Aplicación de la metodología Lean Seis Sigma en salud: revisión integrativa

revisión integral de la literatura, con la siguiente pregunta: ¿cuáles son los resultados en las instituciones de salud que utilizan la metodología Lean Six Sigma y Six Sigma? La búsqueda se realizó en las bases de datos MEDLINE, LILACS, BDENF, CINAHL, Web of Science y Scopus, sin marco de tiempo.

Resultados:

se incluyeron 34 artículos, publicados entre 2005 y 2019, el 52,9% de los Estados Unidos de América. Las mejoras más comunes se encontraron en las instituciones hospitalarias y desde la perspectiva de los clientes y los procesos internos.

Conclusión:

el uso de la metodología Lean Six Sigma demostró ser eficaz en los diferentes escenarios de atención médica, destacando una brecha en su aplicación con respecto al compromiso y la capacitación de las personas.

Descriptores:
Gestión de Calidad Total; Administración en Salud; Prestación de Atención de Salud; Mejoramiento de la Calidad; Control de Calidad

Database	Descriptors/keywords	Articles retrieved
MEDLINE	"Total Quality Management" [MesH Terms] AND "Lean Six Sigma" [All Fields]	227
MEDLINE	"Total Quality Management" [MesH Terms] AND Six Sigma" [All Fields]	55
LILACS	"Gestão da Qualidade Total" AND "Seis Sigma" AND (db: ("LILACS"))	7
BDENF	"Gestão da Qualidade Total" AND "Seis Sigma" AND (db: ("BDENF"))	2
CINAHL	"Six Sigma" AND "Quality Improvement"	132
CINAHL	"Six Sigma" AND "Lean"	89
Web of Science	"Six Sigma" AND "Healthcare"	93
Scopus	"Six Sigma" AND "Healthcare"	179

Title	Year Country	Intervention	Outcomes	Health institution
Use of Lean Six Sigma methodology shows reduction of inpatient waiting time for peripherally inserted central catheter placement⁽⁹9 Hynes JP, Murray AS, Murray OM, Eustace SK, Gilchrist S, Dolan A, et al. Use of Lean Six Sigma methodology shows reduction of inpatient waiting time for peripherally inserted central catheter placement. Clin Radiol. 2019;74(9):733.e5-733.e9. doi: 10.1016/j.crad.2019.04.022 https://doi.org/10.1016/j.crad.2019.04.0... ⁾	2019 Ireland	Use of LSS methodology to improve response time for insertion of peripherally inserted central catheter.	Response time reduction from 3.7 to 1.8 days, representing a 35.8% improvement over the previous time.	University hospital
Implementing Lean Six Sigma in a Kuwaiti private hospital⁽¹⁰10 Al-Zain Y, Al-Fandi L, Arafeh M, Salim S, Al-Quraini S, Al-Yaseen A, et al. Implementing Lean Six Sigma in a Kuwaiti private hospital. Int J Health Care Qual Assur. 2019;32(2):431-46. doi: 10.1108/IJHCQA-04-2018-0099 https://doi.org/10.1108/IJHCQA-04-2018-0... ⁾	2018 Kuwait	Use of LSS to reduce waiting time in an obstetrics and gynecology unit.	67% reduction in waiting time on weekends and 55% on weekdays.	Private hospital
Applying Lean Six Sigma methods to reduce length of stay in a hospital's emergency department⁽¹¹11 Furterer SL. Applying Lean Six Sigma methods to reduce length of stay in a hospital’s emergency department. Qual Engineering. 2018,30(3):389-404. doi: 10.1080/08982112.2018.1464657 https://doi.org/10.1080/08982112.2018.14... ⁾	2018 USA	Use of LSS and its instruments in the emergency room of a hospital.	Reduction in length of stay 30% in three months, in the percentage of patients who leave without treatment from 6.5% to 0.3% and improvement of patient satisfaction from 24% to 89.9%.	Private hospital
Lean Six Sigma to reduce Intensive Care Unit length of stay and costs in prolonged mechanical ventilation⁽¹²12 Trzeciak S, Mercincavage M, Angelini C, Cogliano W, Damuth E, Roberts BW, et al. Lean Six Sigma to reduce Intensive Care Unit length of stay and costs in prolonged mechanical ventilation. J Healthc Qual. 2018;40(1):36-43. doi: 10.1097/JHQ. 0000000000000075 https://doi.org/10.1097/JHQ. 00000000000... ⁾	2018 USA	Use of LSS to reduce hospital stay and associated costs in caring for patients with mechanical ventilation.	Reduction in hospital stay by 24% and in the average cost per case of mechanical ventilation by 27%.	University hospital
An Initiative to Optimize Waste Streams in the Operating Room: RECycling in the Operating Room (RECOR) Project⁽¹³13 Martin DM, Yanez ND, Treggiari MM. An initiative to optimize waste streams in the operating room: RECycling in the Operating Room (RECOR) Project [Internet]. AANA J. 2017 [2019 Sep 07];85(2):108-12. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30501159 https://www.ncbi.nlm.nih.gov/pubmed/3050... ⁾	2017 USA	Use of LSS to reduce material waste in the operating room environment and improve the low-cost material disposal flow.	Reduction from 12% to 6% of waste per day and increase in recyclable material from 19% to 45%.	Private hospital
Assurance of Myeloid Growth Factor Administration in an Infusion Center: Pilot Quality Improvement Initiative⁽¹⁴14 Ramirez PM, Peterson B, Holtshopple C, Borja K, Torres V, Valdivia-Peppers L, et al. Assurance of myeloid growth factor administration in an infusion center: pilot quality improvement initiative. J Oncol Pract. 2017;13(12):e1040-e1045. doi: 10.1200/JOP. 2017.023804 https://doi.org/10.1200/JOP. 2017.023804... ⁾	2017 USA	Use of LSS to reduce the rate of missed doses of myeloid growth factor medications to <0.5%.	Dose omission rate reduction from 3.52 to 0% after the intervention.	Infusion center
Improving performances of the knee replacement surgery process by applying DMAIC principles⁽¹⁵15 Improta G, Balato G, Romano M, Ponsiglione AM, Raiola E, Russo MA, et al. Improving performances of the knee replacement surgery process by applying DMAIC principles. J Eval Clin Pract. 2017;23(6):1401-1407. doi: 10.1111/jep.12810 https://doi.org/10.1111/jep.12810... ⁾	2017 Italy	Use of LSS to cut costs related to the process of knee replacement surgery.	Reduction in hospital stay by 42%, from 14.2 to 8.3 days.	University hospital
Lean Six Sigma techniques to improve ophthalmology clinic efficiency⁽¹⁶16 Ciulla TA, Tatikonda MV, ElMaraghi YA, Hussain RM, Hill AL, Clary JM, et al. Lean Six Sigma techniques to improve ophthalmology clinic efficiency. Retina. 2018;38(9):1688-1698. doi: 10.1097/IAE. 0000000000001761 https://doi.org/10.1097/IAE. 00000000000... ⁾	2017 USA	Use of LSS to decrease the patient's flow time at eye clinics.	Reduced patient flow time by 18% as well as improved patient and employee satisfaction rates.	Clinic
Reducing the risk of healthcare-associated infections through Lean Six Sigma: The case of the medicine areas at the Federico II University Hospital in Naples (Italy)⁽¹⁷17 Improta G, Cesarelli M, Montuori P, Santillo LC, Triassi M. Reducing the risk of healthcare-associated infections through Lean Six Sigma: the case of the medicine areas at the Federico II University Hospital in Naples (Italy). J Eval Clin Pract. 2018;24(2):338-46. doi: 10.1111/jep.12844 https://doi.org/10.1111/jep.12844... ⁾	2017 Italy	Use of LSS to reduce the risk of healthcare-related infections.	Reduction in the percentage of colonized patients from 0.37% to 0.21% and reduction in the average number of days of hospitalization from 45 to 36 days in surgical areas and reduction in colonization from 0.36% to 0.19% in clinics.	University hospital
Supply and demand: application of Lean Six Sigma methods to improve drug round efficiency and release nursing time⁽¹⁸18 Kieran M, Cleary M, De Brún A, Igoe A. Supply and demand: application of Lean Six Sigma methods to improve drug round efficiency and release nursing time. Int J Qual Health Care. 2017;29(6):803-9. doi: 10.1093/intqhc/mzx106 https://doi.org/10.1093/intqhc/mzx106... ⁾	2017 Ireland	Use of LSS to reduce interruptions and time in oral medication administration rounds.	Oral medication administration time reduced from 151 to 51 minutes and interruptions from 12 to 11 times on average.	University hospital
Improving operating room efficiency in academic children's hospital using Lean Six Sigma methodology⁽¹⁹19 Tagge EP, Thirumoorthi AS, Lenart J, Garberoglio C, Mitchell KW. Improving operating room efficiency in academic children’s hospital using Lean Six Sigma methodology. J Pediatr Surg. 2017;52(6):1040-1044. doi: 10.1016/j.jpedsurg.2017.03.035 https://doi.org/10.1016/j.jpedsurg.2017.... ⁾	2017 USA	Using LSS to improve efficiency in the operating rooms of a children's hospital.	The interval between patient departure from the operating room and the arrival of the next one decreased from a median of 41 minutes to 32 minutes, and the interval between dressing and the subsequent surgical incision decreased from 81.5 minutes to 71 minutes.	Hospital
Reducing patients' falls rate in an Academic Medical Center (AMC) using Six Sigma "DMAIC" approach⁽²⁰20 Kuwaiti AA, Subbarayalu AV. Reducing patients’ falls rate in an Academic Medical Center (AMC) using Six Sigma “DMAIC” approach. Int J Health Care Qual Assur. 2017;30(4):373-384. doi: 10.1108/IJHCQA-03-2016-0030 https://doi.org/10.1108/IJHCQA-03-2016-0... ⁾	2017 Saudi Arabia	Use of LSS to reduce the rates of falling patients.	Reduction in the fall rate from 6.57 to 1.91 per thousand patients/day, showing an improvement of 71%.	University hospital
Using Lean Six Sigma Methodology to improve a mass immunizations process at the United States Naval Academy⁽²¹21 Ha C, McCoy DA, Taylor CB, Kirk KD, Fry RS, Modi JR. Using Lean Six Sigma Methodology to improve a mass immunizations process at the United States Naval Academy. Mil Med. 2016;181(6):582-8. doi: 10.7205/MILMED-D-15-00247 https://doi.org/10.7205/MILMED-D-15-0024... ⁾	2016 USA	Application of LSS methodology to improve the mass immunization process.	79% reduction in average vaccination time and 10% need for human resources	Naval health clinic
Use of Six Sigma Methodology to reduce appointment lead-time in obstetrics outpatient department⁽²²22 Ortiz Barrios MA, Felizzola Jiménez H. Use of Six Sigma Methodology to reduce appointment lead-time in obstetrics outpatient department. J Med Syst. 2016;40(10):220. doi: 10.1007/s10916-016-0577-3 https://doi.org/10.1007/s10916-016-0577-... ⁾	2016 Colombia	Use of LSS to reduce the time required to make an appointment at the obstetrics clinic.	Reduction in the average of the consultation process (Lead Time) from 6.89 days to 4.08 days.	Obstetric outpatient clinic
Application of Six Sigma Methodology to reduce medication errors in the outpatient pharmacy unit: a case study from the King Fahd University Hospital, Saudi Arabia⁽²³23 Al Kuwaiti A. Application of Six Sigma Methodology to reduce medication errors in the outpatient pharmacy unit: a case study from the King Fahd University Hospital, Saudi Arabia. IJQR. 2016;10(2):267-8. doi: 10.18421/IJQR10.02-03 https://doi.org/10.18421/IJQR10.02-03... ⁾	2016 Saudi Arabia	Use of LSS to reduce medication errors in the outpatient clinic of a University Hospital.		Outpatient clinic
Decreasing turnaround time and increasing patient satisfaction in a safety net Hospital-Based pediatrics clinic using Lean Six Sigma Methodologies⁽²⁴24 Jayasinha Y. Decreasing turnaround time and increasing patient satisfaction in a safety net Hospital-Based pediatrics clinic using Lean Six Sigma Methodologies. Qual Manag Health Care. 2016;25(1):38-43. doi: 10.1097/QMH. 0000000000000083 https://doi.org/10.1097/QMH. 00000000000... ⁾	2016 USA	Using LSS to reduce waiting time and improve patient and employee satisfaction.	Defect reduction and improvement in sigma capacity from 3.09 to 4.08 sigma.	Pediatric medical center
Improvement in patient transfer process from the operating room to the PICU using a Lean and Six Sigma-Based quality improvement project⁽²⁵25 Gleich SJ, Nemergut ME, Stans AA, Haile DT, Feigal SA, Heinrich AL et al. Improvement in patient transfer process from the operating room to the PICU ssing a Lean and Six Sigma-Based quality improvement project. Hosp Pediatr. 2016;6(8):483-9. doi: 10.1542/hpeds.2015-0232 https://doi.org/10.1542/hpeds.2015-0232... ⁾	2016 USA	Use of LSS to improve the process of transferring patients from the operating room to the pediatric ICU.	Errors in the shift from the surgical center to the pediatric ICU decreased from 1.9 to 0.3 errors per patient and waiting time decreased from 90 to 32 minutes. Moreover, team satisfaction improved after the intervention.	Hospital
The application of Lean Six Sigma methodology to reduce the risk of healthcare-associated infections in surgery departments⁽²⁶26 Montella E, Di Cicco MV, Ferraro A, Centobelli P, Raiola E, Triassi M, et al. The application of Lean Six Sigma methodology to reduce the risk of healthcare-associated infections in surgery departments. J Eval Clin Pract. 2017;23(3):530-539. doi: 10.1111/jep.12662 https://doi.org/10.1111/jep.12662... ⁾	2016 Italy	Use of LSS to implement actions to improve the colonization of sentinel bacteria in hospitalized patients.	Reduction in hospital stay by 20% and in the number of patients affected by infection related to care from 0.37% to 0.21%.	Hospital
Applying Lean Six Sigma methodology to reduce cesarean section rate⁽²⁷27 Chai ZY, Hu HM, Ren XL, Zeng BJ, Zheng LZ, Qi F. Applying Lean Six Sigma methodology to reduce cesarean section rate. J Eval Clin Pract. 2017;23(3):562-566. doi: 10.1111/jep.12671 https://doi.org/10.1111/jep.12671... ⁾	2016 China	Use of LSS to reduce the rate of cesarean section in the hospital.	Reduction in the cesarean section rate from 41.8% to 32% and the sigma capacity increased from 1.70 to 1.96.	Hospital
Lean Six Sigma: a new approach to the management of patients undergoing prosthetic hip replacement surgery⁽²⁸28 Improta G, Balato G, Romano M, Carpentieri F, Bifulco P, Alessandro Russo M, et al. Lean Six Sigma: a new approach to the management of patients undergoing prosthetic hip replacement surgery. J Eval Clin Pract. 2015;21(4):662-72. doi: 10.1111/jep.12361 https://doi.org/10.1111/jep.12361... ⁾	2015 Italy	Use of LSS in the development of a care plan in hip prosthesis surgery.	Reduction in the average stay time from 18.9 to 10.6 days, representing a 44% time reduction and savings of 260 thousand euros.	University hospital
Decreasing the dispatch time of medical reports sent from hospital to primary care with Lean Six Sigma⁽²⁹29 Basta YL, Zwetsloot IM, Klinkenbijl JH, Rohof T, Monster MM, Fockens P et al. Decreasing the dispatch time of medical reports sent from hospital to primary care with Lean Six Sigma. J Eval Clin Pract. 2016;22(5):690-8. doi: 10.1111/jep.12518 https://doi.org/10.1111/jep.12518... ⁾	2015 Netherlands	Using LSS to increase the proportion of cancer staging reports sent on the day of patients' visit to the oncology center.	90.6% of medical reports sent on the day of patient visits, compared to an index prior to the intervention of 12.3%.	Oncology center
How to reduce head CT orders in children with Hydrocephalus using the Lean Six Sigma Methodology: Experience at a major quaternary care Academic Children's Center⁽³⁰30 Tekes A, Jackson EM, Ogborn J, Liang S, Bledsoe M, Durand DJ, et al. How to reduce head ct orders in children with Hydrocephalus using the Lean Six Sigma Methodology: Experience at a major quaternary care Academic Children’s Center. AJNR Am J Neuroradiol. 2016;37(6):990-6. doi: 10.3174/ajnr.A4658 https://doi.org/10.3174/ajnr.A4658... ⁾	2015 USA	Use of LSS to reduce the relative use of pediatric cranial tomography in children with hydrocephalus by 50% within six months.	75% reduction in cranial tomography exams in three months.	Hospital
Impact of Lean on surgical instrument reduction: less is more⁽⁵5 Wannemuehler TJ, Elghouche AN, Kokoska MS, Deig CR, Matt BH. Impact of Lean on surgical instrument reduction: less is more. Laryngoscope. 2015;125(12):2810-5. doi: 10.1002/lary.25407 https://doi.org/10.1002/lary.25407... ⁾	2015 USA	Use of LSS to reduce surgical field processing time, operating time, surgical field assembly time and processing cost.	Surgical material assembly time reduction 8.4 to 4.7 minutes with a 44% joint assembly cost reduction. Reduction in average surgical field processing times from 97.6 to 76.1 seconds and reduction in processing costs.	Hospital
Impact of Lean Six Sigma process improvement methodology on cardiac catheterization laboratory efficiency⁽³¹31 Agarwal S, Gallo JJ, Parashar A, Agarwal KK, Ellis SG, Khot UN, et al. Impact of lean six sigma process improvement methodology on cardiac catheterization laboratory efficiency. Cardiovasc Revasc Med. 2016;17(2):95-101. doi: 10.1016/j.carrev.2015.12.011 https://doi.org/10.1016/j.carrev.2015.12... ⁾	2015 USA	Use of LSS to improve patient efficiency and performance in the catheterization laboratory.	Improvement in room turnover from 43.6% to 56.6%, in addition to the percentage of cases attended on time, from 41.7% to 62.8%.	Catheterization laboratory
Use of Six Sigma strategies to pull the line on central line-associated bloodstream infections in a neurotrauma intensive care unit⁽³²32 Loftus K, Tilley T, Hoffman J, Bradburn E, Harvey E. Use of Six Sigma strategies to pull the line on central line-associated bloodstream infections in a neurotrauma intensive care unit. J Trauma Nurs. 2015;22(2):78-86. doi: 10.1097/JTN. 0000000000000111 https://doi.org/10.1097/JTN. 00000000000... ⁾	2015 USA	Use of LSS to improve the quality of the results of central catheter-related bloodstream infection in a neurological trauma ICU.	Reduction from 1.46 to 1.2 infections per 1,000 catheters.	Hospital
Six Sigma applied to reduce patients' waiting time in a cancer pharmacy⁽³³33 Arafeh M, Barghash M, Sallam E, AlSamhouri A. Six Sigma applied to reduce patients’ waiting time in a cancer pharmacy. International Journal of Six Sigma and Competitive Advantage. 2014;8(2):105-24. doi: 10.1504/IJSSCA. 2014.064256 https://doi.org/10.1504/IJSSCA. 2014.064... ⁾	2014 Jordan	Use of LSS to reduce the waiting time of patients at the oncology pharmacy.	Waiting time was reduced by 50%.	Oncology outpatient clinic
Redesigning an inpatient pediatric service using Lean to improve throughput efficiency⁽³⁴34 Beck MJ, Gosik K. Redesigning an inpatient pediatric service using Lean to improve throughput efficiency. J Hosp Med. 2015;10(4):220-7. doi: 10.1002/jhm.2300 https://doi.org/10.1002/jhm.2300... ⁾	2014 USA	Use of LSS in determining the time of discharge request and patient discharge compared to the control group.	Reduction in the time for requesting discharge to before 11 a.m., with a median reduction in 200 minutes and hospital discharge decreased by an average of 93 minutes.	Pediatric hospital
Patient discharge time improvement by using the Six Sigma approach: a case study⁽³⁵35 El- Banna. Patient discharge time improvement by using the Six Sigma approach: a case study. Quality Engineering. 2013;25(4):401-17. doi: 10.1080/08982112.2013.792352 https://doi.org/10.1080/08982112.2013.79... ⁾	2013 Jordan	Use of LSS to reduce discharge time without adding expenses.	57% improvement in patients discharged within 50 minutes.	Hospital
The usefulness of lean six sigma to the development of a clinical pathway for hip fractures⁽³⁶36 Niemeijer GC, Flikweert E, Trip A, Does RJ, Ahaus KT, Boot AF, et al. The usefulness of lean six sigma to the development of a clinical pathway for hip fractures. J Eval Clin Pract. 2013;19(5):909-14. doi: 10.1111/j.1365-2753.2012.01875.x https://doi.org/10.1111/j.1365-2753.2012... ⁾	2013 Netherlands	Use of LSS in the development of a multidisciplinary clinical pathway.	Reduction in hospital stay in 4.2 days (-31%) and an average duration of surgery in 57 minutes (-36%), in addition to savings of approximately 120 thousand euros.	Private hospital
Application of Six Sigma methodology to a cataract surgery unit⁽³⁷37 Taner MT. Application of Six Sigma methodology to a cataract surgery unit. Int J Health Care Qual Assur [Internet]. 2013 &2019 Sep 07];26(8):768-85. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24422265 https://www.ncbi.nlm.nih.gov/pubmed/2442... ⁾	2012 Turkey	Use of Six Sigma in a cataract unit in a public hospital.	The project team recorded all cataract surgeries that did not improve acuity and also classified intra and postoperative complications, showing an increase in sigma capacity from 2.60 to 3.75.	Hospital
Use of lean and six sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center⁽³⁸38 Cima RR, Brown MJ, Hebl JR, Moore R, Rogers JC, Kollengode A, et al. Use of lean and six sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center. J Am Coll Surg. 2011;213(1):83-94. doi: 10.1016/j.jamcollsurg.2011.02.009. https://doi.org/10.1016/j.jamcollsurg.20... ⁾	2011 USA	Use of LSS to improve the efficiency of operating rooms.	Punctuality on admission to the operating room increased from 52% to 81%, waiting time for surgery in up to 10 minutes reduced from 42% to 12% and improved operating room turnover.	Medical center
Using Six Sigma methodology to reduce patient transfer times from floor to critical-care beds⁽³⁹39 Silich SJ, Wetz RV, Riebling N, Coleman C, Khoueiry G, Abi Rafeh N, et al. Using Six Sigma methodology to reduce patient transfer times from floor to critical-care beds. J Healthc Qual. 2012;34(1):44-54. doi: 10.1111/j.1945-1474.2011.00184.x https://doi.org/10.1111/j.1945-1474.2011... ⁾	2011 USA	Use of Six Sigma to reduce the transfer time from the hospitalization unit to the ICU.	Improvement of the average transfer time from 214 minutes to 84 minutes, with a 6 sigma capacity after 8 months.	University hospital
Using the six sigma process to implement the Centers for Disease Control and Prevention Guideline for Hand Hygiene in 4 intensive care units⁽⁴⁰40 Eldridge NE, Woods SS, Bonello RS, Clutter K, Ellingson L, Harris MA, et al. Using the six sigma process to implement the Centers for Disease Control and Prevention Guideline for Hand Hygiene in 4 intensive care units. J Gen Intern Med[Internet]. 2006 [2019 Oct 17];21(2)35-42. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2557134/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾	2006 USA	Use of Six Sigma to assess hand hygiene practices and increase compliance with CDC recommendations.	Increased adherence to the hygiene rate from 47% to 80%.	Hospital
Use of corporate Six Sigma performance-improvement strategies to reduce incidence of catheter-related bloodstream infections in a surgical ICU⁽³3 Frankel HL, Crede WB, Topal JE, Roumanis AS, Devlin MW, Foley AB. Use of corporate Six Sigma performance-improvement strategies to reduce incidence of catheter-related bloodstream infections in a surgical ICU. J Am Coll Surg. 2005;201(3):349-358. doi: 10.1016/j.jamcollsurg.2005.04.027 https://doi.org/10.1016/j.jamcollsurg.20... ⁾	2005 USA	Use of LSS to reduce the rate of central catheter-related bloodstream infection.	Reduction in the infection rate from 11/1000 days to 1.7/1,000 days of catheter, with an improvement of 650%.	Hospital

BSC perspective	Improvement	Result for health institutions
Customers	Time reduction	Reduction in waiting time for patients and families, time for carrying out assistance and administrative activities, hospital discharge, hospitalization time and flow improvements⁽⁵5 Wannemuehler TJ, Elghouche AN, Kokoska MS, Deig CR, Matt BH. Impact of Lean on surgical instrument reduction: less is more. Laryngoscope. 2015;125(12):2810-5. doi: 10.1002/lary.25407 https://doi.org/10.1002/lary.25407... ^,⁹9 Hynes JP, Murray AS, Murray OM, Eustace SK, Gilchrist S, Dolan A, et al. Use of Lean Six Sigma methodology shows reduction of inpatient waiting time for peripherally inserted central catheter placement. Clin Radiol. 2019;74(9):733.e5-733.e9. doi: 10.1016/j.crad.2019.04.022 https://doi.org/10.1016/j.crad.2019.04.0... 10 Al-Zain Y, Al-Fandi L, Arafeh M, Salim S, Al-Quraini S, Al-Yaseen A, et al. Implementing Lean Six Sigma in a Kuwaiti private hospital. Int J Health Care Qual Assur. 2019;32(2):431-46. doi: 10.1108/IJHCQA-04-2018-0099 https://doi.org/10.1108/IJHCQA-04-2018-0... 11 Furterer SL. Applying Lean Six Sigma methods to reduce length of stay in a hospital’s emergency department. Qual Engineering. 2018,30(3):389-404. doi: 10.1080/08982112.2018.1464657 https://doi.org/10.1080/08982112.2018.14... ^-¹²12 Trzeciak S, Mercincavage M, Angelini C, Cogliano W, Damuth E, Roberts BW, et al. Lean Six Sigma to reduce Intensive Care Unit length of stay and costs in prolonged mechanical ventilation. J Healthc Qual. 2018;40(1):36-43. doi: 10.1097/JHQ. 0000000000000075 https://doi.org/10.1097/JHQ. 00000000000... ^,¹⁵15 Improta G, Balato G, Romano M, Ponsiglione AM, Raiola E, Russo MA, et al. Improving performances of the knee replacement surgery process by applying DMAIC principles. J Eval Clin Pract. 2017;23(6):1401-1407. doi: 10.1111/jep.12810 https://doi.org/10.1111/jep.12810... 16 Ciulla TA, Tatikonda MV, ElMaraghi YA, Hussain RM, Hill AL, Clary JM, et al. Lean Six Sigma techniques to improve ophthalmology clinic efficiency. Retina. 2018;38(9):1688-1698. doi: 10.1097/IAE. 0000000000001761 https://doi.org/10.1097/IAE. 00000000000... 17 Improta G, Cesarelli M, Montuori P, Santillo LC, Triassi M. Reducing the risk of healthcare-associated infections through Lean Six Sigma: the case of the medicine areas at the Federico II University Hospital in Naples (Italy). J Eval Clin Pract. 2018;24(2):338-46. doi: 10.1111/jep.12844 https://doi.org/10.1111/jep.12844... ^-¹⁸18 Kieran M, Cleary M, De Brún A, Igoe A. Supply and demand: application of Lean Six Sigma methods to improve drug round efficiency and release nursing time. Int J Qual Health Care. 2017;29(6):803-9. doi: 10.1093/intqhc/mzx106 https://doi.org/10.1093/intqhc/mzx106... ^,²¹21 Ha C, McCoy DA, Taylor CB, Kirk KD, Fry RS, Modi JR. Using Lean Six Sigma Methodology to improve a mass immunizations process at the United States Naval Academy. Mil Med. 2016;181(6):582-8. doi: 10.7205/MILMED-D-15-00247 https://doi.org/10.7205/MILMED-D-15-0024... ^-²²22 Ortiz Barrios MA, Felizzola Jiménez H. Use of Six Sigma Methodology to reduce appointment lead-time in obstetrics outpatient department. J Med Syst. 2016;40(10):220. doi: 10.1007/s10916-016-0577-3 https://doi.org/10.1007/s10916-016-0577-... ^,²⁴24 Jayasinha Y. Decreasing turnaround time and increasing patient satisfaction in a safety net Hospital-Based pediatrics clinic using Lean Six Sigma Methodologies. Qual Manag Health Care. 2016;25(1):38-43. doi: 10.1097/QMH. 0000000000000083 https://doi.org/10.1097/QMH. 00000000000... 25 Gleich SJ, Nemergut ME, Stans AA, Haile DT, Feigal SA, Heinrich AL et al. Improvement in patient transfer process from the operating room to the PICU ssing a Lean and Six Sigma-Based quality improvement project. Hosp Pediatr. 2016;6(8):483-9. doi: 10.1542/hpeds.2015-0232 https://doi.org/10.1542/hpeds.2015-0232... ^-²⁶26 Montella E, Di Cicco MV, Ferraro A, Centobelli P, Raiola E, Triassi M, et al. The application of Lean Six Sigma methodology to reduce the risk of healthcare-associated infections in surgery departments. J Eval Clin Pract. 2017;23(3):530-539. doi: 10.1111/jep.12662 https://doi.org/10.1111/jep.12662... ^,²⁹29 Basta YL, Zwetsloot IM, Klinkenbijl JH, Rohof T, Monster MM, Fockens P et al. Decreasing the dispatch time of medical reports sent from hospital to primary care with Lean Six Sigma. J Eval Clin Pract. 2016;22(5):690-8. doi: 10.1111/jep.12518 https://doi.org/10.1111/jep.12518... ^,³³33 Arafeh M, Barghash M, Sallam E, AlSamhouri A. Six Sigma applied to reduce patients’ waiting time in a cancer pharmacy. International Journal of Six Sigma and Competitive Advantage. 2014;8(2):105-24. doi: 10.1504/IJSSCA. 2014.064256 https://doi.org/10.1504/IJSSCA. 2014.064... 34 Beck MJ, Gosik K. Redesigning an inpatient pediatric service using Lean to improve throughput efficiency. J Hosp Med. 2015;10(4):220-7. doi: 10.1002/jhm.2300 https://doi.org/10.1002/jhm.2300... 35 El- Banna. Patient discharge time improvement by using the Six Sigma approach: a case study. Quality Engineering. 2013;25(4):401-17. doi: 10.1080/08982112.2013.792352 https://doi.org/10.1080/08982112.2013.79... ^-³⁶36 Niemeijer GC, Flikweert E, Trip A, Does RJ, Ahaus KT, Boot AF, et al. The usefulness of lean six sigma to the development of a clinical pathway for hip fractures. J Eval Clin Pract. 2013;19(5):909-14. doi: 10.1111/j.1365-2753.2012.01875.x https://doi.org/10.1111/j.1365-2753.2012... ^,³⁸38 Cima RR, Brown MJ, Hebl JR, Moore R, Rogers JC, Kollengode A, et al. Use of lean and six sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center. J Am Coll Surg. 2011;213(1):83-94. doi: 10.1016/j.jamcollsurg.2011.02.009. https://doi.org/10.1016/j.jamcollsurg.20... ^-³⁹39 Silich SJ, Wetz RV, Riebling N, Coleman C, Khoueiry G, Abi Rafeh N, et al. Using Six Sigma methodology to reduce patient transfer times from floor to critical-care beds. J Healthc Qual. 2012;34(1):44-54. doi: 10.1111/j.1945-1474.2011.00184.x https://doi.org/10.1111/j.1945-1474.2011... ⁾.
Customers	Patient satisfaction	Improvement of patient and family satisfaction with assistance team and organization⁽¹¹11 Furterer SL. Applying Lean Six Sigma methods to reduce length of stay in a hospital’s emergency department. Qual Engineering. 2018,30(3):389-404. doi: 10.1080/08982112.2018.1464657 https://doi.org/10.1080/08982112.2018.14... ^,²⁴24 Jayasinha Y. Decreasing turnaround time and increasing patient satisfaction in a safety net Hospital-Based pediatrics clinic using Lean Six Sigma Methodologies. Qual Manag Health Care. 2016;25(1):38-43. doi: 10.1097/QMH. 0000000000000083 https://doi.org/10.1097/QMH. 00000000000... ^-²⁵25 Gleich SJ, Nemergut ME, Stans AA, Haile DT, Feigal SA, Heinrich AL et al. Improvement in patient transfer process from the operating room to the PICU ssing a Lean and Six Sigma-Based quality improvement project. Hosp Pediatr. 2016;6(8):483-9. doi: 10.1542/hpeds.2015-0232 https://doi.org/10.1542/hpeds.2015-0232... ⁾.
Internal processes	Clinical indicators	Reduction in the rate of mechanical ventilation use, in the rate of care-related infection, in surgical complications, in the fall rate, in the number of cesareans, and improvement in the rate of hand hygiene⁽³3 Frankel HL, Crede WB, Topal JE, Roumanis AS, Devlin MW, Foley AB. Use of corporate Six Sigma performance-improvement strategies to reduce incidence of catheter-related bloodstream infections in a surgical ICU. J Am Coll Surg. 2005;201(3):349-358. doi: 10.1016/j.jamcollsurg.2005.04.027 https://doi.org/10.1016/j.jamcollsurg.20... ^,¹²12 Trzeciak S, Mercincavage M, Angelini C, Cogliano W, Damuth E, Roberts BW, et al. Lean Six Sigma to reduce Intensive Care Unit length of stay and costs in prolonged mechanical ventilation. J Healthc Qual. 2018;40(1):36-43. doi: 10.1097/JHQ. 0000000000000075 https://doi.org/10.1097/JHQ. 00000000000... ^,²⁰20 Kuwaiti AA, Subbarayalu AV. Reducing patients’ falls rate in an Academic Medical Center (AMC) using Six Sigma “DMAIC” approach. Int J Health Care Qual Assur. 2017;30(4):373-384. doi: 10.1108/IJHCQA-03-2016-0030 https://doi.org/10.1108/IJHCQA-03-2016-0... ^,²⁶26 Montella E, Di Cicco MV, Ferraro A, Centobelli P, Raiola E, Triassi M, et al. The application of Lean Six Sigma methodology to reduce the risk of healthcare-associated infections in surgery departments. J Eval Clin Pract. 2017;23(3):530-539. doi: 10.1111/jep.12662 https://doi.org/10.1111/jep.12662... 27 Chai ZY, Hu HM, Ren XL, Zeng BJ, Zheng LZ, Qi F. Applying Lean Six Sigma methodology to reduce cesarean section rate. J Eval Clin Pract. 2017;23(3):562-566. doi: 10.1111/jep.12671 https://doi.org/10.1111/jep.12671... ^-²⁸28 Improta G, Balato G, Romano M, Carpentieri F, Bifulco P, Alessandro Russo M, et al. Lean Six Sigma: a new approach to the management of patients undergoing prosthetic hip replacement surgery. J Eval Clin Pract. 2015;21(4):662-72. doi: 10.1111/jep.12361 https://doi.org/10.1111/jep.12361... ^,³¹31 Agarwal S, Gallo JJ, Parashar A, Agarwal KK, Ellis SG, Khot UN, et al. Impact of lean six sigma process improvement methodology on cardiac catheterization laboratory efficiency. Cardiovasc Revasc Med. 2016;17(2):95-101. doi: 10.1016/j.carrev.2015.12.011 https://doi.org/10.1016/j.carrev.2015.12... ^-³²32 Loftus K, Tilley T, Hoffman J, Bradburn E, Harvey E. Use of Six Sigma strategies to pull the line on central line-associated bloodstream infections in a neurotrauma intensive care unit. J Trauma Nurs. 2015;22(2):78-86. doi: 10.1097/JTN. 0000000000000111 https://doi.org/10.1097/JTN. 00000000000... ^,³⁷37 Taner MT. Application of Six Sigma methodology to a cataract surgery unit. Int J Health Care Qual Assur [Internet]. 2013 &2019 Sep 07];26(8):768-85. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24422265 https://www.ncbi.nlm.nih.gov/pubmed/2442... ^,⁴⁰40 Eldridge NE, Woods SS, Bonello RS, Clutter K, Ellingson L, Harris MA, et al. Using the six sigma process to implement the Centers for Disease Control and Prevention Guideline for Hand Hygiene in 4 intensive care units. J Gen Intern Med[Internet]. 2006 [2019 Oct 17];21(2)35-42. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2557134/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾.
Internal processes	Error reduction	Reduction in diagnostic errors, medication errors, and errors in shift passage⁽¹¹11 Furterer SL. Applying Lean Six Sigma methods to reduce length of stay in a hospital’s emergency department. Qual Engineering. 2018,30(3):389-404. doi: 10.1080/08982112.2018.1464657 https://doi.org/10.1080/08982112.2018.14... ^,¹⁴14 Ramirez PM, Peterson B, Holtshopple C, Borja K, Torres V, Valdivia-Peppers L, et al. Assurance of myeloid growth factor administration in an infusion center: pilot quality improvement initiative. J Oncol Pract. 2017;13(12):e1040-e1045. doi: 10.1200/JOP. 2017.023804 https://doi.org/10.1200/JOP. 2017.023804... ^,²³23 Al Kuwaiti A. Application of Six Sigma Methodology to reduce medication errors in the outpatient pharmacy unit: a case study from the King Fahd University Hospital, Saudi Arabia. IJQR. 2016;10(2):267-8. doi: 10.18421/IJQR10.02-03 https://doi.org/10.18421/IJQR10.02-03... ^,²⁵25 Gleich SJ, Nemergut ME, Stans AA, Haile DT, Feigal SA, Heinrich AL et al. Improvement in patient transfer process from the operating room to the PICU ssing a Lean and Six Sigma-Based quality improvement project. Hosp Pediatr. 2016;6(8):483-9. doi: 10.1542/hpeds.2015-0232 https://doi.org/10.1542/hpeds.2015-0232... ⁾.
Financial	Cost-cutting	Cost-cutting of surgical procedures, processing hospital waste, and surgical materials⁽⁵5 Wannemuehler TJ, Elghouche AN, Kokoska MS, Deig CR, Matt BH. Impact of Lean on surgical instrument reduction: less is more. Laryngoscope. 2015;125(12):2810-5. doi: 10.1002/lary.25407 https://doi.org/10.1002/lary.25407... ^,¹²12 Trzeciak S, Mercincavage M, Angelini C, Cogliano W, Damuth E, Roberts BW, et al. Lean Six Sigma to reduce Intensive Care Unit length of stay and costs in prolonged mechanical ventilation. J Healthc Qual. 2018;40(1):36-43. doi: 10.1097/JHQ. 0000000000000075 https://doi.org/10.1097/JHQ. 00000000000... ^-¹³13 Martin DM, Yanez ND, Treggiari MM. An initiative to optimize waste streams in the operating room: RECycling in the Operating Room (RECOR) Project [Internet]. AANA J. 2017 [2019 Sep 07];85(2):108-12. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30501159 https://www.ncbi.nlm.nih.gov/pubmed/3050... ^,³⁶36 Niemeijer GC, Flikweert E, Trip A, Does RJ, Ahaus KT, Boot AF, et al. The usefulness of lean six sigma to the development of a clinical pathway for hip fractures. J Eval Clin Pract. 2013;19(5):909-14. doi: 10.1111/j.1365-2753.2012.01875.x https://doi.org/10.1111/j.1365-2753.2012... ⁾.
Financial	Productivity	Improvement in bed turnover, surgical room turnover, and optimization of hospital resources⁽¹⁹19 Tagge EP, Thirumoorthi AS, Lenart J, Garberoglio C, Mitchell KW. Improving operating room efficiency in academic children’s hospital using Lean Six Sigma methodology. J Pediatr Surg. 2017;52(6):1040-1044. doi: 10.1016/j.jpedsurg.2017.03.035 https://doi.org/10.1016/j.jpedsurg.2017.... ^,³⁰30 Tekes A, Jackson EM, Ogborn J, Liang S, Bledsoe M, Durand DJ, et al. How to reduce head ct orders in children with Hydrocephalus using the Lean Six Sigma Methodology: Experience at a major quaternary care Academic Children’s Center. AJNR Am J Neuroradiol. 2016;37(6):990-6. doi: 10.3174/ajnr.A4658 https://doi.org/10.3174/ajnr.A4658... ^-³¹31 Agarwal S, Gallo JJ, Parashar A, Agarwal KK, Ellis SG, Khot UN, et al. Impact of lean six sigma process improvement methodology on cardiac catheterization laboratory efficiency. Cardiovasc Revasc Med. 2016;17(2):95-101. doi: 10.1016/j.carrev.2015.12.011 https://doi.org/10.1016/j.carrev.2015.12... ^,³⁸38 Cima RR, Brown MJ, Hebl JR, Moore R, Rogers JC, Kollengode A, et al. Use of lean and six sigma methodology to improve operating room efficiency in a high-volume tertiary-care academic medical center. J Am Coll Surg. 2011;213(1):83-94. doi: 10.1016/j.jamcollsurg.2011.02.009. https://doi.org/10.1016/j.jamcollsurg.20... ⁾.
Learning and knowledge	Human Resources	Optimization of human resources and care team training⁽⁵5 Wannemuehler TJ, Elghouche AN, Kokoska MS, Deig CR, Matt BH. Impact of Lean on surgical instrument reduction: less is more. Laryngoscope. 2015;125(12):2810-5. doi: 10.1002/lary.25407 https://doi.org/10.1002/lary.25407... ^,²¹21 Ha C, McCoy DA, Taylor CB, Kirk KD, Fry RS, Modi JR. Using Lean Six Sigma Methodology to improve a mass immunizations process at the United States Naval Academy. Mil Med. 2016;181(6):582-8. doi: 10.7205/MILMED-D-15-00247 https://doi.org/10.7205/MILMED-D-15-0024... ^,⁴⁰40 Eldridge NE, Woods SS, Bonello RS, Clutter K, Ellingson L, Harris MA, et al. Using the six sigma process to implement the Centers for Disease Control and Prevention Guideline for Hand Hygiene in 4 intensive care units. J Gen Intern Med[Internet]. 2006 [2019 Oct 17];21(2)35-42. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2557134/ https://www.ncbi.nlm.nih.gov/pmc/article... ⁾.

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[1] Corresponding author: Guilherme dos Santos Zimmermann. E-mail: guizimmer@gmail.com