Assurance by doctors
(X6) Assurance by technicians
(X7) Assurance by administrative staff
Responsiveness (X8) Waiting time for treatment
Table 4. (X9) Turnaround time between request and response
Dimensions and Reliability (X10) Process standardization
technical Empathy (X11) Process management route guidance
requirements Cost (X12) Cost for treatment

4.3.6 The relationship matrix. Building the relationship matrix requires the analysis of Six sigma in
relationships existing between every “what” and “how.” All relationships are categorized as health-care
strong, medium or weak. Different numbers (1, 3 and 9 for weak, medium and strong) are
used to signify different relationship strengths and the relational matrix is constructed.
service
Referring to Figure 4, an example of a strong relationship would be between hospital
buildings and premises and general infrastructure. Another example of a weak relationship
would be between research work and publication by the doctors and general infrastructure.
4.3.7 The how much.
X
Column weight ¼ ðImportant rating * relationship weightÞ
Using the above formula, column weights are calculated. Thus, the column weight for the
first column is (9 * 9) þ (8 * 9) þ (10 * 9) þ (4 * 1) þ (4 * 9) þ . . .. . .. . .. . .. . .. . . þ (4 * 1).
T5 After calculating the column weights, all the technical requirements are ranked. Table 5
represents QFD matrix for COVID 19 patients’ satisfaction.
From Table 5, the result of prioritized patients’ requirements found, namely, assurance
by doctors (AD), process standardization (PS), general infrastructure (GI), waiting time for
treatment (WT), cost for treatment (CT) and assurance by technicians (AT).
Codes Rating X1 X2 X3 X4 X5 X6 X7 X8 X9 X10 X11 X12
A0 9 9 1 3 1 1 1 1 1 1 1 1 3
A1 8 9 1 3 1 1 1 1 9 1 3 1 9
A2 10 9 1 3 1 1 1 1 9 9 3 1 9
A3 4 1 1 1 1 1 1 1 1 1 1 1 1
A4 4 9 9 1 1 1 1 1 1 1 1 1 3
B0 5 1 1 1 1 9 9 9 1 1 1 1 1
B1 5 1 1 1 1 9 9 9 1 1 1 1 1
B2 9 1 1 1 1 3 1 3 9 1 9 9 9
B3 6 3 1 3 1 9 1 1 1 1 1 1 1
C0 5 1 3 1 1 1 1 1 1 1 1 1 1
C1 5 1 1 1 1 9 1 1 1 1 1 1 1
C2 5 1 1 1 1 1 1 1 1 1 1 1 1
C3 9 1 1 1 1 1 1 1 1 1 9 1 1
C4 8 1 1 1 1 1 1 9 1 1 3 1 1
D0 10 1 1 1 9 1 1 1 1 1 1 1 1
E0 5 9 1 3 1 9 3 3 1 1 9 9 3
E1 5 1 1 1 1 9 1 1 1 1 1 1 1
E2 6 1 1 9 1 1 1 1 1 1 1 1 1
F0 4 3 1 3 1 9 1 1 1 1 1 1 1
F1 8 3 1 3 1 9 1 1 1 1 1 1 1
G0 7 1 1 1 1 1 1 1 9 1 9 3 3
G1 7 1 1 1 1 1 1 1 9 3 9 3 1
G2 5 3 1 1 1 1 1 1 1 1 1 1 9
H0 5 1 1 1 1 9 3 3 1 1 1 1 1
H1 4 1 1 1 1 9 1 1 1 1 1 1 1 Table 5.
H2 4 1 1 1 1 1 9 1 1 1 1 1 1 QFD matrix for
Column weight 496 204 310 242 596 294 320 490 256 510 312 468 COVID-19 patients’
Rank order 3 12 8 11 1 9 6 4 10 2 7 5 satisfaction

J_ID: IJLSS ART NO: 10.1108/IJLSS-11-2020-0189 Date: 30-March-21 Page: 10 Total Pages: 19 4/Color Figure(s) ARTTYPE="ResearchA
IJLSS 4.4 Improve

The goal of the improve phase is to establish the relationship between key input variables
such as assurance by doctors (AD), process standardization (PS), general infrastructure (GI),
waiting time for treatment (WT), cost for treatment (CT), assurance by technicians (AT) and
output variable (patients’ satisfaction). Improve and control phases activities and tools are
shown in flowchart Figure 6.
4.4.1 Multiple regression model development for patients’ satisfaction. Regression
analysis is a mathematical measure of the average relationship between two or more
variables in terms of original units of data. Regression is used to create an equation (or)
transfer function from the measurements of the system’s inputs and outputs acquired
during a passive or active experiment (Kazmier, 2005). The transfer function is then used for
sensitivity analysis, optimization of system performance and tolerance the system’s
components (Antis et al., 2006). A Path diagram Figure 5 represents the response (overall F5
patients’ satisfaction) and the predictors (top six ranks from QFD result) such as assurance
by doctors (AD), process standardization (PS), general infrastructure (GI), waiting time for
treatment (WT), cost for treatment (CT) and assurance by technicians (AT). F6
SPSS was used to analyze the response for this study. Pearson correlation was used to
analyze the correlation among the seven variables. Multiple regression analysis was
conducted using patient satisfaction (PAS) as a dependent variable and prioritized patient
requirements such as assurance by doctors (AD), process standardization (PS), general
infrastructure (GI), waiting time for treatment (WT), cost for treatment (CT) and assurance
by technicians (AT) as the independent variables. From the regression analysis, cost for
treatment (CT), assurance by technicians (AT) are not significant in explaining the variation
in COVID 19 patient satisfaction, we developed the reduced regression that excluded the
variables. Table 6 shows a summary of the regression results. The reduced and final T6
regression model has the following form:
PAS ¼ f ðAD; PS; GI; WTÞ
SPSS based on the analysis formulated the transfer function for patient satisfaction shown
in the equation:
Process
Standardization (PS)
General Infrastructure
Assurance by Doctors
(GI)
(AD)
RESPONSE (PAS)
COVID 19 Patients’
Satisfaction
Figure 5.
Assurance by
Response and Waiting time for
predictors for COVID- Treatment (WT)
Technicians (AT)
19 patients’ Cost for Treatment (CT)
satisfaction

Start Six sigma in

health-care
service
Read the prioritized
patients’ requirements
from QFD matrix
Develop the multiple linear regression model between

prioritized patients’ requirements and patient satisfaction
by using SPSS
If one patient requirements

have interact any others
No
Yes
Develop the response surface regression model between

prioritized patients’ requirements andYes
patient satisfaction
Run Monte Carlo simulation with sensitivity analysis

by using Crystal ball ( Control Phase) Figure 6.
Improve and control
phases for COVID-19
End patients’ satisfaction
PAS ¼ 0:382 AD þ 0:460 PS þ 0:364 GI 0:101WT – 1:003 (1)
4.4.2 Response surface model development for patients’ satisfaction. The above transfer
function is simple and not specifies the interaction between the predictors and need
additional experimental data to estimate squared terms. So that RSM as chosen and
R R2 Adjusted R2 Std. error of the estimate

0.929 0.864 0.851 0.5485
ANOVA Sum of squares Df Mean square F Sig.
Regression 85.683 4 21.421 71.208 0.000
Residual 13.537 45 0.301
Total 99.220 49
Regression coefficients Unstandardized coefficients Standardized coefficients T Sig.
B Std. error Beta
(Constant) 1.003 0.486 2.065 0.000
Assurance by doctors 0.382 0.095 0.306 4.006 0.000
Process Standardization 0.460 0.104 0.397 4.406 0.000
General infrastructure 0.364 0.101 0.302 3.585 0.001
Table 6.
Waiting time 0.101 0.041 0.140 2.436 0.019
Summary of
Notes: Dependent variable: patients’ satisfaction; predictors: assurance by doctors, process regression result for
standardization, general infrastructure, waiting time reduced model

IJLSS formulate the transfer function with interaction reported by Minitab. RSM is a collection of
mathematical and statistical techniques that are useful for the modeling and analysis of
problems in which a response of interaction is influenced by several variables (Montgomery,
2020). Response surface regression analysis was carried out through Minitab software.
Based on the Minitab analysis, formulated the transfer function with interaction shown in
this equation:
PAS ¼ 1:19766 AD þ 0:29454 PS þ 0:97778 GI – 0:07197 WT 0:03665 CT

þ :91014 AT 1:26633 AD*AD þ 2:73581 PS*PS 1:87540 GI*GI
þ 1: 09435 WT*WT þ :14880 AD*PS 1:04637 AD*GI
þ 2:77196 AD*CT – 1:20609 AD*AT – 2:46949 PS*GI þ 1:83315 PS*CT
3:12945 PS*AT 1:42517 GI*CT þ 4:45458 GI*AT – 1:794049 CT*AT
þ 3:26786:
(2)
4.4.3 Surface plot. The above transfer function is a mathematical description of the system
behavior and validated the transfer function with interaction using surface plot. Surface plot
allows us to visualize the system’s behavior (Antis et al., 2006). The two surface plots are
shown in Figures 7 and 8. F7 F8
From Figures 9 and 10, the assurance by doctors (AD) vs cost for treatment (CT) surface F9 F10
plot is curved due to the interaction between the predictors (Montgomery, 2002). The
waiting time for treatment (WT) vs cost for treatment (CT) surface plot is a plane because
waiting time for treatment and cost for treatment appear as linear terms and they do not
interact (Montgomery, 2020).
Patient satisfaction
Assurance by Doctors
Cost for medical check up
PS 4
2 6
Figure 7. 4 AD
2
Surface plot for 4 2
6
assurance by doctors CT
vs cost for treatment

Six sigma in
Surface Plot of PAS vs WT, CT
health-care
service
PA S
4
2 6 Figure 8.
4 WT Surface plot for
2
4
2 waiting time for
CT
6 treatment (WT) vs
cost for treatment
(CT)
Figure 9.
Per cent contribution
to variation
4.5 Control
The goal of the control phase is to identify the major driver of the COVID patients’
satisfaction model. Monte Carlo simulation run with sensitivity analysis was carried out in
the controlled phase by using a crystal ball. Simulation is the imitation of the operation of a
real world process (or) system over time. Monte Carlo simulation is one of the static
simulation models, represents a system at a particular point in time (Shahbudeen et al.,
2007). The main objective of the sensitivity analysis is to identify the main driver of the
patient satisfaction variation. During the control phase, predictions of patient satisfaction
variation are provided using Monte Carlo simulations. The input variables such as
assurance by doctors (AD), process standardization (PS), general infrastructure (GI), waiting
time for treatment (WT), cost for treatment (CT) and assurance by technicians (AT) are
assigned normal distribution. Finally, a specified number of Monte Carlo trials to run at; in
this case 1,100,000 trials and run a sensitivity analysis to determine the main driver of the

IJLSS Versus Fits

(response is PAS)
1.0
0.5
Residual
0.0
–0.5
–1.0
Figure 10.
Residuals vs fitted –1.5
0 1 2 3 4 5 6 7
value Fitted Value
patient satisfaction variation. Sensitivity charts displayed the per cent contribution to
variation for each input parameters as shown in Figure 9.
From the sensitivity chart Figure 9, general infrastructure (GI), waiting time for
treatment (WT) contributed almost 74.1% of all the variation in the patient satisfaction.
5. Findings
From the QFD matrix, prioritized patient requirements were found, namely, assurance by
doctors (AD), process standardization (PS), general infrastructure (GI), waiting time for
treatment (WT), cost for treatment (CT) and assurance by technicians (AT). The two
regression models such as the multiple regression model and response surface regression
model have explained the variation accounts for 87.5% and 98.7% (R2 0.858 and R2 0.987) of
the total variation seen in the experiment (Ng et al., 2004). The F ratio is significant at
the 0.000 level, which means that the results of the regression models could hardly have
occurred by chance (Chaker and Jabnoun, 2003). The quality of the regression can also be
assessed from a plot of residuals vs the fitted values. The plot shows no observable
structure (Figure 9). The above three points indicate that the model is a good and acceptable
one (Antis et al., 2003).
5.1 The resulting multiple regression model equation (1)

There is a positive relationship between the process standardization (PS) and patients’
satisfaction (PAS) as the regression coefficient is 0.460. It indicates that patient satisfaction
increases by 0.460% if the process standardization is increased by 1% without changing all
other predictors (Cao et al., 2006). There is a positive relationship between the assurance by
doctors (AD) and patient satisfaction (PAS) as the regression coefficient is 0.382. Similarly,
patients’ satisfaction will increase 0.382% if the assurance by doctors increases 1% without
change of all other predictors. Patients’ satisfaction will increase 0.364% if the general
infrastructure increases 1% without change of all other predictors. Three predictors such as
process standardization (PS), assurance by doctors (AD) and general infrastructure (GI)
have a large coefficient, which strongly affect the response. Small variation in this input
causes large variation in the response (patient satisfaction) (Antis et al., 2006). There is a
negative relationship between the waiting time for treatment (WT) and the patients’
satisfaction (PAS) as the regression coefficient is 0.101. Patients’ satisfaction will decrease

0.101% if the waiting time increases 1% without change in all other predictors. It shows that Six sigma in
COVID 19 health-care people should focus on the patients waiting time. health-care
service
5.2 The resulting response surface regression model equation (2)
General infrastructure (GI) and assurance by technicians (AT) pair, assurance by doctors
(AD) and cost for treatment (CT), assurance by doctors and process standardization (PS)
pair appeared in the equation. General infrastructure (GI) and assurance by technicians (AT)
pair, assurance by doctors (AD) and cost for treatment (CT) and assurance by doctors and
process standardization (PS) pair have large interaction coefficient, which interaction
strongly affect the response. From the sensitivity chart, general infrastructure (GI), waiting
time for treatment (WT) contributed almost 74.1% of all the variation in patient satisfaction.
So, general infrastructure (GI), waiting time for treatment (WT) are the main drivers in the
patients’ satisfaction model (Goldman et al., 2005).
5.3 Discussions
Vijaya Sunder et al. (2020), have done a case study for improving patients’ satisfaction in a
mobile hospital using lean six sigma through the DMADV roadmap. Similarly, we have
applied six sigma DMAIC roadmap for patients satisfaction analysis. World Health
Organization has described the protocols for COVID 19 treatment process. Our study reveals
that process standardization is essential for COVID 19 patients’ satisfaction. The regression
model indicated that process standardization (reliability dimension) contributed the most to
the variation in patient satisfaction. This finding is consistent with what was found by other
researchers (Chaker and Jabnoun, 2003), i.e. reliability dimension contributed the most
important variations in overall service quality. Assurance by doctors is the second
important factor in the regression model. This finding is consistent with what was found by
other researchers (Ng et al., 2004), i.e. the fact that interpersonal quality is important in the
private hospital model could indicate a higher level of psychological needs in their patient.
Waiting time is another important factor in the regression model. This finding is consistent
with what was found by other researchers (Ng et al., 2004), i.e. patient waiting time has an
important hospital service quality dimension in the overall perception of quality. Waiting
time is a negative impact for COVID 19 patients’ satisfaction. The patients are dissatisfied
when they have to wait to treat doctors. One unexpected finding is that the cost dimension is
insignificant influencing COVID patients’ satisfaction. Globally, as of 3:35 p.m. CET,
February 13 2021, there have been 107,838,255 confirmed cases of COVID-19, including
2,373,398 deaths, reported to WHO. So, COVID 19 patients’ data collection, analyzes and
modeling are essentially needed one for the future. We have used regression analysis and
sensitivity analysis tool for research. Arafeh et al. (2014) research work supported data
modeling with six sigma methodology.
6. Conclusion
Six sigma is heavily data based for particularly COVID 19 patients’ data aspect and a key to
resolving problems. The hospitals should properly measure and analyze the COVID 19
patients’ data and use it to drive decisions dealing with this current COVID 19 patient’s
satisfaction factor and it could change how certain processes are run or how we handle a
pandemic. In this study, COVID patients’ satisfaction falls under the applied six sigma
thematic area. Achieving high level COVID 19 patient satisfaction through six sigma should
be one of the top priorities of any health-care organization. The present study views that the
COVID 19 patient satisfaction and has analyzed the major influenced factors in the health-
care system. This paper identifies the key factors influencing COVID 19 patients’

IJLSS satisfaction in India. The proposed six sigma conceptual framework model with DMAIC for
COVID 19 patients’ satisfaction would identify the key role of the variables influencing
the performance of the Indian health-care system and also will be instrumental in improving
the performance of Indian health-care industries. The major limitation of this study that the
respondents were limited to patients from one city in India. Though the concurs with other
studies conducted in other cities, future research exercises should consider taking samples
from different parts of India that conclusions are universally relevant. AQ: 8
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Corresponding author
Kaja Bantha Navas Raja Mohamed can be contacted at: [email protected]
For instructions on how to order reprints of this article, please visit our website:
www.emeraldgrouppublishing.com/licensing/reprints.htm
Or contact us for further details: [email protected]
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Six sigma in health-care service: a case study on COVID 19 patients’

Article in International Journal of Lean Six Sigma · May 2021

Kaja BANTHA Navas R John Rajan A

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Sl. no Authors Study location Parameters

1 Trakulsunti et al. (2020) Inpatient pharmacy of a Dispensing errors

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3.1 Gaps in literature

4. Methods and analysis

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MEASURE  Measure current Identify the

 Formulate the Multiple Tools: SPSS Output:

Suppliers Inputs Process Flow Outputs Customers

Referring Physicians Defect free

Total no of respondents = 1,000.

ID: bhardwaj.singh Time: 19:42 I Path: //mumnasprod/home$/Bhardwaj.Singh$/EM-IJLS210027

IJLSS Defects per Million Opportunities (DPMO) = (98 * 1,000,000)/(1,000 * 6)

Check the COVID 19 patients’ voice statement

Organize the customer needs

ID: bhardwaj.singh Time: 19:42 I Path: //mumnasprod/home$/Bhardwaj.Singh$/EM-IJLS210027

The Hows  translate patient requirements in to Outputs:

 Categorize the whats and the hows Outputs:

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Infrastructural (A0) Hospital building and premises 9

Dimensions Voice of the COVID-19 patients

Tangible (X1) General infrastructure

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Codes Rating X1 X2 X3 X4 X5 X6 X7 X8 X9 X10 X11 X12

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IJLSS 4.4 Improve

PAS ¼ f ðAD; PS; GI; WTÞ

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Start Six sigma in

Develop the multiple linear regression model between

If one patient requirements

Develop the response surface regression model between

Run Monte Carlo simulation with sensitivity analysis

PAS ¼ 0:382 AD þ 0:460 PS þ 0:364 GI 0:101WT – 1:003 (1)

R R2 Adjusted R2 Std. error of the estimate

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PAS ¼ 1:19766 AD þ 0:29454 PS þ 0:97778 GI – 0:07197 WT 0:03665 CT

vs cost for treatment

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IJLSS Versus Fits

5.1 The resulting multiple regression model equation (1)

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MEASURE Measure current Identify the

Formulate the Multiple Tools: SPSS Output:

The Hows translate patient requirements in to Outputs:

Categorize the whats and the hows Outputs: