J. Multidiscip. Res. Healthcare

Streamlining the Processes Preceding an Operation Using Six Sigma

Ankit Singh, Sougrakpam Sushillo Singh and Priya Ravi

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Six Sigma, Operation Theatre Utilization, Pareto analysis, Cause and Effect Diagram

PUBLISHED DATE April 02, 2018
PUBLISHER The Author(s) 2012. This article is published with open access at www.chitkara.edu.in/publications.

Purpose: The operation theatre is the major cost and revenue centre in a hospital. The operation theatre’s optimum utilization will not only increase the revenue for the hospital but will also have a significant positive impact on customer satisfaction, for both internal and external customers. The present study aims in improving the existing process in an operation theatre suite of a tertiary care private hospital in Siliguri (West Bengal), which suffers from a process related problem, delay in scheduling operations (Sigma level 2.17), as found out in the Pilot Study. The study is carried out to improve the sigma level. Aligning with it, the operation theatre utilization is calculated with the objective of its bench marking, as per industry standards.

Design/Methodology/Approach: The study is conducted within the framework of Defining, Measuring, Analysing, Improving, and Controlling (DMAIC) method of Six Sigma. To begin with, the Pilot Study is carried out to identify and define the problem. At the measuring and analysing stage, Pareto analysis technique is employed, aided by the Cause and Effect diagram. After the identification, causes are categorised as controllable and uncontrollable. This is followed by a brainstorming session, which is conducted in order to work out solutions relating to controllable causes. The Time Motion study data of 192 surgery cases is collected for the pre-implementation phase, while that of 236 surgery cases is collected for the post-implementation phase. An independent t test is carried out to find out the difference in the outcomes, both in the pre-implementation and the post-implementation phases, thereby reflecting the effectiveness of the solutions implemented.

Findings: The baseline sigma level of 2.17 is improved to reach the 3.0 sigma level, concerning delay of scheduled operations. This is achieved by reducing the time lag that is experienced when shifting the patient from the Ward to the Operation Theatre, as also that relating to the cleaning and setting up of the Operation Theatre, between two surgeries.

Practical implications: Reducing the set up and the cleaning time between two procedures helps in reducing the delay in scheduled operations, which can be achieved by the practice of shifting the patient one hour prior to the scheduled surgery. Similarly, when more surgeries need to be performed, their turnaround time can be reduced by deploying an adequate number of housekeeping staff. Thus, more number of surgeries can be done in a day and operation theatre utilization can be optimised.


There has been an increase in the number of case studies and research articles relating to healthcare settings, where Six Sigma or Lean or Lean Six Sigma is used to reduce ‘Muda’, i.e., wastes, or to improve processes’ efficiency and effectiveness, with an objective to reduce variation. The Six Sigma application in healthcare settings is recent in origin, in comparison to its application in the manufacturing sector. There are various ways to define Six Sigma, as Six Sigma is defined by various scholars as a method (Linderman, Schroeder, Zaheer, & Choo, 2003), philosophy (Chowduhry, 2002) and business strategy (Antony & Banuelas, 2002). The Six Sigma methodology is used in several departments of a hospital, such as the outpatient department (Gijo & Antony, 2014), discharge process (ElEid, Kaddoum, Tamim, & Hitti, 2015), admission process (Tolga Taner, Sezen, & Antony, 2007), medication process (Chassin, 2009), diagnostic imaging (Tolga Taner, Sezen, & Atwat, 2012) and operation theatres (Singh, Remya, Shijo, & Nair, 2014). However, there are not enough studies which have tried to solve the operation theatre delay problem with the Six Sigma approach. The operation theatre is one among the major revenue producing departments in a hospital (Siddharth, Kumar, Vij, & Gupta, 2015). It is both labour intensive and cost intensive, as it requires a huge investment and a large team of professionals, consisting of surgeons, anaesthetists, operation theatre technicians, operation theatre assistants, operation theatre nurses, and so on. Good investments are required for installations of fixtures and equipment, and meeting design parameters, so as to ensure strict aseptic conditions. On an average, an operation theatre follows an eight-hour work schedule, per operating room, excluding emergency cases. In that eight hour work schedule, at the most, four major operations can be carried out, and if an optimal mix of operations is done, this can reach up to five-six operations per day .However, the operations department in most hospitals struggle with the problem relating to operation theatre’s optimum utilization, caused by system inefficiencies and human errors; there are delays and wastes, which act as bottlenecks for optimum utilization of operating rooms (Vinukondaiah, Ananthakrishnan, & Ravishankar, 2000).

Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry. Operation theatre utilization was studied with respect to the starting and closing of the operation theatre, interval between surgical procedures, cancellation of surgical procedures and reasons thereof. RESULTS: The operation theatre was functional for 279 days during the year of the study, and 1773 cases were operated (6.3 cases per day. The hospital, in question, also suffers from delay in scheduling operations as found out in interaction with operation theatre staff, which resulted in underutilization. Hence, this study is carried out with the following objectives:

  • To measure utilization of the operation theatre department
  • To identify the reasons for the delay when carrying out operations, and to improve the process by reducing them with Defining, Measuring, Analysing, Improving and Controlling (DMAIC) method.
Page(s) 101-107
URL http://dspace.chitkara.edu.in/jspui/bitstream/123456789/801/1/42009_JMRH_Ankit.pdf
ISSN 2393-8536, Online : 2393-8544
DOI http://doi.org/10.15415/jmrh.2018.42009

The Six Sigma methodology is a promising one to address problems concerning operation theatre efficiency. The study also establishes that support service departments, such as the housekeeping department, can play a vital role in improving the Operation Theatre utilization. Hence, adequate consideration should be given for goal-oriented policies and manpower assessment of the Operation Theatre department. Further, coordination between all the healthcare team members has prime importance for the departments optimal functioning. In this case study, it is found that if the patient from the Ward can be shifted one hour to the Operation Theatre prior to the commencement of the operation, it will reduce the delay in scheduling operations and for this, adequate beds should be there as pre-operative beds; coordination and communication between the Operation Theatre’s nurses and the Ward’s nurses should be strong and smooth. Similarly, smooth coordination between nurses in wards and the housekeeping staff, who are responsible for shifting the patient from the Ward to the Operation Theatre, is also very important.

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