PROCESS FLOW IMPROVEMENT USING VALUE

STREAM MAPPING TO REDUCE WASTE AND LEAD

TIME IN MALAYSIA HEALTHCARE

SITI HAIZATUL AISHAH BT HARON

UNIVERSITI TUN HUSSEIN ONN MALAYSIA

PROCESS FLOW IMPROVEMENT USING VALUE STREAM MAPPING TO

REDUCE WASTE AND LEAD TIME IN MALAYSIA HEALTHCARE

SITI HAIZATUL AISHAH BT HARON

A thesis submitted in

fulfilment of the requirement for the award of the

Degree of Master of Science in Technology Management

Faculty of Technology Management and Business

Universiti Tun Hussein Onn Malaysia

FEBRUARY 2017

iii

DEDICATION

I dedicate this thesis to

Almighty ALLAH S.W.T,

My father (Haron Bin Mohd Saad), my mother (Zainah Binti Buang) and

siblings,

For your love, care and encouragement.

My supervisor and co-supervisor,

For your help, encouragement and guidance to ensure the success of this thesis.

Friends,

For your help, encouragement, helped me through, make me feel like I am not alone,

may Allah ease their journey and never give up.

And everyone who involves directly and indirectly in the process of completing

this thesis.

Thank you.

iv

ACKNOWLEDGEMENTS

All praise to God, the Greatest that gives perfection and facility in applying all tasks

and responsibilities.

I would like to acknowledge the generous contribution of individuals and

organisations to this research, without them this research would not have been

successfully completed.

First and foremost, I would like to express my gratitude to my supervisor, Puan

Rohaizan Binti Ramlan, my co-supervisor, Dr Kamilah Binti Ahmad, and lecturer,

Dr Ahmad Aizat Bin Ahmad for providing me with invaluable guidance, inspiration,

encouragement for my research and for being a mentor and supporter with their

constant inspiration.

I would also like to express my gratitude to Office of Research, Innovation,

Commercialisation and Consultancy (ORICC), UTHM, for supporting this research

under the Exploratory Research Grant Scheme (ERGS), Vot E045. I would also like

to thank organisations, which participated in this research.

Finally, I would like to thank my parents, siblings and friends for all the love,

understanding, and encouragement throughout the research period.

v

ABSTRACT

The implementation of Value Stream Mapping (VSM) method in healthcare

institutions has started since the 1990s, mainly to fulfill the current need for an

improved quality and efficiency in delivering services. However, the application of

VSM in Malaysia healthcare institutions is still at an early stage. These institutions

are under pressure to improve service quality and costs. Most of the healthcare

institutions are facing an issue regarding long waiting time. Therefore, the intentions

of this study are to investigate any process improvement that is currently being

practiced by Healthcare Industry within Malaysia and reduce the waste and lead time

in the process flow of patient by using VSM. VSM is one of the lean tools that can be

used for process improvement in reducing both waste and lead time. Furthermore,

VSM strengthens the analysis and provides clearer vision and plans by connecting all

improvement methods in one figure. The study implemented a mixed method which

includes distribution of questionnaires to explore the current practices on process

improvement and observation process in order to reduce waste and also the lead

time. The questionnaires were distributed to 141 respondents from the management

team of healthcare industry in Malaysia. This study received 34% feedback through

the survey of quantitative data. Results from quantitative data analysis shows that

currently, 5S is the most applied process improvement practice in Malaysia

healthcare industry. The results from the qualitative data showed that the waste and

lead time in the process flow of patient are successfully reduced. The findings

proposed that the healthcare should combine the process of registration with the

blood and urine tests into one process, and also combine the process of check-up

with the process of treatment. The number of staff remains the same. This study also

suggests for the health centre to relocate the filing shelves to facilitate easier staff

access, reorganize the layout of the clinic and relocate the room according to the

process. These suggestions will improve the total lead time and reduced the cycle

vi

time and waste in the process flow for patient. The result of this study is significant

for other healthcare as well who are looking for further insight to implement VSM in

their process flow, and intended to reduce the waste occurred within their healthcare.

vii

ABSTRAK

Perlaksanaan kaedah Peta Aliran Nilai (VSM) di dalam institusi kesihatan telah

bermula sejak tahun 1990-an, terutamanya untuk memenuhi keperluan semasa bagi

meningkatkan kualiti dan kelancaran dalam menyampaikan servis. Walau

bagaimanapun, perlaksanaan VSM di institusi penjagaan kesihatan Malaysia adalah

masih di peringkat awal. Institusi-institusi ini menghadapi tekanan untuk

memperbaiki kualiti servis dan juga kos. Kebanyakan pusat kesihatan menghadapi

isu berkaitan masa menunggu yang lama. Oleh itu, tujuan kajian ini adalah untuk

mengkaji proses penambahbaikan semasa yang digunakan di dalam industri

penjagaan kesihatan Malaysia serta mengurangkan waste dan masa di dalam carta

aliran proses untuk pesakit dengan menggunakan VSM. VSM adalah salah satu

alatan lean yang boleh digunakan untuk proses penambahbaikan dalam

mengurangkan kedua-dua waste dan masa. Tambahan pula, VSM dapat

mengukuhkan analisis dan memberikan gambaran dan rancangan yang lebih jelas

dengan menyatukan semua kaedah penambahbaikan dalam satu rajah. Kajian ini

dilaksanakan dengan menggunakan kaedah campuran yang merangkumi pengedaran

borang soal selidik untuk mengkaji amalan semasa bagi proses penambahbaikan dan

proses pemerhatian untuk mengurangkan waste dan masa. Borang kaji selidik telah

diedarkan kepada 141 responden yang terdiri daripada pasukan pengurusan industri

penjagaan kesihatan di Malaysia. Kajian ini menerima 34% maklum balas melalui

hasil kajian data kuantitatif. Keputusan daripada analisis data kuantitatif

menunjukkan bahawa 5S merupakan proses penambahbaikan yang paling kerap

digunakan di dalam industri penjagaan kesihatan Malaysia. Keputusan bagi data

kualitatif kajian ini menunjukkan waste dan masa dalam aliran proses untuk pesakit

telah berjaya dikurangkan. Hasil daripada dapatan kajian mencadangkan supaya

pusat kesihatan perlu menggabungkan proses pendaftaran dengan proses ujian darah

dan air kencing dalam satu proses, serta menggabungkan proses pemeriksaan dan

viii

proses rawatan. Jumlah kakitangan bagi setiap proses adalah masih sama. Kajian ini

turut mencadangkan supaya pusat kesihatan mengubah posisi rak penyimpanan

dokumen bagi memudahkan kakitangan mengakses fail/dokumen, mengubah susun

atur klinik serta megubah kedudukan bilik mengikut proses. Kesemua cadangan ini

akan memperbaiki jumlah masa dan mengurangkan kitaran masa dan waste pada

proses aliran pesakit. Hasil daripada kajian ini adalah penting bagi pusat kesihatan

lain yang mencari gambaran untuk melaksanakan VSM di dalam aliran process

mereka, serta ingin mengurangkan bilangan waste yang berlaku di dalam pusat

kesihatan mereka.

ix

TABLE OF CONTENTS

TITLE i

DECLARATION ii

DEDICATION iii

ACKNOWLEDGEMENT iv

ABSTRACT v

ABSTRAK vi

TABLE OF CONTENTS ix

LIST OF TABLES xiii

LIST OF FIGURES xiv

LIST OF ACRONYMS /ABBREVIATIONS xvii

APPENDIXES

CHAPTER 1 INTRODUCTION 1

1.1 Introduction 1

1.2 Research Background 3

1.3 Problem Statement 6

1.4 Research Questions 10

1.5 Research Objectives 11

1.6 Scope of Research 11

1.7 Significance of Research 12

x

1.8 Thesis structure 13

1.9 Conclusion 14

CHAPTER 2 LITERATURE REVIEW 15

2.1 Introduction 15

2.2 Healthcare 15

2.2.1 Healthcare in developing countries 16

2.2.2 Healthcare in Malaysia 17

2.3 Process Improvement 20

2.3.1 Previous studies of process improvement in

healthcare

21

2.3.2 Six Sigma 23

2.3.2.1 Six Sigma in Healthcare 25

2.3.3 Lean 26

2.3.3.1 Lean in healthcare 27

2.4 Value Stream Mapping 28

2.4.1 Sections of Value Stream Mapping 29

2.4.2 General terminology used in Value Stream

Mapping

30

2.4.3 Eight wastes of lean 31

2.4.4 Previous Studies on Value Stream Mapping

in Healthcare

32

2.5 Research Flow of Value Stream Mapping 39

2.6 Conclusion 41

CHAPTER 3 RESEARCH METHODOLOGY 42

3.1 Introduction 42

3.2 Research Purpose 43

3.3 Research Design 44

3.4 Quantitative Research Design 46

3.4.1 Population and Data Collection

(Quantitative)

46

xi

3.4.2 Questionnaire Design 48

3.4.3 Structure of Questionnaire 48

3.5 Qualitative Research Design 49

3.5.1 Observation 49

3.5.2 Population and Data Collection

(Qualitative)

49

3.5.3 Data Analysis Instrument (Qualitative) 50

3.6 Conclusion 52

CHAPTER 4 DATA ANALYSIS 53

4.1 Introduction 53

4.2 Quantitative Data Analysis 53

4.2.1 Type of respondent and length of experience 54

4.2.2 Introduction of process improvement in

healthcare

60

4.2.3 Current practices of process improvement

within Malaysian healthcare industry

63

4.2.4 Identification of issues while implementing

process improvement

67

4.2.5 Overall support on process improvement

within healthcare

68

4.3 Qualitative Data Analysis 70

4.3.1 Development of Value Stream Mapping

(VSM) in healthcare.

73

4.3.1.1 Process flow of the mapping 75

4.3.1.2 Current state map 78

4.3.1.3 Value Added Time and Non-Value added

Time

80

4.3.1.4 Calculation of TAKT Time, Cycle Time and

Value Added Time.

81

4.3.1.5 Waste 85

4.3.1.6 Data of the current state 93

4.3.1.7 Future State Map 96

4.3.1.8 Comparison of data between the Current 105

xii

State and Future State

4.4 Conclusion 107

CHAPTER 5 CONCLUSION 109

5.1 Introduction 109

5.2 Discussion of the result attained for research

questions.

110

5.2.1 Research Question 1 110

5.2.2 Research Question 2 112

5.2.3 Research Question 3 114

5.3 Contribution of research 115

5.4 Limitation of research 117

5.5 Recommendations for further research 117

5.6 Conclusions 118

REFERENCES 119

xiii

LIST OF TABLES

1.1 Admissions and outpatients attendances in 2013 9

2.1 Trend for Total Health Expenditure, 1997-2011 (RM

Million & Percent GDP)

19

2.2 Previous studies of process improvement in healthcare 22

2.3 Previous Studies of Value Stream Mapping in

Healthcare

32

3.1 Questionnaire distributions method and respond rate 47

3.2 Type of question design 48

4.1 The gender of the respondent 54

4.2 The age of the respondent 55

4.3 Familiarity with Process Improvement 56

4.4 Length of experience working with process

improvement

57

4.5 Respondent’s department of work. 59

4.6 Introduction of process improvement in healthcare 61

4.7 Formal training on process improvement within

healthcare

62

xiv

4.8 Process Improvement tools applied within healthcare 64

4.9 Obstacles while implementing process improvement in

healthcare.

67

4.10 Level of support while implementing process

improvement in healthcare.

69

4.11 Legend for Figure 4.11 71

4.12 Table of data collection from observation (refer Figure

4.11).

72

4.13 The symbol and definition for Figure 4.14. 77

4.14 Comparison of TAKT time between morning session

and whole day session

82

4.15 The comparison of TAKT time for each process

between morning session and whole day session in the

healthcare.

83

4.16 The related time for each process 83

4.17 Observation during the process of registration 86

4.18 Observation during the process of blood and urine test 88

4.19 Observation during the process of check-up 90

4.20 Observation during the process of treatment 92

4.21 Calculated data from the current state 94

4.22 Proposed data for future state map 97

4.23 The comparison in performance between the current 105

xv

state and future state

5.1 The comparison in performance between the current

state and future state

115

xvi

LIST OF FIGURES

1.1 Malaysian Health Budget Allocation from 2010-2016. 2

1.2 Trends for Total Health Expenditure 1997-2013 5

2.1 Research flow of study 40

3.1 Research design through mixed methods approach 45

3.2 Process flow of VSM for this study 51

4.1 The gender of respondent 55

4.2 The age of respondent 56

4.3 Familiarity with Process Improvement 57

4.4 Length of experience working with process

improvement

59

4.5 The respondent’s department of work 60

4.6 Introduction of process improvement in healthcare 62

4.7 Formal training on process improvement within

healthcare

63

4.8 Process Improvement tools applied within healthcare 66

4.9 Issues while implementing process improvement in 68

xvii

healthcare

4.10 Level of support while implementing process

improvement in healthcare

69

4.11 Figure for table of data collection in Table 4.12 71

4.12 The process of implementing VSM 74

4.13 Process flowchart of patient 76

4.14 The movement of patient 77

4.15 Current State Map 79

4.16 The total lead time 81

4.17 The comparison chart between TAKT time, cycle time

and value added time for morning session in the

healthcare (current state of VSM)

85

4.18 The idle time in each process 95

4.19 The capacity of patient in each process per day 96

4.20 Comparison of cycle time during current state and

future state for the process of registration and the

process of blood and urine test

98

4.21 Comparison of cycle time during current state and

future state for the process of check-up and the process

of treatment

99

4.22 Comparison of the total lead time during current state

and future state.

101

4.23 Comparison of the value added time during current

state and future state

101

xviii

4.24 Comparison of the non-value added time during current

state and future

state.

102

4.25 Future State Map 103

4.26 Process flowchart of patient for future state 104

4.27 The data of value added time for future state after VSM 107

5.1 The waiting time of patient for each process 113

5.2 The waiting time for each patient (min) 113

xix

LIST OF ACRONYMS /ABBREVIATIONS

CQI - Continuous Quality Improvement

DES - discrete-event simulation

DMAIC - Define, Measure, Analyze, Improve, Control

EPU - Economic Planning Unit

GDP - Gross Domestic Product

LMI - Lean Management Initiatives

MHTC - Malaysia Healthcare Travel Council

MoH - Ministry of Health

RFID - Radio frequency identification

SSI - Six Sigma Initiatives

VSM - Value Stream Mapping

VA - Value Added

NVA - Non-Value Added

C/T - Cycle Time

C/O - Change Over Time

SIPOC - Supliers, Inputs, Process, Outputs, Customers

xx

LIST OF APPENDICES

Table of data collection from observation

Survey Questions

1

CHAPTER 1

INTRODUCTION

1.1 Introduction

Malaysia has been listed as one of the developing countries that are successful in various

fields. Malaysia is one of the developing countries listed by the World Bank in a group

category of upper-middle-income economies with the range of $4,086 to $12,615.

Malaysia has enjoyed economic growth and underwent major development programmes

aiming to be a fully developed nation by 2020. In order to achieve the target as a

successful nation, lots of action/programmes had been done in various fields such as

economy, technology, social, cultural, spiritual, and more. Malaysian Plan is one of the

steps taken to achieve the target for a better Malaysia in the future that includes services,

manufacturing, agriculture, mining, construction and others. Health industry is included

under the service sector as stated in the first Malaysian Plan.

Since the first Malaysian Plan, the Ministry of Health had introduced various

health programmes to improve patient’s safety and the population’s health. The Health

Plan which has been detailed out in 10th Malaysian Plan 2011-2015 aims to improve the

country’s healthcare system based on the concept of ―1 Care for 1 Malaysia‖. This 1

Care is a structured national health system that is responsive and provides choice

in quality healthcare, ensuring universal coverage for the population’s healthcare needs

based on solidarity and equity. This Health Plan was formulated based on a deep

understanding on the needs and challenges, the government’s ability to finance it, and

2

value for money. It was developed to reflect the aspirations in achieving a high-income

country status by 2020 (MoH, 2010). Since Malaysia is categorized in a group of upper-

middle-income economies with the range of $4,086 to $12,615 which is considered high,

citizens are experiencing the consequences where it involves the rise in hospitalisation,

institutional care and health insurance costs (Malaysia Economic Planning Unit, 2010).

The major issues that have been discussed in Malaysian Health Plan 2011-2015

are regarding the increase in healthcare costs. From the report, it was stated that the

rising cost of care is due to several factors which are inefficiency, increasing demand for

health services in institutions and also wasted resources (MoH, 2010). Besides, there are

five cost drivers that had been mentioned which are wealth, epidemiological transition,

facing emerging/re-emerging infectious diseases, demographic transition and lastly,

technology (MoH, 2010). Other than the aim to maintain the low cost, the healthcare

sector also needs to meet the goals in providing care and enhancing health (Dahlgaard,

Pettersen, & Dahlgaard-Park, 2011). According to the previous reports, it were

mentioned that the allocation budget for Malaysian Health increased each year since

2010 until 2016 except 2011 and 2016 where the amount slightly decreased. Figure 1.1

summarise the data for Malaysian health budget allocation from 2010 until 2016.

Figure 1.1 Malaysian Health Budget Allocation from 2010-2016.

15.3 15.2

16.9

19.3

22.1

23.3

23

0

5

10

15

20

25

2010 2011 2012 2013 2014 2015 2016

Malaysian Health Budget Allocation

budget allocation (RM

Billion)

billion

3

On the other hand, to complement the continuous growth of Malaysian

healthcare, the research organizations are required to study the cost-effectiveness and

performance measurement during the implementation of 10th Malaysia Plan. Therefore,

it is important for the management to fully utilise available process improvement for

healthcare in order to curb the hardship issues from mushrooming. The process

improvement methodologies such as Lean and Six Sigma have tremendously improved

the quality and efficiency of manufacturing and service sectors for decades (Antony,

Krishnan, Cullen, & Kumar, 2012).

Process improvement method has been widely used around the world in

improving the operation of an organization (Abdulmalek & Rajgopal, 2007; Mujtaba,

Feldt & Petersen, 2010; Shahrbabaki & Jackson, 2011). Value Stream Mapping is one of

the process improvement tools that has been tremendously used in healthcare (Castle &

Harvey, 2009; Nelson-Peterson & Leppa, 2007; Puterman et al., 2012). However, the

implementation of Value Stream Mapping (VSM) in Malaysian healthcare industry is

still low. In fact, the result obtained from the preliminary study showed that VSM is one

of the process improvement tools that has not been used by respondents of the study.

Therefore, this research aims to study the current practice of process improvement in

Malaysian Healthcare to the extent of implementing the VSM in the process flow of

patient in healthcare.

1.2 Research Background

Healthcare industries are experiencing an extremely challenging situation in

maintaining a competitive edge. In recent years, the healthcare providers for example in

Malaysia are under a great deal of pressure to improve the quality of services as well as

costs. This is due to the growing number of population and greater expectation for

healthcare services in Malaysia. The Malaysian government has shown its commitment

to improve the country’s healthcare system as detailed out in The Health Plan under the

10th Malaysian Plan 2011-2015. In fact, the government had introduced various health

programmes to improve patients’ safety and the population’s health since the first

Malaysian Plan (1966-1970). In 2014, the Malaysian government had allocated RM22.1

4

billion, in order to minimise any possible gap in priorities area for the health sector

which includes operation and development expenses (MoH, 2013). The budget

allocation for health had been increased in 2015, where the Malaysian government had

allocated about RM23.3 billion. In Malaysia, the public healthcare sector is heavily

subsidised by the Malaysian government which is almost 90 percent of the total cost and

the patient pays a minimum amount for treatment.

Healthcare providers in Malaysia has been urged to transform the way they

deliver their service to improve the quality in order to meet the Millennium

Development Goals and the Malaysian Health Plan which has been set by the Malaysian

government. Malaysia needs to restructure the national healthcare financing and

healthcare delivery system, for example by using process improvement method in order

to achieve the target (MoH, 2010). In October 2011, the Malaysian Healthcare Travel

Council (MHTC) was corporatised to develop and promote Malaysia as the main

destination for healthcare services in the region. As stated in Health Expenditure Report

1997-2011, Malaysia had recorded 3.9% GDP in health spending which was similar to

other countries in Asia such as The Philippines, Thailand, India and Bangladesh. While

in 2015, it recorded 4.3% spending in GDP on healthcare. However, these countries

have much lower spending capita compared to Malaysia which ranging from USD67 in

Bangladesh to USD353 in Thailand, while in Malaysia spending was USD616 per

capita. According to Malaysia National Health Account database 2013, Malaysian

Healthcare spending continues to grow at about 12% rate on average per year for the

past 15 years. As reported in MNHA Health Expenditure Report (2015), the trend for

total health expenditure keeps on increasing since 1997 until 2013. Figure 1.2 shows the

data of escalating total health expenditure for 1997-2013.

5

Figure 1.2 Trends for Total Health Expenditure 1997-2013

(Source: Malaysia, & Malaysia National Health Account Unit, 2015)

The implementation of process improvement or change management in

healthcare has started for decades. This method manages to save operational costs where

available resources were used diligently in delivering continuous healthcare services

across the programmes, healthcare settings and also healthcare providers (Gill, 2012).

The advantages of applying process improvement method in an organization have also

been mentioned in previous studies (Celano, Costa, Fichera & Tringali, 2012;

Liberatore, 2013; Southard, Chandra, & Kumar, 2012).

Lean and Six Sigma are tools that have been used and evolved in healthcare for

the process and operations efficiency improvement, as well as financial concern in

healthcare delivery (Gamal, 2010; Revere, Black & Huq, 2004; Rohini & Mallikarjun,

2011). Six Sigma is a method that helps to identify problems on medical errors, quality

and costs improvements (Revere et al., 2004; Taner, Sezen, Antony, 2007). Lean is well-

known as the best tool for removing waste and related lead time reduction in process and

operations. Previous researchers suggest than lean can be described as a medium to

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

8303 8964 9837 11707

12990 14187

17931 19234

19487

23802

26144

29150

31453

36646 38830

42347

44748

Total Health Expenditure, Nominal (RM Million)

6

reduce waiting time, repeated visits, errors and inappropriate procedures, enhance the

process steps that are valuable and crucial, standardize the process flow, eliminate non-

value added activities and even make the value streams be more noticeable (Arumugam,

Antony & Douglas, 2012; Langabeer, Dellifraine, Heineke & Abbas, 2009; Wan &

Chen , 2008).

Lean in healthcare was known as lean healthcare where it is an improvement

system that systematically amends the cost, quality, and safety issues incurred in

healthcare. Lean healthcare helps the healthcare organization to reduce waste and cost,

as well as improving the quality and safety of healthcare (Lowe, 2013). The process of

removing waste and reducing the lead time in healthcare can be done through process

mapping or Value Stream Mapping (VSM) (Gill, 2012). VSM can be defined as the

representation of value stream with symbols and numbers, as the key to understand the

entire transformation of raw materials into finished goods (Nielsen, 2008). VSM was

chosen in the past researches as one of the preferred tools to detect the transactional and

communication mismatches, process inefficiencies and also for improvement (Gill,

2012). Previous scholars have conducted studies on VSM in different settings (Cookson,

Read & Cooke, 2011; Lowe, 2013; Persoon, Zaleski & Frerichs, 2006). However most

of the studies focus on the VSM implementation in service industries.

1.3 Problem Statement

Healthcare sectors in Malaysia have changed and growing since the early 90’s. The

changes such as demographics, political environment, social perceptions of healthcare

quality and information technology have led to dramatic change in the healthcare sector

(Trusko, Pexton, Gupta & Harrington, 2003). The advancement in healthcare sector

progress is in line with the developing countries growth (Cheong, Shin & Joeng, 2009).

New issues and challenges are faced as Malaysian healthcare sector develops. Among

major issues identified throughout healthcare delivery are increasing healthcare costs,

service and quality performances and also the efficiency of processes and operations

(Shazali, Habidin, Ali, Khaidir & Jamaludin, 2013). Rising costs in healthcare are due to

several factors namely escalating health expenditure which includes medical care,

7

consultations, medication, medical procedures and other factors (Gowen, McFadden &

Settaluri, 2012; Olszak & Batko, 2012). Besides, the increasing costs are also due to the

increasing number of population size where it leads to the rise in demand for healthcare

services.

Over the years, service performance has become one of the target issues that

need to be emphasized by the healthcare management. This is because the aim of

providing care and enhancing health towards the citizen, have become the national goal

and focus that need to be achieved (Dahlgaard et al., 2011). Poor healthcare delivery

system and crisis in management are among the factors that will affect the overall

healthcare quality. The focus on restructuring the national healthcare financing and

healthcare delivery system are by adopting process improvement method where it is

relevant and significant to fulfil the aspiration in achieving the target of creating an

effective, efficient, fair and high-tech system of healthcare as well as responsiveness

where it can further improve the access to various levels of appropriate healthcare to all

Malaysian citizen (MoH, 2010).

However, there is a lack of evidence on the current state for type of process

improvement used by the Malaysian Healthcare providers (Khaidir, Habidin, Ali,

Shazali & Jamaludin, 2013). Lack of knowledge in this area may prevent the policy

makers and top management of healthcare providers to understand the necessary

continuous improvement approaches in healthcare systems and their impact on the

quality of services. It should be the main priority for healthcare’s higher management to

find ways to be more efficient and effective in delivering services. Therefore, this study

attempts to investigate the current practices of process improvement approaches in

Malaysian healthcare.

Lean and Six Sigma are two popular continuous process improvement methods.

These methods had tremendously improved the quality and efficiency of manufacturing

and service sectors for decades (Laureani & Antony, 2012). Lean and Six Sigma has

also been applied to healthcare delivery system as a solution to problems that occur

within healthcare industry (Celano et al., 2012; Willoughby, Chan & Strenger, 2010). As

clarified in a study by Laureani and Antony (2012), there is a small number of previous

empirical studies aimed to understand the benefits of Lean and Six Sigma methodologies

8

in improving clinical outcomes, patient safety, efficiency, and financial performance.

Organization that utilized Lean methodology alone with the absence of Six Sigma shows

restricted improvement across organization. Indeed, by integrating the best approach of

Lean and Six Sigma methodologies, the organization will magnify improvements in

customer satisfaction, cost, quality, speed and others (Laureani & Antony, 2012).

Lean specifically has been recognized as one of the methods for removing waste

and reducing lead time. Lean is an alternative of doing more with less where it focuses

on eliminating non-value added activities and to increase the efficiency of activities. In

previous researches, lean has been widely used as a waste removal and lead time reducer

for productions, processes and operations (Murrel, Offerman & Kauffman, 2011). The

long waiting time has become one of the major issues that burdens healthcare

management and patients (Kollberg, Dahlgaard & Brehmer, 2006). This issue requires a

solution to curb the problem from further escalating. The combination of lean and Six

Sigma known as Lean Sigma, is able to develop forceful recognition and reduce the non-

value added activities in a workflow process (Bahensky, Roe & Bolton, 2005).

The issues regarding waste and long waiting time in previous studies had been

solved by implementing Value Stream Mapping (Cadro, 2013; Rahani & al-Ashraf,

2012; Tyagi, Choudhary, Cai & Yang, 2015). In Malaysia, there is still lack of studies

regarding the implementation of VSM in Malaysian Healthcare as process improvement

tool (Haron, Ramlan, Ahmad & Ahmad, 2015). Referring to this situation, this study

attempts to utilize the VSM approach in finding a better solution for improving lead time

and the patient process flow in healthcare systems.

The preliminary study on the particular healthcare shows that there is waste issue

occurrence (Haron & Ramlan, 2015). However, the waste here is waiting time only.

From the study, non-value added time that is considered as waste (waiting time), is

greater than the value added time. The study proposed a few solutions to reduce the

waste occurrence and successfully improved the process flow of patient.

In Malaysia, the number of admissions has been increasing by 3% annually

(MoH, 2010). Given the growing number of demand especially for outpatient services,

the healthcare systems is now facing longer and increasing waiting times for medical

services. Based on the statistics from Ministry of Health Malaysia, the recorded number

9

of admissions and outpatients’ attendances in 2013 is in Table 1.1. This situation may

have slight medical effect, but excessive waiting time may be detrimental to the patients'

health. This situation may be worse in a larger public healthcare centre where the

demand for outpatient medical services is generally higher than in the private sector.

Table 1.1: Admissions and outpatients attendances in 2013

Government

Ministry of Health

Admissions total

Hospitals 2,110,628 2,163,082

Special Medical Institutions 52,454

Outpatient Attendances

Hospitals 19,353,222 53,000,929

Special Medical Institutions 268,104

Public Health Facilities 33,379,603

Day Care Attendances

Hospitals 1,189,409 1,189,409

Clinical Support Service Attendances

Medical Rehabilitation (Hearing) 92,109 359,831

Medical Rehabilitation (Speech) 44,508

Medical Social Services 83,495

Dietetic 139,719

Dental Health Attendances

Dental Clinics 10,984,728 10,984,728

Maternal & Child Health Attendances

Ante-natal Attendances 5,794,544 14,067,279

Post-natal attendances 556,852

Child Attendances 7,715,883

10

Table 1.1 (continued)

Non Ministry of Health Hospitals

Admissions 139,545 2,141,075

Outpatient Attendances 2,001,530

Private Hospitals

Admissions 1,020,397 4,888,065

Outpatient Attendances 3,867,668

(Source: MoH, 2015)

As shown in Table 1.1, the patient attendances in 2013 for Maternal & Child

Health Attendances shows the highest number except for Outpatient Attendances

compared to other department with a total of 14,067,279 attending patients. The high

number of attending patients in Maternal & Child Health Attendances will increase the

probability of long waiting time. This is the reason why maternity clinic being selected

as the location for this study. Thus, this research aims to study the issues in selected

maternity clinic because it is important to determine the most critical waste and propose

a solution on how to eliminate or reduce wastes that occur during the process flow of

patient.

1.4 Research Questions

Based on the problem statement discussed before, there are three research questions

which are:

i. What are the current practices of process improvement method in Malaysian

Healthcare industry?

ii. What is the most critical waste that occur during the process flow of patient in

healthcare?

11

iii. What can be suggested to eliminate or reduce the wastes that occur during the

process flow of patient in healthcare systems?

1.5 Research Objectives

According to the research questions, there are three objectives to be accomplished:

i. To investigate the current practices of process improvement method within

Malaysian Healthcare Industry.

ii. To determine the most critical wastes that occurs during the process flow of

patient in healthcare.

iii. To propose a solution on how to eliminate or reduce wastes that occurs during

the process flow of patient in healthcare.

1.6 Scope of Research

This research was conducted within the Malaysian healthcare industry and this research

was divided into two scopes. The first scope focuses on Malaysian healthcare where it

covers the first objective of this study. The target respondents are healthcare

professionals who work in healthcare. The second scope is government health clinic in

Parit Raja, Batu Pahat where it covers the second and third objectives for this study. This

research focused on lean healthcare and Value Stream Mapping (VSM) in the process

flow of patient. Observation was done in order to monitor the process flow of patient

without interrupting the staffs in the selected healthcare. Potential solutions are proposed

to the healthcare in order to improve the process flow of patient and eliminate waste. In

this study, the maternity clinic was selected because pregnancy, childbirth, and the

puerperium have been recorded as the number one cause of hospitalization in Ministry

of Health and private hospitals in 2013.

12

1.7 Significance of Research

This study investigates the current practices of process improvement in Malaysian

Healthcare Industry. Six Sigma and lean are necessary for organizations in order to

move to the next level in business achievement (Black & Revere, 2006; Gowen et al.,

2012). Through Six Sigma and lean methodology, organization will be able to identify

problems, improve the efficiency of task, review customer satisfaction, and also attain

strategic objectives. Lean healthcare is a method that has been applied in healthcare

organization as a crucial method for improvement and Value Stream Mapping (VSM) is

a tool used to improve the delivery of service in process flow of patient. By proposing

the implementation of VSM in healthcare, it will help the healthcare to:

1. Reduce errors where it will result in enhancing the patient satisfaction (Gowen et

al., 2012; Langabeer et al., 2009; Lummus, Vokurka & Rodeghiero, 2006).

2. Remove waste in the system of healthcare delivery as waste will become

restriction to performance and most of the non-value added activities will be

eliminated (Lummus et al., 2006).

3. Improve the process flow of patient where it will reduce the lead time and

increase the efficiency of process and operations (Lummus et al., 2006).

Moreover, this study contributes to the development of methodology used in

conducting the research. Data for this study was collected using structured questionnaire

and observation in order to achieve the research objectives. Mixed methodology was

used in order to ensure that the data matches the need of the study (Saunders, Lewis &

Thornhill, 2009). A mixed method approach contributes in maximizing the usage of

qualitative and quantitative approaches, provides a sophisticated and complex approach

for the study, and as a useful strategy to have a complete understanding of the research

problems (Creswell, 2014).

13

Finally, this study will contribute to scholarly literatures and academic

knowledge between the healthcare industry and process improvement method. The

development of healthcare industry and process improvement are essential to the growth

of the nation, and the healthcare providers in Malaysia had been urged to transform the

way they deliver their services in order to meet the goal and objectives of the health plan

that had been detailed out in 10th Malaysia Plan 2011-2015.

1.8 Thesis structure

In general, the thesis structure is as follows:

i. Chapter 1

This chapter consists of an overview for this study. It includes introduction of

this research, research background, problem statement, research questions,

research objectives, scope of research, and significance of research.

ii. Chapter 2

In this chapter, literature review from previous study that is related to this

research had been discussed. The literature review will include the explanation

from previous studies starting with healthcare, healthcare in developing

countries, and healthcare in Malaysia. Next is literature review of process

improvement, where it explains the definition, including tools and function of

process improvement, as well as the advantages of implementing each of process

improvement. Lastly, literature review of Value Stream Mapping (VSM) is

included in this chapter followed by the research flow of VMS used in this study.

iii. Chapter 3

This chapter discusses the methodology used in order to accomplish the aim of

this study. The techniques use answers to the research questions and achieve the

objectives of this research. This chapter covers research purpose, research design

(quantitative and qualitative), data collection, and also research instrument used.

14

iv. Chapter 4

Data collected from the survey was used to achieve the objective of this research.

Surveys from questionnaires and data collected through observation were

analysed and also used as input for the process of Value Stream Mapping.

v. Chapter 5

This chapter consists of discussions on the results from the research findings. It

explained all further details including the limitations encountered while

conducting this study, and also discussed the suggestions for future research.

1.9 Conclusion

This chapter discussed the introduction and issues that are related to this study. This

chapter even discussed the background of research, research objectives, scope of

research and also the significance of research. It started with healthcare, followed by the

aim of this research concerning the issue related to Malaysian Healthcare and how to

solve the related issues.

15

CHAPTER 2

LITERATURE REVIEW

2.1 Introduction

This chapter presents an overview of process improvement in healthcare. It starts with

an exploration on the characteristics of healthcare in Malaysia and other developing

countries. As Malaysia is one of the developing countries listed by the World Bank, the

characteristics and issues related to the healthcare in developing countries were

discussed in furtherance of quality and performance. Information collected from health,

business and service management literature shows that process improvement is directly

linked to quality and performance where features, costs, and revenues were included.

The process improvement in the context of operation, business and service management

leads to the discussion of methodologies and tools with an emphasis on process

improvement in the healthcare industry.

2.2 Healthcare

Healthcare is a health institution that provides care services to patients. It is the duty of

hospital and healthcare centres to take care of the public health. Generally, healthcare

organization throughout the world can be divided into three types which are the public,

private and also the non-governmental organization. In Malaysia, healthcare is divided

into public, private, non-governmental organization, semi-government and semi-private.

16

Globally, healthcare is one of the sectors that have witnessed significant improvement

concerning the public health and healthcare system (Abor, 2013). Most of the countries

are facing problem in managing the healthcare system due to the costs (Dahlgaard et al.,

2011; Shazali et al., 2013). The costs of healthcare are rising each year where it includes

personal healthcare spending, the net cost of insurance, public health activities by the

government, research and also construction of medical facilities (Kumar & Steinebach,

2008). Matthews (2013) argued that processes involved in healthcare delivery are crucial

to the operational success of healthcare due to impact on the medical errors, throughput,

and quality of care within the system. The sources of medical errors in healthcare are

related to communication, systems and the failure of culture (Garbutt et al., 2008).

2.2.1 Healthcare in developing countries

In most developing countries, healthcare organizations are continuously improving their

healthcare service delivery to the patient (Cheong, Shin & Joeng, 2009). The process

improvement is expected to generate an improvement in healthcare such as the

healthcare system, increased patients’ accessibility to medical care and satisfaction,

improvement in medical quality, reduction in costs, and business rationalization of

hospitals (MoH, 2010). In other developing countries such as Korea, the Korean

government promoted the national e-health project where the function is aimed to

systematically build an integrated healthcare system from 2004 until 2010 (Cheong et

al., 2009). E-health can be described as total reform to healthcare system since

healthcare production, supply, and management system is exchanged in a digital form.

Such innovation is also expected to improve healthcare services as a whole, reduce the

imbalance of healthcare benefit, lower the costs of healthcare and strengthen the

competitiveness of the related industry.

17

2.2.2 Healthcare in Malaysia

In Malaysia, the healthcare system is primarily under the jurisdiction of the Ministry of

Health Malaysia. The Ministry of Health was established decades ago in order to play

the role as the regulator by enforcing the regulations. Within the ministry, the composed

health system is fair, equitable, efficient, compatible and appropriate to the customer

environment (MoH, 2013). In addition, this system was designed to satisfy the quality,

innovation, health promotion, respect for human dignity, and promote individual and

also community participation towards improving the quality of life (MoH, 2013).

Besides the Ministry of Health, university hospitals which are under the Ministry of

Higher Education are also the important providers to the public, and there is a military

hospital for military personnel and their families which fall under the Ministry of

Defence jurisdiction. Public healthcare in Malaysia was organized based on the National

Health Plan that has been drafted according to Malaysian Plan. According to the

Ministry of Finance Malaysia, healthcare services include:

a) medical, dental, nursing, midwife, allied health, pharmacy, ambulance services

and any other service provided by a healthcare professional,

b) any accommodation and food for the purpose of providing healthcare services,

c) any service for screening, diagnose, or treatment of a person suffering any

disease, injury or disability of mind and body,

d) any service for preventive or promoting health purposes,

e) any service provided by private healthcare facilities,

f) any service for curing or alleviating any abnormal condition of the human body

by application of any apparatus, equipment, instrument or device or any other

medical technology, and

g) any related healthcare service which includes the supply of drugs and medicines,

haemodialysis services and blood bank services.

18

(Source: MoF, 2014)

Malaysia Plan is an extensive 5-year strategic plan developed by the Cabinet of

Malaysia and the Economic Planning Unit (EPU). Since the 9th Malaysia Plan, the

theme of Malaysia Health Plan focuses on achieving a better health among citizens

through consolidation of health services (MoH, 2010). In the 10th Malaysia Health Plan

period from 2011-2015, the content is still consistent with the 4th National Mission

which is an improvement to the standard and sustainability on the quality of life. Apart

from focusing on the improvement of the standard and the quality of life, the 10th

Malaysia Health Plan stressed on the quality of healthcare and aimed for a healthy

community. The plan supports a healthy lifestyle by gearing towards the establishment

of a comprehensive healthcare system, public recreation, as well as sports infrastructure.

As stated in Health Expenditure Report 1997-2011 which is reported by Malaysia

National Health Accounts, the total health expenditure in Malaysia keeps on escalating

since 1997 until 2011 as stated in Health Expenditure Report from 1997 to 2011 in Table

2.1.

19

Table 2.1: Trend for Total Health Expenditure, 1997-2011 (RM Million & Percent GDP)

(Source: MoH, 2013)

The deliveries of public healthcare were intended to be affordable for the society

and can be readily accessed at all levels. Access to the public healthcare is direct, where

the people may enter as walk-in patients while access to the specialist is through referral.

However, access to private healthcare is based on ability of the patient to pay and it does

not require any referral. Even though the number of private healthcare has been

multiplying ever since, public healthcare is still dominating the healthcare industry as

the Ministry of Health is the largest healthcare provider in Malaysia. Malaysia health

system faces challenges due to increasing expectations from the public, changing trends

in disease patterns and socio-demography, and even fulfilling greater efficiencies

requirement by the citizens.

20

2.3 Process Improvement

To stay competitive and sustain long-term profitability, process improvement

methodologies become strategically important for healthcare industry in recent years.

Process improvement is also known as change management in the industry. Process

improvement as defined by Stamatis (2003) is the act of changing a process to reduce

variability and cycle time and makes the process more effective, efficient, and

productive. Specifically, process improvement focuses on incremental solutions to

eliminate or reduce defects, errors, costs, or cycle time. The application of process

improvement techniques has increased in popularity especially for healthcare

(Dellifraine, Langabeer & Nembhard, 2010). This statement is supported by Lighter

(2011) where process improvement initiatives were rated by healthcare personnel as

more important and experienced more frequent improvements to resolve medical errors

and others which include patient safety, quality, employee satisfaction, efficiency and

also competitiveness. Furthermore, Koelling, Eitel, Mahapatra, Messner and Grove

(2005) stated that process improvement is an initiative to increase the operational

efficiency and cost-effectiveness of the healthcare delivery process.

The process improvement programmes also include quality groups that use

process improvement tools in order to improve the process outcomes (Gowen et al.,

2012). Moreover, Arthur (2011) mentioned that healthcare organizations have highly

taken process improvement as an effective technique for improving quality, profitability,

productivity and even competitiveness. The goals of healthcare process improvement are

to enhance the effectiveness of systems across departments while maximizing profits

and improving the quality of the patient’s experience and care. Goldstein and Iossifova

(2012) reviewed that a high degree of financial resource slack was related to successful

implementation of process improvement initiatives for reducing four adverse medical

errors. Besides that, Gowen et al. (2012) mentioned that previous healthcare research

reported on effective deployment of process improvement programmes depends on other

dynamic capabilities, such as organizational structure, hospital ownership, and

leadership style.

21

The implementation of process improvement is associated with improved

organizational effectiveness, in terms of service quality, customer satisfaction, net cost

savings and patient satisfaction (Marley, Collier & Meyer, 2004). This is in line with the

past researchers, who argued that the healthcare organizations implemented process

improvement targeting to improve their organizational performance (Gowen et al., 2012;

Hilton, Balla & Sohal, 2008). The effectiveness and efficiency were considered as part

of organizational performance that can be enhanced by certain process improvement

factors such as DMAIC and Value Stream Mapping (De Mast, 2006). Many

organizations have implemented process improvement method and have proved that

process improvement method has yielded significant result in operations (Bateman,

2005). There are a variety of process improvement tools/technique such as Six Sigma,

Lean, Lean Six Sigma, Just-In-Time, Re-engineering, Design of Experiments, Total

Quality Management, and others (Gershon, 2010).

Process improvement in healthcare should not be neglected by the management

of healthcare organizations since inefficient and faulty of processes in healthcare are one

of the main causes that can lead practitioners to make technical mistakes (Rebuge &

Ferreira, 2012). In addition, Garland (2005) found that 15% of medical errors are due to

human error while the balance of 85% is the result of flaws in processes and the overall

healthcare system that obstructs individuals from performing their jobs. In other words,

processes involved are the contributing factors to quality and performance as they affect

the efficiency and outcomes of the entire system (Matthews, 2013). Lowe (2013) stated

that everyone should rethink the way they work and make inevitable changes as they go

on their daily tasks. Healthcare professionals will need a strategy or method to attain this

aim while maintaining or improving their current level of care.

2.3.1 Previous studies of process improvement in healthcare

Process improvement has been tremendously implemented in healthcare industry. Table

2.2 shows the summary of the studies on process improvement that had been done in

healthcare by previous scholars.

22

Table 2.2: Previous studies of process improvement in healthcare

AUTHOR (YEAR) PROCESS

IMPROVEMENT DESCRIPTION

Taner, Sezen & Antony

(2007) Six Sigma

Minimize delays, measurement, and medical

errors.

Maximize resource utilization.

Increase patient and physician satisfaction.

Reduce cost.

Taner & Sezen (2009) Six Sigma Reduce turnover rate

Celano et al. (2012)

Six Sigma and discrete-

event simulation (DES)

Increase awareness among staff

Eliminate unnecessary activities

Reduce Six Sigma project cost when

adopting DES.

Southard et al. (2012)

Six Sigma and radio

frequency identification

(RFID) technology.

Time saving

Cost effectiveness

Improve safety of the patient

Gowen et al. (2012)

Continuous Quality

Improvement (CQI), Six

Sigma Initiatives (SSI),

and Lean Management

Initiatives (LMI)

CQI is the most effective PI approach

LMI offers some added benefits over and

above CQI.

CQI enhances patient safety

Hospitals report only a moderate level of SSI

implementation.

Liberatore (2013) Six Sigma

From study, only

67% had initial improvement in the key

process metric

10% reported sustained improvement.

28% reported cost savings

8% offered revenue enhancement.

Al-Balushi et al., (2014) Lean

Factors for implementing lean in healthcare:

culture of a healthcare setting

lean as a long-term policy

good measurement system

23

Table 2.2 (Continued)

AUTHOR (YEAR) PROCESS

IMPROVEMENT DESCRIPTION

Haron & Ramlan (2015) Lean

Reduce lead time and waste in process flow

of patient

Improve the capacity of patient, idle time,

utilized time and the number of operations

As mentioned in Table 2.2, process improvement method had been implemented

in healthcare since decades ago where it focuses on improving the quality of services in

healthcare. From the table, Six Sigma methodology had managed to minimize delays

and medical errors, eliminate unnecessary activities, reduce costs, time and turnover

rate, maximize resource utilization and awareness among staffs, and even increase

patient safety, give patient and physician satisfaction, and also the revenue (Taner et al.,

2007; Taner & Sezen, 2009; Celano et al., 2012; Southard et al., 2012; Gowen et al.,

2012; Liberatore, 2013).

In addition, one of the studies mentioned in Table 2.2 stated that lean

methodology had been implemented in healthcare due to the culture of healthcare

settings, lean as a long term policy, and also a good measurement system. Lean managed

to reduce the waste and lead time, and also improve the capacity of patient, idle time,

utilized time and operations in the healthcare (Al-Balushi et al., 2014; Haron & Ramlan,

2015).

2.3.2 Six Sigma

Six Sigma is one of the process improvement initiatives that was designed by leading

manufacturing companies and applied to service industry for managing better operation

system. Six Sigma started as an improvement programme at Motorola in 1982 in order

to assist Motorola to reduce costs and improve the quality of their product (Stamatis,

2003). Six Sigma is a systematic approach to problem solving. Six Sigma has been

described by previous researchers in different forms. These differences led to

24

uncertainty and confusion by others. In a study reviewed by Schroeder, Linderman,

Liedtke and Choo (2008), they had collected a few definitions of Six Sigma. The first

definition in the study defined that Six Sigma as a high-performance, data-driven

approach to analyse the root causes of business problems and solve them. The second

definition in the study defined Six Sigma as business process that allows companies to

drastically improve their bottom line by designing and monitoring everyday business

activities in ways that minimize waste and resources while increasing customer

satisfaction. The third definition from the study defined Six Sigma as a disciplined and

statistically based approach for improving product and process quality. The fourth

definition in the study stated Six Sigma as a management strategy that requires a culture

change in the organization (Schroeder et al., 2008).

Six Sigma definition by Gowen (2012) is known as a radical breakthrough

approach that is extensively focused on the bottom line results, specifically for process

improvement projects. However, Stamatis (2003) defined Six Sigma as a quality

objective that specifies the variability required of a process in terms of the specifications

of the product/service so that the reliability and the quality meet and exceed today’s

demanding customer requirements. Other definitions indicate Six Sigma as an

organized, parallel-mesostructure to reduce variation in organizational processes by

using improvement specialists, a structured method, and performance metrics with the

aim of achieving strategic objectives (Schroeder et al., 2008). Specifically, the term Six

Sigma refers to a process capability that generates 3.4 defects per million opportunities.

Descriptions that have been collected from previous researches suggest that Six Sigma

definitions covered almost all aspects. This is proven by a variation of definitions from

different practitioners and academic literatures.

Six Sigma plays an important role as one of the main process improvement tool

and has four main goals which are to reduce defects/non-conformance, improve yield,

for customer satisfaction and shareholder value (Stamatis, 2003). Six Sigma offers a

framework that gathers the basic quality tools and combines them with high-level

management support. A disciplined approach towards measurement and improvement

that have not been evident in previous quality improvement efforts are required by Six

Sigma. Besides that, Six Sigma also encourages customer-focused approach which at the

119

REFERENCES

Abdulmalek, F. A., & Rajgopal, J. (2007). Analyzing the benefits of lean manufacturing

and value stream mapping via simulation: A process sector case study.

International Journal of production economics, 107(1), 223-236.

Aboelmaged, G. M. (2010). Six Sigma quality: a structured review and implications for

future research. International Journal of Quality & Reliability Management,

27(3), 268-317.

Abor, P. A. (2013). Managing healthcare waste in Ghana: a comparative study of public

and private hospitals. International journal of health care quality

assurance, 26(4), 375-386.

Aguezzoul, A., & Nyoungue, A. (2012, July). A preliminary analysis on Lean Six Sigma

application in healthcare. In ICSSSM12 (pp. 714-717). IEEE.

Al-Aomar, R. (2012). A lean construction framework with Six Sigma rating.

International Journal of Lean Six Sigma, 3(4), 299-314.

Al-Balushi, S., Sohal, A. S., Singh, P. J., Al Hajri, A., Al Farsi, Y. M., & Al Abri, R.

(2014). Readiness factors for lean implementation in healthcare settings–a

literature review. Journal of health organization and management, 28(2), 135-

153.

Antony, J., Jiju Antony, F., Kumar, M., & Rae Cho, B. (2007). Six sigma in service

organisations: Benefits, challenges and difficulties, common myths, empirical

observations and success factors. International journal of quality & reliability

management, 24(3), 294-311.

120

Antony, J., Krishnan, N., Cullen, D., & Kumar, M. (2012). Lean Six Sigma for higher

education institutions (HEIs) Challenges, barriers, success factors,

tools/techniques. International Journal of Productivity and Performance

Management, 61(8), 940-948.

Ari, V. R. (2010). Value Stream Mapping of Information Flow in Infrastructure Projects

(Doctoral dissertation, Cleveland State University).

Arumugam, V., Antony, J., & Douglas, A. (2012). Observation: a Lean tool for

improving the effectiveness of Lean Six Sigma. The TQM Journal, 24(3), 275-

287.

Bahensky, J. A., Roe, J., & Bolton, R. (2005). Lean sigma—will it work for healthcare.

J Healthc Inf Manag, 19(1), 39-44.

Bateman, N. (2005). Sustainability: the elusive element of process improvement.

International journal of operations & production management, 25(3), 261-276.

Ben-Tovim, D. I., Bassham, J. E., Bolch, D., Martin, M. A., Dougherty, M., &

Szwarcbord, M. (2007). Lean thinking across a hospital: redesigning care at the

Flinders Medical Centre. Australian Health Review, 31(1), 10-15.

Black, K., & Revere, L. (2006). Six Sigma arises from the ashes of TQM with a twist.

International Journal of Health Care Quality Assurance, 19(3), 259-266.

Burgess, T. F. (2001). A general introduction to the design of questionnaires for survey

research. UK: University of Leeds.

Cadro, T. (2013). Finalization of a lean manufacturing process within the customer

support service of Latécoère

Casey, J. J. W. (2007). A lean enterprise approach to process improvement in a health

care organization (Doctoral dissertation, Massachusetts Institute of Technology).

121

Castle, A., & Harvey, R. (2009). Lean information management: the use of

observational data in health care. International Journal of Productivity and

Performance Management, 58(3), 280-299.

Celano, G., Costa, A., Fichera, S., & Tringali, G. (2012). Linking Six Sigma to

simulation: a new roadmap to improve the quality of patient care. International

journal of health care quality assurance, 25(4), 254-273.

Cheong, H. J., Shin, N. Y., & Joeng, Y. B. (2009). Improving Korean service delivery

system in health care: Focusing on national E-health system. In eHealth,

Telemedicine, and Social Medicine, 2009. eTELEMED'09. International

Conference on (pp. 263-268).

Collis, J., Hussey, R., Crowther, D., Lancaster, G., Saunders, M., Lewis, P., & Robson,

C. (2003). Business research methods.

Cookson, D., Read, C., & Cooke, M. (2011). Improving the quality of Emergency

Department care by removing waste using Lean Value Stream mapping. The

international journal of clinical leadership, 17(1), 25-30.

Coons, J. A. Beginning the lean improvement journey in the clinical laboratory

Creswell, J. W., & Plano-Clark, V. L. (2006). Understanding mixed methods research.

Designing mixed methods research. California: Sage Publications.

Creswell, J. W. (2014). A concise introduction to mixed methods research. California:

Sage Publications.

Dahlgaard, J. J., Pettersen, J., & Dahlgaard-Park, S. M. (2011). Quality and lean health

care: A system for assessing and improving the health of healthcare

organisations. Total Quality Management & Business Excellence, 22(6), 673-

689.

De Mast, J. (2006). Six Sigma and competitive advantage. Total Quality Management

and Business Excellence, 17(04), 455-464.

122

DelliFraine, J. L., Langabeer, J. R., & Nembhard, I. M. (2010). Assessing the evidence

of Six Sigma and Lean in the health care industry. Quality Management in

Healthcare, 19(3), 211-225.

Dickson, E. W., Anguelov, Z., Vetterick, D., Eller, A., & Singh, S. (2009). Use of lean

in the emergency department: a case series of 4 hospitals. Annals of emergency

medicine, 54(4), 504-510.

El-Haik, B. & Yang, K. "Design for Six Sigma, A Roadmap for Product Development."

(2003): 1-35.

Erfan, O. M. (2010). Application of lean manufacturing to improve the performance of

health care sector in Libya. International Journal of Engineering &

Technology, 10(6), 117-128.

Garbutt, J., Waterman, A. D., Kapp, J. M., Dunagan, W. C., Levinson, W., Fraser, V., &

Gallagher, T. H. (2008). Lost opportunities: how physicians communicate about

medical errors. Health Affairs, 27(1), 246-255.

Garland, A. (2005). Improving the ICUPart 2. CHEST Journal, 127(6), 2165-2179.

Gershon, M. (2010). Choosing which process improvement methodology to implement.

The Journal of Applied Business and Economics, 10(5), 61.

Gill, S. P. (2012). Application of value stream mapping to eliminate waste in an

emergency room. Global Journal of Medical Research, 12(6).

Goldstein, S. M., & Iossifova, A. R. (2012). Ten years after: Interference of hospital

slack in process performance benefits of quality practices. Journal of Operations

Management, 30(1), 44-54.

Gowen Iii, C. R., McFadden, K. L., & Settaluri, S. (2012). Contrasting continuous

quality improvement, Six Sigma, and lean management for enhanced outcomes

in US hospitals. American Journal of Business, 27(2), 133-153.

123

Hadid, W., & Afshin Mansouri, S. (2014). The lean-performance relationship in

services: a theoretical model. International Journal of Operations & Production

Management, 34(6), 750-785.

Haron, S. H. A., & Ramlan, R. (2015). Patient Process Flow Improvement: Value

Stream Mapping. Journal of Management Research, 7(2), 495-505.

Haron, S. H. A., Ramlan, R., Ahmad, K., Ahmad, A. N. A., (2015).Value Stream

Mapping Implementation in Healthcare – A literature Review. Malaysian

Technical Universities Conference on Engineering and Technology 2015

(MUCET 2015). Paper presented at Malaysian Technical Universities

Conference on Engineering and Technology 2015 (MUCET 2015), Johor Bahru,

11-13 October 2015. Manuscript submitted for publication.

Hilton, R., Balla, M., & Sohal, A. S. (2008). Factors critical to the success of a Six-

Sigma quality program in an Australian hospital. Total Quality

Management,19(9), 887-902.

Holden, R. J. (2011). Lean thinking in emergency departments: a critical review. Annals

of emergency medicine, 57(3), 265-278.

Jenkins, J. (2006). Eliminating common PACU delays. Journal of healthcare

information management: JHIM, 21(2), 53-58.

Jimmerson, C., Weber, D., & Sobek, D. K. (2005). Reducing waste and errors: piloting

lean principles at Intermountain Healthcare. Joint Commission Journal on

Quality and Patient Safety, 31(5), 249-257.

Joosten, T., Bongers, I., & Janssen, R. (2009). Application of lean thinking to health

care: issues and observations. International Journal for Quality in Health Care,

21(5), 341-347.

Kamma, T. K. (2010). Framework for lean thinking approach to healthcare

organizations: Value stream mapping to reduce patient waiting time.

SOUTHERN ILLINOIS UNIVERSITY AT CARBONDALE.

124

Khaidir, N. A., Habidin, N. F., Ali, N., Shazali, N. A., & Jamaluddin, N. H. (2013). Six

Sigma practices and organizational performance in Malaysian healthcare

industry. IOSR Journal of Business and Management, 6(5), 29-37.

Koelling, C. P., Eitel, D., Mahapatra, S., Messner, K., & Grove, L. (2005). Value stream

mapping the emergency department. Grado Department of Industrial and

Systems Engineering, Virginia Tech. Blacksburg, VA.

Kollberg, B., Dahlgaard, J. J., & Brehmer, P. O. (2006). Measuring lean initiatives in

health care services: issues and findings. International Journal of Productivity

and Performance Management, 56(1), 7-24.

Kothari, C. R. (2004). Research methodology: methods and techniques. New Delhi:

New Age International.

Kumar, S., & Steinebach, M. (2008). Eliminating US hospital medical errors.

International journal of health care quality assurance, 21(5), 444-471.

Langabeer, J. R., DelliFraine, J. L., Heineke, J., & Abbass, I. (2009). Implementation of

Lean and Six Sigma quality initiatives in hospitals: A goal theoretic perspective.

Operations Management Research, 2(1-4), 13-27.

Laureani, A., & Antony, J. (2012). Critical success factors for the effective

implementation of lean sigma: results from an empirical study and agenda for

future research. International Journal of Lean Six Sigma, 3(4), 274-283.

Lee, P. M., Khong, P., & Ghista, D. N. (2006). Impact of deficient healthcare service

quality. The TQM Magazine, 18(6), 563-571.

Lewis, P., Thornhill, A., & Saunders, M. (2007). Research methods for business

students. Pearson Education UK.

Liberatore, M. J. (2013). Six Sigma in healthcare delivery. International journal of

health care quality assurance, 26(7), 601-626.

125

Lighter, D. (2011). Basics of health care performance improvement. Burlington: Jones

& Bartlett Publishers.

Llyod, D. H., and Holsenback, J. E. (2006). The use of six sigma in health care

operations: Application and opportunity. Academy of Health Care Management

Journal, 2, 41-49

Lowe, F. R. (2013). Lean Healthcare: Controlling Cost through Better Care (Doctoral

dissertation, University of Minnesota).

Lummus, R. R., Vokurka, R. J., & Rodeghiero, B. (2006). Improving quality through

value stream mapping: a case study of a physician's clinic. Total Quality

Management, 17(8), 1063-1075.

Malaysia. Economic Planning Unit. (2010). Tenth Malaysia Plan 2011-2015. Putrajaya:

The Economic Planning Unit, Prime Minister's Department

Mark, S., Philip, L., & Adrian, T. (2009). Research methods for business students.

Harlow: Prentice Hall.

Marley, K. A., Collier, D. A., & Meyer Goldstein, S. (2004). The role of clinical and

process quality in achieving patient satisfaction in hospitals. Decision

Sciences, 35(3), 349-369.

Mathey, A. (2012). An application of the Value Stream Mapping method in order to

identify sources of wastes and opportunities for improvements.

Matthews, L. (2013). Process mining to facilitate process improvement in a healthcare

environment: An emergency department case study (Doctoral dissertation,

STATE UNIVERSITY OF NEW YORK AT BINGHAMTON).

126

Mazzocato, P., Savage, C., Brommels, M., Aronsson, H., & Thor, J. (2010). Lean

thinking in healthcare: a realist review of the literature. Quality and Safety in

Health Care, 19(5), 376-382.

McClean, S., Young, T., Bustard, D., Millard, P., & Barton, M. (2008, September).

Discovery of value streams for Lean Healthcare. In Intelligent Systems, 2008.

IS'08. 4th International IEEE Conference (Vol. 1, pp. 3-2).

Melton, T. (2005). The benefits of lean manufacturing: what lean thinking has to offer

the process industries. Chemical Engineering Research and Design, 83(6), 662-

673.

MoF. 2014. Guide Healthcare Services. Retrieved 27 January 2015 from

http://www.customs.gov.my/ms/pg/pg_ig/Healthcare%20Services%20(revised%

20as%20at%2019%20November%202014).pdf

MoH. (2010). Country health plan 2011-2015. Retrieved 05 January 2014 from

www.moh.gov.my/images/gallery/Report/Country_health.pdf

MoH. (2013). Bajet 2014 Impak dan Faedah. Retrieved 27 January 2015 from

http://www.penerangan.gov.my/index.php/bm/penerbitan/dbook

MoH. (2015). Health Facts 2014. Retrieved 20 May 2015 from

http://www.moh.gov.my/images/gallery/publications/HEALTH%20FACTS%20

2014.pdf

Mujtaba, S., Feldt, R., & Petersen, K. (2010, April). Waste and lead time reduction in a

software product customization process with value stream maps. In 2010 21st

australian software engineering conference (pp. 139-148). IEEE.

127

Murrell, K. L., Offerman, S. R., & Kauffman, M. B. (2011). Applying lean:

implementation of a rapid triage and treatment system. Western Journal of

Emergency Medicine, 12(2), 184.

Nash, M. A., & Poling, S. R. (2011). Mapping the total value stream: A comprehensive

guide for production and transactional processes. New York: CRC Press.

Nelson-Peterson, D. L., & Leppa, C. J. (2007). Creating an environment for caring using

lean principles of the Virginia Mason Production System. Journal of nursing

administration, 37(6), 287-294.

Nielsen, A. (2008). Getting Started with Value Stream Mapping. Salt Spring Island:

Gardiner Nielsen Associated Inc.

Olszak, C. M., & Batko, K. (2012). The use of business intelligence systems in

healthcare organizations in Poland. In Computer Science and Information

Systems (FedCSIS), 2012 Federated Conference on (pp. 969-976). IEEE.

Padma, P., Rajendran, C., & Sai, L. P. (2009). A conceptual framework of service

quality in healthcare: perspectives of Indian patients and their attendants.

Benchmarking: An International Journal, 16(2), 157-191.

Pate, D. C., & Puffe, M. (2007). Improving patient flow. Physician executive,33(3), 32.

Pepper, M. P. J., & Spedding, T. A. (2010). The evolution of lean Six

Sigma.International Journal of Quality & Reliability Management, 27(2), 138-

155.

Persoon, T. J., Zaleski, S., & Frerichs, J. (2006). Improving preanalytic processes using

the principles of lean production (Toyota Production System).American journal

of clinical pathology, 125(1), 16-25.

Pluto, D. M., & Hirshorn, B. A. (2003). Process mapping as a tool for home health

network analysis. Home health care services quarterly, 22(2), 1-16.

128

Puterman, M. L., Zhang, Y., Aydede, S. K., Palmer, B., MacLeod, S., Bavafa, H., &

MacKenzie, J. (2012). ―If You’re Not Keeping Score, You’re Just Practicing”: A

Lean Health Care Program Evaluation Framework. Healthcare quarterly

(Toronto, Ont.), 16(2), 23-30.

Radnor, Z. J., Holweg, M., & Waring, J. (2012). Lean in healthcare: the unfilled

promise?. Social science & medicine, 74(3), 364-371.

Rahani, A. R., & al-Ashraf, M. (2012). Production flow analysis through value stream

mapping: a lean manufacturing process case study. Procedia Engineering, 41,

1727-1734.

Ramlan, R., Ismail, S. N., Kassim, N. A., (2010). Aplikasi Promodel Dalam Mengkaji

Masa Menunggu Rawatan Di Klinik. Prosiding Seminar Kebangsaan Aplikasi

Sains dan Matematik 2010 (SKASM 2010). Paper presented at Simposium

Kebangsaan Sains Matematik ke-18 (SKSM 18), Johor Bahru, Johor, 8-10

December 2010 (pp. 169-175). Batu Pahat, Johor: Penerbit Universiti Tun

Hussein Onn Malaysia

Rebuge, Á., & Ferreira, D. R. (2012). Business process analysis in healthcare

environments: A methodology based on process mining. Information Systems,

37(2), 99-116.

Revere, L., Black, K., & Huq, A. (2004). Integrating Six Sigma and CQI for improving

patient care. The TQM Magazine, 16(2), 105-113.

Robson, C. (2002). Real world research. 2nd. Edition. Malden: Blackwell Publishing.

Rohana, A., Nooririnah, O., Isa, H., Kamat, S., & Mehad, M. (2013) Lean Waste

Analysis and Improvement Using Dynamic Value Stream Mapping. Global

Engineers and Technologists Review, 3, 1-8.

Rohini, R., & Mallikarjun, J. (2011). Six Sigma: Improving the Quality of Operation

Theatre. Procedia-Social and Behavioral Sciences, 25, 273-280.

129

Roscoe, J.T. (1975) Fundamental Research Statistics for the Behavioural Sciences, 2nd

edition. New York: Holt Rinehart & Winston.

Rother, M., & Shook, J. (2003). Learning to see: value stream mapping to add value

and eliminate muda. Cambridge: Lean Enterprise Institute.

Saunders, M., Lewis, P., & Thornhill, A. (2009). Research methods for business

students, 5/e. England: Pearson Education.

Schonberger, R. J. (2008). World class manufacturing. New York: The Free Press.

Schroeder, R. G., Linderman, K., Liedtke, C., & Choo, A. S. (2008). Six Sigma:

definition and underlying theory. Journal of operations Management, 26(4), 536-

554.

Shahrbabaki, S. A. D., & Jackson, M. (2011). Green and lean production visualization

tools; a case study exploring EVSM. Kersten W International supply chain

management and collaboration practices, Josef Eul Verlag, Lohmar Köln, 399-

412.

Shazali, N. A., Habidin, N. F., Ali, N., Khaidir, N. A., & Jamaludin, N. H. (2013). Lean

Healthcare Practice and Healthcare Performance in Malaysian Healthcare

Industry. International Journal of Scientific and Research Publications, 3(1), 1-

5.

Sobek II, D. K., & Jimmerson, C. (2003, January). Applying the Toyota Production

System to a Hospital Pharmacy. In IIE Annual Conference. Proceedings (p. 1).

Institute of Industrial Engineers-Publisher.

Southard, P. B., Chandra, C., & Kumar, S. (2012). RFID in healthcare: a Six Sigma

DMAIC and simulation case study. International Journal of Health Care Quality

Assurance, 25(4), 291-321.

Spear, S. J. (2005). Fixing health care from the inside, today. Harvard business

review, 83(9), 78.

130

Stamatis, D. H. (2003). Six Sigma for financial professionals. Indiana University: John

Wiley & Sons.

Stone, K. B. (2012). Four decades of lean: a systematic literature review.International

Journal of Lean Six Sigma, 3(2), 112-132.

Taiichi, O. (1988). Toyota production system: Beyond large-scale production.

Productivitiy Pres, Cambridge, MA.

Taner, M. T., Sezen, B., & Antony, J. (2007). An overview of six sigma applications in

healthcare industry. International Journal of Health Care Quality Assurance,

20(4), 329-340.

Taner, M. T., & Sezen, B. (2009). An application of Six Sigma methodology to turnover

intentions in health care. International Journal of Health Care Quality

Assurance, 22(3), 252-265.

Teichgräber, U. K., & de Bucourt, M. (2012). Applying value stream mapping

techniques to eliminate non-value-added waste for the procurement of

endovascular stents. European journal of radiology, 81(1), e47-e52.

Towill, D. R., & Christopher, M. (2005). An evolutionary approach to the architecture of

effective healthcare delivery systems. Journal of Health Organization and

Management, 19(2), 130-147.

Trusko, B. E., Pexton, C., Gupta, P. K., & Harrington, J. (2003). Improving healthcare

quality and cost with Six Sigma. Pearson Education.

Tsasis, P., & Bruce-Barrett, C. (2008). Organizational change through lean

thinking. Health Services Management Research, 21(3), 192-198.

Tyagi, S., Choudhary, A., Cai, X., & Yang, K. (2015). Value stream mapping to reduce

the lead-time of a product development process. International Journal of

Production Economics, 160, 202-212.

131

Wan, H. D., & Frank Chen, F. (2008). A leanness measure of manufacturing systems for

quantifying impacts of lean initiatives. International Journal of Production

Research, 46(23), 6567-6584.

Willoughby, K. A.,Chan, B. T. B., & Strenger, M. (2010). Achieving wait time

reduction in the emergency department. Leadership in Health Services, 23(4),

304-319.

Womack, J. P., & Jones, D. T. (2010). Lean thinking: banish waste and create wealth in

your corporation. London: Simon and Schuster.

Yang, K., & El-Haik, B. S. (2003). Design for Six Sigma (pp. 184-186). New York:

McGraw-Hill

Yusoff, M. S. B. (2015) retrieved from https://www.scribd.com/document/47700170/Dr-

Saiful-s-Notes-on-Medical-26-Allied-Health-Education-Statistics-26-Research-

Methodology