Tsinukal Bezabih

ADDIS ABABA UNIVERSITY
ADDIS ABABA INSTITUTE OF TECHNOLOGY
SCHOOL OF MECHANICAL AND INDUSTRIAL ENGINEERING
INDUSTRIAL ENGINEERING CHAIR
QUALITY IMPROVEMENT OF HEALTHCARE THROUGH LEAN SIX

SIGMA: A CASE OF YEKATIT 12 HOSPITAL
BY
TSINUKAL BEZABIH
OCTOBER, 2019
ADDIS ABABA, ETHIOPIA
Tsinukal.B
QUALITY IMPROVEMENT OF
HEALTHCARE THROUGH LEAN SIX-
SIGMA: A CASE OF YEKATIT 12 HOSPITAL
BY TSINUKAL BEZABIH
ID NO: GSR/8179/09
A THESIS SUBMITTED TO SCHOOL OF GRADUATE STUDIES OF ADDIS ABABA

UNIVERSITY FOR THE PARTIAL FULFILLMENT OF MASTERS OF SCIENCE DEGREE IN
INDUSTRIAL ENGINEERING
ADVISOR: AMEHA.M (PHD)
CO-ADVISOR:GEZAHEGN.T(PHD) Oct, 2019
Tsinukal.B
QUALITY IMPROVEMENT OF HEALTHCARE THROUGH

LEAN SIX-SIGMA: A CASE OF YEKATIT 12 HOSPITAL
TSINUKAL BEZABIH
APPROVED BY BOARD OF EXAMINERS
Dr. YILMA TADESSE …………………… ……………………...
DEAN, SMIE SIGNATURE DATE
DR. AMEHA MULUGETA ……………………. …….……………….
ADVISOR SIGNATURE DATE
Dr. GEZAHEGN TESFAYE ……………………. ……………………..
CO ADVISOR SIGNATURE DATE
DR. ERMIAS TESFAYE ……………………. ……………………..
INTERNAL EXAMINER SIGNATURE DATE
DR. EPHREM GIDEY ……………………. ……………………..
EXTERNAL EXAMINER SIGNATURE DATE
Tsinukal.B
Author’s declaration
I hereby declared that this thesis entitled as Quality improvement of healthcare through lean six-
sigma: A case YEKATIT 12 hospital is my own research work. It has not been and will not be
submitted in whole or in part to another university for the award of any degree.
……………….. ………………..
Tsinukal Bezabih Signature Date
……………….. …………………
Dr.Ameha Mulugeta Signature Date
………………... …………………
Dr. Gezahegn Tesfaye Signature Date
Tsinukal.B
Abstract
Health care organizations are now facing different challenges that brought them to a decision to
obtain efficiency improvement, quality and cost reduction. The growth in health sectors access and
delivery in Ethiopia has been improved markedly in the last decade. Despite the improvement
made in expanding access to health sectors, the disease burden is still high and the service
utilization rate remains low. According to the study made by WHO patient satisfaction rate is 50%
and average length of stay is 6-7 days and patients are forced to spend a prolonged waiting time in
different service stations to get served. Uneven distribution of facilities, shortage of workforce and
complicated path flows are among the causes of this prolonged waiting time in public hospitals.
This research aims in experimenting the possibilities of process improvement opportunities in

YEKATIT 12 hospital by utilizing lean six sigma methodology. In doing so qualitative and
quantitative data collection tools and analysis tools have been used. A literature has been reviewed
and hospital documents are referred as a secondary source of data. Based on the literatures Yekatit
12 hospital is selected as a case hospital and based on the preliminary data assessment laboratory
service station is selected as a case area. Primary source data has been collected from patients,
laboratory technologists and management personnel’s.
Data has been analyzed by using the DMAIC framework of LSS. The DMAIC clearly shows the
existing system and the bottlenecks are clearly defined. In addition to DMAIC arena simulation
software have been used for analysis. Then a new process is developed by value stream mapping
and it is simulated by arena simulation software. The results after improvement show that Cycle
time of processes are reduced which directly reduces the prolonged waiting time within the
laboratory department. Therefore, it is safe to conclude that Lean Six Sigma can indeed be applied
for process improvement in Hospitals.
Key words: LSS, DMAIC, value stream mapping, process improvement
i
Table of contents
Contents
Table of contents ............................................................................................................................. ii
List of figures ................................................................................................................................. iv
List of tables ................................................................................................................................... vi
List of Abbreviation’s ................................................................................................................... vii
CHAPTER ONE ............................................................................................................................. 1
INTRODUCTION AND BACKGROUND ................................................................................... 1
1.1 Introduction ........................................................................................................................... 1
1.2 Problem Statement ................................................................................................................ 3
1.3 Research Questions ............................................................................................................... 4
1.4 Objectives of the Research .................................................................................................... 4
1.5 Scope ..................................................................................................................................... 4
1.6 Significance of the Study ...................................................................................................... 5
CHAPTER TWO ............................................................................................................................ 6
LITERATURE REVIEW ............................................................................................................... 6
2.1 Introduction ........................................................................................................................... 6
2.2 Definition and History of Lean manufacturing ..................................................................... 7
2.3 History and Definition of Six Sigma ..................................................................................... 8
2.4 Why Lean Six Sigma............................................................................................................. 9
2.5 Lean Six Sigma in service industry ..................................................................................... 11
2.6 Previous researches on lean six sigma in health sectors ..................................................... 14
ii
CHAPTER THREE ...................................................................................................................... 21
RESEARCH METHODOLOGY.................................................................................................. 21
3.1 Introduction ......................................................................................................................... 21
3.2 Research phases................................................................................................................... 23
3.3 Sampling technique and procedures .................................................................................... 30
CHAPTER FOUR ......................................................................................................................... 31
DATA PRESENTATION AND ANALYSIS .............................................................................. 31
4.1 BACKGROUND OF YEKATIT 12 HOSPITAL ............................................................... 31
4.2 Data collection results ......................................................................................................... 31
4.2 Data analysis ....................................................................................................................... 35
4.2 Discussion ........................................................................................................................... 71
CHAPTER FIVE .......................................................................................................................... 72
CONCLUSION AND RECOMMENDATIONS ......................................................................... 72
5.1Conclusion............................................................................................................................ 72
5.2 Recommendations ............................................................................................................... 74
5.3 Future Study area ................................................................................................................ 74
References ..................................................................................................................................... 75
ANNEX......................................................................................................................................... 80
iii
List of figures
Figure 1: Reviewed literatures based on objectives .................................................................................... 16

Figure 2: Methodological review ................................................................................................................ 17
Figure 3: Methodological review of Define stage....................................................................................... 17
Figure 4; Methodological review of Measure stage .................................................................................... 18
Figure 5: Methodological Review of Analyze stage ................................................................................... 19
Figure 7: EHRIG adherences of Addis Ababa Health Bureau Hospitals for the Past four years starting from
2012 ............................................................................................................................................................ 23
Figure 8: Research framework .................................................................................................................... 24
Figure 10: Interview Results ....................................................................................................................... 32
Figure 11: DMAIC framework(Source: Author’s Analysis) ...................................................................... 36
Figure 12: process Map of YEKATIT 12 Hospital(Source: Author’s observation) ................................... 36
Figure 13: SIPOC of laboratory department (Author’s) observation) ........................................................ 38
Figure 14: process mapping of the laboratory service station (Author’s observation) ............................... 39
Figure 15; Process mapping of urinalysis(Author’s observation)............................................................... 40
Figure 16: process mapping of stool analysis(Author’s observation) ......................................................... 41
Figure 17: process Mapping of CBC(Author’s observation) ...................................................................... 42
Figure 18: process mapping for Chemistry(Author’s observation) ............................................................ 43
Figure 19: VSM of chemistry (Author’s observation) ................................................................................ 45
Figure 20: VSM of urinalysis (Author’s observation) ................................................................................ 47
Figure 21: VSM of stool analysis (Author’s observation) .......................................................................... 49
Figure 22: VSM of CBC (Author’s observation)........................................................................................ 50
Figure 23: Ishikawa diagram....................................................................................................................... 52
Figure 24: Pareto for stool .......................................................................................................................... 53
Figure 25: Pareto for CBC .......................................................................................................................... 53
Figure 26: Pareto for chemistry .................................................................................................................. 54
Figure 27: Pareto for urine .......................................................................................................................... 54
Figure 28: Improved VSM of CBC............................................................................................................. 59
Figure 29: Improved VSM for Chemistry................................................................................................... 61
Figure 30: Improved VSM for Stool Analysis ............................................................................................ 63
Figure 31: Improved VSM for urinalysis .................................................................................................... 63
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Figure 32: Simulation of Urinalysis ............................................................................................................ 65
Figure 33: Simulation results of Urine ........................................................................................................ 66
Figure 34: Simulation results of chemistry ................................................................................................. 67
Figure 35: Simulation of Chemistry............................................................................................................ 68
Figure 36: Simulation results of stool Analysis .......................................................................................... 69
Figure 37: Simulation of stool Analysis ..................................................................................................... 69
Figure 38: Simulation of CBC analysis ...................................................................................................... 70
Figure 39: Simulation results of CBC ......................................................................................................... 70
v
List of tables
Table 1: Purpose Of Reviewed Literatures(Source: Author’s Analysis) .................................................... 15

Table 2 : Methodological Review Of Define Stage .................................................................................... 18
Table 3: Methodological Review Of Measure Stage .................................................................................. 19
Table 4: Methodological Review Of Analyze Stage................................................................................... 20
Table 8: Purpose Of Objective .................................................................................................................... 26
Table 5: Data Collection ............................................................................................................................. 27
Table 6: Analysis Used For The Research .................................................................................................. 29
Table 7: Software Used For The Research ................................................................................................. 29
Table 9: Complaints Of Patients ................................................................................................................. 33
Table 10: Time Measurement Results ........................................................................................................ 34
Table 11: Standard And Existing Time Of Laboratory Processes .............................................................. 51
Table 12: Control Chart For Cbc ................................................................................................................ 55
Table 13: Control Charts For Chemistry..................................................................................................... 56
Table 14: Control Charts For Urinalysis ..................................................................................................... 57
Table 15: Control Charts For Cbc ............................................................................................................... 58
Table 16: Simulation Results Of Urinalysis ............................................................................................... 64
Table 17: Simulation Results Of Chemistry ............................................................................................... 67
Table 18: Simulation Results Of Stool Analysis ........................................................................................ 68
Table 19: Simulation Results Of Cbc ......................................................................................................... 70
Table 20: Cycle Time Of The Before And The After ................................................................................. 71
vi
List of Abbreviation’s
CT -Cycle time
CTS-Critical to satisfaction
DMAIC- Define-measure-analyze-improvement-control
EHRIG- Ethiopian hospital reform implementation guideline
JIT-just in time
LAB -Laboratory
LSS -Lean six-sigma
LT - Lead-time
MOH -Ministry of health
NVA-Non-value adding activity
SPC-statistical process control

SS -Six-sigma
TPM -Total productivity management
TQM-Total quality management
VA-Value added activity
VSM -Value stream mapping
WHO-world health organization
vii
Acknowledgment
I have no words to praise the Almighty GOD, the Beneficent, the Merciful, whose infinite love,
Protection, blessings and mercy is abounding joy and source of my inspiration in completing all
My work and enabled me to pass all the ups and downs I faced during my work.
I would like to express my sincere and immense gratitude to my advisor Ameha Mulugeta(PHD)
and my co advisor Gezahegn.T (PHD) for providing their guidance and unwavering support. I
cannot express enough how thankful I am to Shimelis Tilahun (PHD candidate) for his continued
support and encouragement.
Despite the fact that so many people have helped me in so many different ways, it is very difficult
to list all them. Yet it is a must, at least, to thank those who have the lions share. Special thanks
must go to all members of the YEKATIT 12 Hospital Quality assurance and laboratory staff
members specially Ato. Deriso Furgasa, Ato Andualem Garedewu, W/ro Tigist Tola, Ato Mesfin
Tesema and Sister Betelehem Tsega, for their expert advice and extraordinary support in this thesis
and I would like to thank my colleagues for their wonderful collaboration and encouragement. You
supported me greatly and were always willing to help me.
Lastly and certainly not in the least, I would like to thank my family and my dearest friends the
deepest gratitude for offering their words of encouragement, undying support and patience. I could
not have done anything without them. God bless you all!
viii
Improving Quality Of Health Service Through Lean Six-Sigma
CHAPTER ONE
INTRODUCTION AND BACKGROUND
1.1 Introduction
Health Care organizations today are facing a new and unique set of challenges bringing them under
pressure to obtain efficiency improvements and cost reduction. Expenditures have grown steadily,
and budgets are increasingly being shortened while requested services and expected quality
continue to increase. To overcome these challenges in a sustainable way, Health Care
organizations need to improve their services in terms of costs, response times, and service quality
as well as resource utilization. Similar challenges occur also in other industries like manufacturing,
where Lean Management approaches showed promising results and potential in the reduction of
inefficiencies and in increasing value for the customer (Arcidiacono, 2017). Nowadays, in order
to improve the organization of care of patients with a specific clinical problem, health care facilities
use clinical pathways, which are structured multidisciplinary care plans. LSS, providing a
systematic approach, is an ideal tool to develop clinical pathways capable of achieving optimized
processes, which are continuously improved with plan – do – check –act cycles (Improta, Lean
Six Sigma: a new approach to the management of patients undergoing prosthetic hip replacement
surgery, 2015).
Costs and quality are two key points concerning the health care industry worldwide: one of the
major problems is to find a solution that allows to improve quality and to reduce costs. In
particular, Lean Six Sigma (LSS) methodology, thanks to the synergy of both Lean and Six Sigma
methodologies, is the most innovative and effective approach in terms of ‘Operational Excellence’.
LSS is a combination of Lean Thinking and Six Sigma aimed at the continuous improvement of a
production process through the push for speed and flexibility given by Lean Thinking and
statistical support provided by Six Sigma. Lean allows for speed and elimination of waste, Six
Sigma seeks quality understood as less variability in the results of process (Importa, 2015).
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Various business management strategies have been developed to improve the performance of
organizations by improving the processes by which they carry out their work. These strategies
include Lean and Six Sigma; aim to implement process improvements through a coordinated set
of principles and practices that promote greater efficiency and effectiveness, with fewer wasteful
practices or errors. Lean and Six Sigma are business management strategies commonly used in
production industries to improve process efficiency and quality (Mason, 2015).
Though initially used in manufacturing, LSS has been increasingly gaining acceptance in the
healthcare industry, which faces many of the same issues and challenges--how to reduce waiting
time, how to increase capacity, how to best deploy resources, etc (Kuo, 2010).
Where the strength of Lean lies in providing a set of proven techniques for eliminating waste, Six
Sigma provides a structured methodology based on quantitative analysis for carrying out and
sustaining Lean initiatives (or any other initiative for that matter). Lean and Six Sigma thus
complement each other in driving process improvement. The standard Six Sigma methodology for
process improvement is called the DMAIC process (Yeh, 2011).
Despite major strives to improve the health of the population in the last one and half decades,
Ethiopia’s population still face a high rate of morbidity and mortality and the health status remains
relatively poor and the service delivery system is poor even when compared to sub Saharan
countries (Ethiopia, 2010). The growth in health sectors access and delivery in Ethiopia has been
improved markedly in the last decade. Despite the improvement made in expanding access to
health sectors, the disease burden is still high and the service utilization rate remains low. In
addition, nothing has been done to analyze and improve the hospital settings using the LSS
methodology.
This research proposes the synergistic combination of Lean and SS for process improvement. It
aims to experiment the LSS methodology to improve the efficiency and effectiveness of the
process.
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1.2 Problem statement
According to WHO in any health system, good health services are those that deliver effective, safe
and good quality personnel and personal care to deliver to those that needed it, when needed with
minimum waste. Ethiopia is among 57 countries in the world identified by WHO to be facing a
critical shortage of health workforce. The customer satisfaction rate is 50% and average length of
stay is 6-7 days. The pharmaceutical department faces 8.24% of stock wasted due to expiry and
procurement lead time is 240days (Ethiopia, 2010). The shortage of facilities, uneven distribution
of facilities and workforce, poor skill mix and service utilization and high attrition of trained health
professionals remain the major concerns of the country. The health care delivery is so poor even
when compared to the sub-Saharan counties (Ethiopia, 2010). There is a prolonged waiting time
to get served in every service stations, a fragmented workflow, incorrect and incomplete
documentation, excessive motions because of incorrect floor layout and inappropriate placement
of hospital utensils and because of this both patients and employees of the hospital are forced to
expend extra time searching for information. There is also high process variation because of
patients that get served without joining the queue, because of un automated instruments and
improper process flows.
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1.3 Research questions
1. What is the severity and the contributors of waste in YEKATIT 12 hospital?

2. How can we control process variation in YEKATIT 12 Hospital?
3. How can LSS helps to eliminate or minimize wastes and process variation in YEKATIT
12 hospital in order to improve service quality?
1.4 Objectives of the research
General objective
To experiment the possibilities of process improvement opportunities in YEKATIT 12 hospital

through lean Six-Sigma methodology to increase the service quality of the hospital.
Specific objectives
 Analyzing the existing system to clearly identify the wastes and the causes of the process
variation in the hospital
 To determine the value and non-value adding processes in YEKATIT 12 hospital
 To develop a framework by using six sigma DMAIC procedure to understand and Improve
the process
 To develop ways to control the process variation in YEKATIT 12 hospital
 Developing a new model by arena simulation software and measuring the performance of
the newly improved system in terms of time.
1.5 Scope
This research investigates the use of lean Six-Sigma methodology in YEKATIT 12 hospital and it
develops a way to minimize waste and process variation within the hospital. Thus, in this research
the existing system is analyzed and solutions for process improvement are given by using the LSS
methodology. Because of the time given for this research YEKATIT 12 hospital is selected as a
case among the thirteen public hospitals in Addis Ababa and because of the complexity of the
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system only one case area is selected and the reason why this hospital s selected is explained in
detail in other session of the research.
1.6 Significance of the study
This research will benefit the hospital by reducing costs and increasing revenues and also increase
the performance of the hospital by different performance metrics through waste reduction, defect
minimization and minimization of process flow time. Minimization of process complications also
benefits the employees by reducing overloads and unnecessary motions. And mainly it benefits
the main victims of poor health service delivery those are patients by reducing the prolonged
queues the face during their stay with in the hospital in various services stations.
The findings of this research will also be used as an input for different researchers in different
institutions who will be interested in this particular area.
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CHAPTER TWO
LITERATURE REVIEW
In this literature review different articles, reviews, manuscripts, case studies and reports are
reviewed to get a thorough knowledge on the area under study. The literature reviews mainly
focused on lean, Six Sigma, and the importance of integrating lean and six-sigma, application of
lean and Six Sigma in healthcare and previous studies on lean Six Sigma in healthcare sector. As
a result, the literature gaps are being identified, areas that need further researching, and the
importance of this particular research is identified.
2.1 Introduction
The concept of lean Six Sigma has been used in different manufacturing industries. Though
initially used in manufacturing LSS has been increasingly gaining acceptance in the healthcare
industry, which faces many of the same issues and challenges. Both these concepts lean and Six
Sigma came from quality but Six Sigma was founded by Motorola Corporation and subsequently
adopted by many US companies, including General Electrical GE and Allied Signal. Lean
management originated at Toyota in Japan and has been implemented by many major US firms,
including Danaher Corporation and Harley-Davidson. Six Sigma and lean management have
diverse roots. As Sharon and Allard (2010), lean (also known as Lean Production, Lean Enterprise,
and Lean Thinking) involves a set of principles, practices, and methods for designing, improving,
and managing processes.
Six-Sigma is a data-driven process improvement methodology used to achieve stable and
predictable process results, reducing process variation and defects. Six-Sigma is defined as: “a
business strategy that seeks to identify and eliminate causes of errors or defects or failures in
business processes by focusing on outputs that are critical to customers” (Nicoletti, 2013).
Both Lean and Six Sigma emerged as business improvement philosophies in the late
1990’s and at that time, many practitioners were set on differentiating one
methodology from the other. Today, most practitioners will agree that the two
methodologies complement one another and when the statistical approach is used in
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conjunction with waste elimination techniques, the improvement philosophy is more

versatile and complete. Hence, today many publications refer to the philosophy as ‘Lean
Six Sigma (Scachitti, 2008).
Even if those two concepts used extensively in manufacturing industries at the past now they are
dragging high attentions to the service industries especially at the health care sector. Therefore,
this review examines different literatures regarding lean six sigma, their tools and techniques and
the possible literature gaps.
2.2 Definition and history of lean manufacturing

Among the several quality management concepts that have been developed, the lean concept is
one of the more widespread and successful attempts. The concept was introduced at a larger scale
by Toyota in the 1950s (Kulkarni et al, 2010). The lean philosophy Lean manufacturing extends
the scope of the Toyota production philosophy by providing an enterprise-wide term that draws
together the five elements of “the product development process, the supplier management process,
the customer management process, and the policy focusing process for the whole enterprise”
(Peeper and Spedding,2009). Lean management emphasizes on eliminating waste so that all
activities along the value stream can create value. It focuses on the reduction of waste and pursuing
continuous improvements. Thus, a core element of Lean management is the distinction between
value-adding and non-value-adding activities (Huang et al., 2013). So lean is generally understood
as to represent a systematic approach to identifying and eliminating elements not adding value to
the process. Consequences of this are striving for perfection and a customer-driven pull of the
process (Kulkarni et al, 2010).
Lean tools and techniques
Lean principles are fundamentally customer value driven, which makes them appropriate for many
manufacturing and distribution situations. Five basic principles of lean manufacturing are
generally acknowledged:
1. Understanding customer value: Only what the customers perceive as value is important.
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2. Value stream analysis: Having understood the value for the customers, the next step is to
analyze the business processes to determine which ones actually add value. If an action
does not add value, it should be modified or eliminated from the process.
3. Flow: Focus on organizing a continuous flow through the production or supply chain rather
than moving commodities in large batches.
4. Pull: Demand chain management prevents from producing commodities to stock, i.e.
customer demand pulls finished products through the system. No work is carried out unless
the result of it is required downstream (Kulkarni1, 2010).
5. Perfection: The elimination of non-value-adding elements (waste) is a process of
continuous improvement. “There is no end to reducing time, cost, space, mistakes, and
effort” (Kulkarni et al, 2010).
Lean principles do not always apply, however, when customer demand is unstable and
unpredictable. The main elements contributing to the elimination of non-value-added activities are
the following: excess production, excess processing, delays, transport, inventory, defects, and
movement. Varieties of approaches are available for reducing or eliminating waste. These
approaches include value stream analysis, total productive maintenance, Kaizen costing and cost
analysis, engineering and change management, and document management. Tools used include
Kanban cards for pull through the supply chain and the closely related JIT system for inventory
reduction (Kulkarni et al, 2010).
2.3 History and definition of six sigma

From managerial point of view, Six Sigma is defined as improving the profitability, effectiveness,
and efficiency of all operations to meet or exceed customer’s needs and expectations by identifying
and removing the cause of defects or errors and minimizing variability. From statistical point of
view, Six Sigma is defined as having less than 3.4 defects per million opportunities or a success
rate of 99.9997%, where sigma is a term used to represent the variation about the process average
(Huang et al., 2012). Six-Sigma could also be described as an improvement program for reducing
variation, which focuses on continuous and breakthrough improvements. Improvement projects
are driven in a wide range of areas and at different levels of complexity, in order to reduce
variation. The main purpose of reducing variation on a product or a service is to satisfy customers
(Anderson et al., 2006). The fundamental principle of Six Sigma is to take an organization to an
improved level of sigma capability through rigorous applications of statistical tools and techniques.
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With additional innovations that enhance its effectiveness while expanding its focus, Six Sigma
today has become a systematic and data-driven approach to using the define, measure, analysis,
improve, and control (hereinafter DMAIC) process and utilizing design for six sigma method.
More comprehensive than prior quality initiatives such as TQM, Six Sigma methodology includes
measured and reported financial results, uses additional and more advanced data analysis tools,
focuses on customer concerns, and uses project management tools and methodologies (Huang et
al., 2012).
Six sigma tools and techniques
There are usually many different improvement tools used in a six-sigma program. The six-sigma
toolbox contains the seven design tools, the seven statistical tools, the seven project tools, the seven
lean tools, the seven customer tools, the seven quality control tools and the seven management
tools. The tools are often easy to use in both ongoing and breakthrough improvement projects, but
there are also some more advanced statistical tools in the toolbox (Anderson et al., 2006).
There are two major improvement methodologies in Six Sigma, DMAIC for already existing
processes and DMADV for new processes. DMADV is often used when the existing processes do
not satisfy the customers or are not able to achieve strategic business objective. Both
methodologies have five phases (Kulkarni et al, 2010).
DMAIC provides data-driven practices and tools for improving, optimizing, and stabilizing
business processes and designs. Hence it can support Super network framework both in the
problem definition phase (where DMAIC can help in identifying causes mainly affecting patient
flow) and problem analysis phase (where DMAIC may support in validating outcomes from the
optimal problem solution) (Cirrone et al., 2015).
2.4 Why lean six sigma

Generally, lean has the advantages of standardized solutions to common problems and its focus on
the customer. Lean seeks to prevent the sub-optimization by its focus on the entire value chain.
However, Lean is weak on organizational infrastructures, deployment plans, analytical tools, and
quality improvement and control. Six-Sigma, on the other hand, offers a structured, analytic, and
logically sound approach to problem solving, as well as a strong organizational framework for its
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deployment. It deploys problem-solving strategies through DMAIC process, and offers an option
to sub-optimization. It is characterized by its customer-driven or project-by-project approach,
emphasis on decision-making based on careful analysis of quantitative data, and a priority on cost
reduction. One perceived weakness of Six Sigma method is its complexity. In the case of simple
problems with obvious and easy-to-implement solutions, rigorous adherence to the Six Sigma
problem-solving process (DMAIC) may be considered “overkill” and inefficient. Furthermore, Six
Sigma typically does not resort to standard solutions to common problems as Lean does. Finally,
sub-optimizing a process sometimes will jeopardize the entire value chain due to failing to consider
entire system. Thus, the ideal solution is to combine the two approaches. In the following sections,
we introduce the integration of Lean management and Six Sigma and how it will work for
healthcare sector (Huang et al., 2012).
Lean and Six Sigma have complementary benefits. For integration, Lean may use the management
structures that Six Sigma offers. For example, Six Sigma’s DMAIC approach provides an effective
embedding framework to apply Lean principles. Further, Lean does not analyze the economic
performance indicators of a process to establish where the main points of improvement are, but
focuses on inefficiencies in the process flow, even if that is not where the main opportunities for
improvement are. Six Sigma’s DMAIC method offers a thorough roadmap for analysis and
diagnosis, driven by powerful tools and techniques. However, Six Sigma is a general problem-
solving framework. Given the ubiquity of process inefficiencies, Six Sigma projects can benefit
from the standard solutions that Lean offers. The key to a successful integration of Lean and Six
Sigma is to regard Six Sigma’s project management and its DMAIC method as a general
framework for problem solving and process improvement, but within this framework, Lean’s
standard solutions and mindset should find their places. Thus, the value stream map could be found
as one of tools used in DMAIC steps of designing improvement actions and improving quality
control systems (Koning et.al, 2006)
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Lean Six sigma

Offers a structured, analytic and
Focuses on the entire value chain logically sound approach to
Gives a standard solution to problem solving
common problems and focus on strong organizational
customers framework for deployement
Lacks methods for diagonisis offers an option to sub
Doesn't have economic otimization
indicators cost reduction
Eliminate process variation
Integration
Six sigma’s DMAIC approach

provides an effective embedding
framework to apply lean principles
Figure 0: Integration of lean and six-sigma (source Author’s analysis)
2.5 Lean six sigma in service industry

Lean Six Sigma has been initially used in manufacturing industries. However, recent researches
show that it can also be applied in service industries Such as in healthcare sectors, banking,
financial services, utility services, and others. In health sectors, it is applied to increase throughput,
decrease cost and to minimize poor patient safety due to high medication, and to decrease high
waiting time in different service stations. In banking systems, LSS is applied to reduce customer
complaints and to reduce excessive market loses as well as cost. In financial services, it has been
applied to reduce high administrative costs. In utility services it is applied to minimize poor service
delivery, to minimize high contract complains which resulted in customer dissatisfaction and high
costs.
According to Laureani (2009), the service industry has its own special characteristics, like its
intangibility, Perishability, Inseparability and variability that differentiate it from manufacturing
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and make it harder to apply Lean Six Sigma tools. However, there are also great opportunities in
the service organizations (George 2003):
 Empirical data has shown the costs of services are inflated by 30–80% of waste.
 Service functions have little or no history of using data to make decisions. It is often
difficult to retrieve data and many key decision-makers may not be as ‘numerically literate’
as some of their manufacturing counterparts.
 Approximately 30–50% of the cost in a service organization is caused by costs related to
slow speed, or carrying out work again to satisfy customer needs.
Lean six sigma in healthcare
Lean Sigma is a process of combining Six Sigma quality with Lean speed. Overall Lean Sigma
incorporates Lean’s principles into Six Sigma’s improvement process itself to increase the speed
of improvement projects and results. Lean Sigma also incorporates Six Sigma’s view of the evil
of variation and reduces its impact on the lead-time and process speed. Finally, Lean Sigma has
unique advantage of recognizing that unnecessary complexity adds costs, time, and enormous
waste to the process (Koning et al., 2006).
Health care is a complex business, having to balance continuously the need for medical care and
attention to financial data. It offers pocket of excellence, with outstanding advances in technology
and treatment, together with inefficiencies and errors (Alessandro, 2010). Patient care significantly
involves human element as compared to machine elements, in which the variability is subtle and
very difficult to quantify. Therefore, challenge in adopting Six Sigma approach to healthcare is to
find a way to leverage the data from Six Sigma to drive human behavior (Jayanta K. and Karen.C,
2005).
Health care organizations, especially large health systems, began studying and adopting industrial
quality management methods in the late 1980’s including TQM and CQI approaches. Early
applications focused primarily on establishing programs and infrastructure to measure quality and
enhancing organizational culture surrounding quality issues. Lean and Six Sigma “emerged from
the fertile environment” created by TQM. Recent applications of Lean and Six Sigma in health
care attempt to improve on previous experiences with TQM by making project deliverables more
Tsinukal.B Page 12
discrete and measurable, retaining a strong customer (rather than organizational) focus,
quantifying results, and attempting to deliver specific quality improvements within a designated
time frame (Sharon and Allard, 2010).
Baltimore (2015) describes that different researches has been made regarding the application of
lean Six Sigma in USA, Scotland, Turkey, Netherlands, USA, Ireland and Taiwan. According to
Baltimore (2015), most of the researches are made in USA as well as the applicability. These
researches are made to reduce cycle time, for defect reduction, quality improvement, cost
reduction, and waste minimization.
Lean Six Sigma can be applied in different service station within the hospital for different
purposes. According to Alessandro(2010) Lean Six Sigma projects so far in the health-care
literature have focused on direct care delivery, administrative support and financial administration
with projects executed in different process like to increase capacity in x-ray room reducing
avoidable emergency admissions , improving day case performance ,improving accuracy of
clinical coding ,improving patient satisfaction in Accident and Emergency, reducing turn-around
time in preparing medical reports, reducing bottle necks in emergency departments , reducing cycle
time in various inpatient and outpatient diagnostic area, reducing number of medical errors and
hence enhancing patient safety ,reducing errors from high-risk medication, increasing accuracy of
laboratory results, reducing lost MRI films , improving turn-around time for pharmacy orders ,
improving nurse or pharmacy technician recruitment , improving operating theatre throughput ,
increasing surgical capacity , reducing length of stay in A&E , reducing A&E diversions ,
improving revenue cycle, reducing inventory levels ,improving patient registration accuracy and
to improve employee retention.
Those researches shows that lean Six Sigma can bring a dramatic change in health sectors
especially in countries like Ethiopia in which there is high scarcity of resources, the available
resources are not utilized, complicated systems, high wastage etc.
Tsinukal.B Page 13
2.6 Previous researches on lean six sigma in health sectors
Different studies have been conducted on the application of lean Six Sigma in both manufacturing
and service industries. In addition, countries around the globe tried to implement this concept.
Yeh et al (2011) claims that LSS can be implemented to improve the process of hospital.
According to them LSS can provide a powerful process improvement solution. Their study applies
LSS to improve the medical process of acute myocardial infarction. The ‘define, measure, analyze,
improve, and control steps’ of SS find critical-to quality factors and draw the value stream map to
seek out non-value-added activities. The cause and effect diagram is also employed to analyze the
root causes of waste and generate the improvement project by brainstorming. Eliminating waste
raises the process cycle efficiency. Cycle time of the improved door-to-balloon process decreased
by 58.4% and even became less than the ACC/AHA standard (90 min). Process cycle efficiency
increased from 32.27 to 51.81%, and the average days of hospital stay decreased by 3 days. Such
effects helped save NT$ 4.422 million in medical resource. The study results indicate that LSS not
only improved medical quality but also strengthened market competitiveness.
Yara et al. (2015) used the lean six-sigma methodology to Decrease the dispatch time of medical
reports sent from hospital to primary care. And in order to achieve the objective the DMAIC
roadmap have been used and as a result the reasons for the prolonged waiting time was identified
and After implementation, 90.6% of the reports were dispatched on the day of the visit.
A study made in Italy shows that the lean six-sigma methodology can be applied to patients
undergoing prosthetic hip replacement surgery to reduce the prolonged length of stay and the time
is reduced by 44%. In doing so the DMAIC roadmap has been used.
Again, another study made by Montella et al (2016) in Italy showed that the lean six-sigma
methodology could be applied to reduce the risk that patients are facing. Data has been collected
from 20, 000 patients who underwent a wide range of surgical procedures and the pre intervention
and post intervention phases were compared to analyze the effects of methodology that was
implemented. As a result, the average hospitalization days have been reduced.
A study conducted in India by Antony (2013) addressed the use of lean six-sigma methodology to
reduce patient waiting time in outpatient department. In this case, employees were forced more
than the working time because of the prolonged waiting time. As a methodology, the DMAIC
roadmap has been used along control charts, cause and effect diagram, normality test and other
Tsinukal.B Page 14
statistical quality control tools. As a result, the waiting time has been reduced from 54minutes to
24.5 minutes and the standard deviation was reduced from 9.27minutes to 31.15minutes.
Summary of reviewed literatures
The reviewed literatures are articles, case studies, reports and reviews from different websites.
Generally, 78 literatures are reviewed for this research. However, only 27 literatures were directly
related to the case of this research. These 27 literatures are analyzed and discussed based on their
methods and structures and based on their objectives.
Summary of literatures based on their objectives

Based on the purpose of the studies the reviewed literatures are categorized as follows:
No Authors Objective of the study

1 Yara L, et al., (2015), Hseng, et al., (2011), Sandy, et Process improvement
al., 2011, Mehmet, et.al.,(2013), Jeroen, et al.,(2011),
Ahmed,(2017), Susan, et al., (2014)
2 Patricia, et al., (2016), Rahul, (2014), David, (2011) Waste reduction
3 (Federico Barnabè, 2016) To maximize productivity
4 Emma, et al., (2016), Andrea, (2012) Risk reduction
5 E.V Gijo, et al., (2013), Mathew, (2016), Gloria, et al., Reduction of prolonged waiting
(2010) time
6 De.Lama, et al., (2013) , Berna, (2010), Gloria, et al., Maximizing efficiency
(2010)
7 Nabeel, et al., (2011) Increasing productivity
8 G.Muthukumaran, et al., (2013), Sara, (2017) The advantage of integrating
lean and six sigma
9 Barabe, (2016) Performance evaluation
10 G.Importa, (2015) Cost reduction
Table 1: purpose of reviewed literatures(source: Author’s analysis)
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REVIEWED LITERATURES BASED

ON OBJECTIVES
Reduction of complexity of the process 7
Risk reduction 2
OBJECTIVES
Advantage of integrating lean and six sigma 2
Cost reduction 2
Performance evaluation 1
Waiting time reduction 13
0 2 4 6 8 10 12 14
NUMBER OF LITERATURES
Figure 1: Reviewed literatures based on objectives
Those researches resulted with different outcomes by using the concept of lean six-sigma
methodology. They are able to reduce cycle time and maximize process cycle efficiency, reduced
average length of stays during hospitalization, decrease dispatch time, minimize the prolonged
waiting times in different service stations and reduce the risks that patients are facing inside the
hospital. They are also able to reduce costs, optimize patient flow, minimized patients risk and
able to improve quality of service. They also deduce that lean six sigma can bring a significance
difference if it got applied in health sectors and it can able to strengthen market competitiveness.
Hospitals have different wastes but most of the reviewed literatures are concerned on waiting time
reduction and inappropriate processing. The researcher agrees this wastes have a high impact on
the service delivery as well as on the profitability of the hospital but the other wastes also needs
high attention as well as these ones. Therefore, this research focuses on waste of unnecessary
motions too other than inappropriate processing and waiting time.
Methodological review of literatures

Among the 27 literatures that has been reviewed three of them are reviews which explains about the use of
lean six sigma in health care sector. The next five literatures are case studies, which do not use any
six-sigma framework. However, in order to analyze and understand the process these literatures
used SIPOC, value stream mapping, cause and effect diagram and brainstorming.
Tsinukal.B Page 16
LITERATURES WITHOUT SIX SIGMA FRAMEWORK
BRAIN STORMING
CAUSE A ND EFFECT DIAGRAM
PROCESS MAPPING
SIPOC
VSM
0 1 2 3 4
Figure 2: Methodological review
The remaining 17 literatures use case studies illustrate the application of lean six sigma for process
improvement using the DMAIC roadmap of six-sigma along with lean tools. In doing, so all
literatures used different ways of integration.
Under the define stage of DMAIC the researchers used critical to quality, SIPOC, pareto analysis,
cause and effect diagram, process flow and FMEA to define and select the project.
DEFINE STAGE
Pareto 1
cause and effect 1
process flow 4
CTQ 12
SIPOC 9
0 2 4 6 8 10 12 14
SIPOC CTQ process flow cause and effect Pareto

Figure 3: Methodological review of Define stage
Tsinukal.B Page 17
Methods Steps
CTQ (5) Pareto (1)
SIPOC (1)
SIPOC(1) Process mapping
SIPOC(1) CTQ(4) Process mapping (1)
Cause Process mapping (1) SIPOC
and effect FMEA(1)
Pareto
Process SIPOC
flow
Table 2 : Methodological review of Define stage
Under the measure phase of DMAIC CTQ, time measurement, fishbone diagram, process
mapping, cheek sheet, histogram, control charts, SIPOC and VSM has been used.
MEASURE STAGE
HISTOGRAM 1
CHEEK SHEET 1
CAUSE AND EFFECT 3
SIPOC 1
PROCESS MAPPING 3
TIME MEASUREMENT 11
CTQ 6
0 2 4 6 8 10 12
CTQ TIME MEASUREMENT PROCESS MAPPING

SIPOC CAUSE AND EFFECT CHEEK SHEET
HISTOGRAM
Figure 4; Methodological review of Measure stage
Tsinukal.B Page 18
METHODS STEPS
CTQ Time measurement (2)
Cause and effect diagram
Histogram
TIME Control charts

MEASUREMNT
(5)
CHEEKSHEET Check sheet
PROCESS MAP CTQ Time measurement
Time measurement
VSM Cause and effect diagram
CTQ
SIPOC Process mapping Cause and effect
Table 3: Methodological review of Measure stage
During analyze stage value stream mapping, cause and effect diagram, pareto, histograms, control charts,
time measurement, brainstorming and FMEA has been used.
ANALYZE STAGE
Time measurement 1
Histograms 1
FMEA 1
pareto 3
control charts 3
cause and effect diagram 6
VSM 10
0 2 4 6 8 10 12
VSM cause and effect diagram control charts

pareto FMEA Histograms
Time measurement
Figure 5: Methodological Review of Analyze stage
Tsinukal.B Page 19
Methods Steps
VSM (5) Cause and effect diagram (2)
Control charts
Pareto
Cause and effect VSM (2) Control charts (2)
diagram
FMEA Cause and effect diagram Pareto analysis
Control charts Histogram Chi square
Pareto Control charts
Time
measurement
Brainstorming Cause and effect diagram
Table 4: Methodological review of Analyze stage
From the above collection of literatures, it can be concluded that different researches have been
done on the application of lean Six Sigma in healthcare. Most of the researches have been focused
on minimizing the prolonged waiting time during hospitalization in different service stations. This
shows how much long waiting time in hospitals is affecting the quality of health care sector. Most
of the reviewed literatures lacks integration between the tools, redundant use of methods and value
is defined by the customers. Based on the methodological review of the literature the researches
develops a framework that can able to address the problems of YEKATIT 12 hospital by filling
the gaps which are mentioned above.
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CHAPTER THREE
RESEARCH METHODOLOGY
3.1 Introduction
This chapter discusses the methods in which data is being collected and analyzed. Both qualitative
and quantitative data collection and analysis methods are being used in this research. Data has
been collected by direct observation, by interviewing patients, through Questionnaires and time
measurement. Management personnel’s, laboratorians and patients were the sources of data for
this research study. It also explains how the case is selected among different public hospitals in
Ethiopia and how the research is organized starting from the preliminary assessment and
observation to the extermination by Arena simulation software. Mainly the research study has two
main parts, system analysis or the ASIS and the about to be improved system which is the TO-BE.
Both are analyzed by the DMAIC framework of LSS. Under the ASIS, the existing process of the
hospital is analyzed by value stream mapping to differentiate the value and the non-value adding
activities in the existing system, pareto study, time measurement, cause and effect analysis and
etc. Those tools clearly showed where the bottlenecks exist within the process and the areas that
needs major improvement. QI Macros and arena simulator software’s are also used for analysis
and improvement. In addition, problems related to process variation are clearly defined under the
define stage of the DMAIC framework. Under the TOBE process, solutions are given for the
bottlenecks, being identified on the ASIS and the newly improved process is simulated to measure
the performance of the new system. Purposive sampling is used as a sampling method and data
has been collected from 304 patients from each department.
Case hospital selection:
Ethiopia has a three-tier system of primary, secondary and territory care. The territory care system
includes specialized hospitals, which are expected to cover a population of 3.5-5millions, and
Black Lion Hospital is the only territory care hospital in the country. The secondary hospitals
include general and primary hospitals with an expectation of covering a population of 1-
1.5millions and at last, the primary care system includes rural and urban health sectors with an
expectation of covering 10,000-25,000 population. Depending on the number of patients to be
treated on those care systems, the concern of this research is public hospitals.
Tsinukal.B Page 21
There are twelve public hospitals in Addis Ababa, and those hospitals are mainly categorized into
two, which are federal hospitals and health bureau hospitals.
o ALERT Hospital
o St. Amanuel Hospital
o Armed forces Hospital
o Black lion Hospital
o GANDI Memorial Hospital
o MENELIK II Hospital
o RAS DESTA Hospital
o St. Paul’s Hospital
o St. Peter Hospital
o YEKATIT 12
o ZEWDITU Memorial Hospital
According to The Ethiopian health center reform implementation guideline(EHRIG) the

performance of these hospitals is assessed independently based on 124 hospital management
standards. Some of these hospitals are under the federal ministry of health and some of them are
under Addis Ababa health Bureau. Hospitals under federal are TIKUR ANBESA referral hospital,
St. PAWLOS, ST. PETER, Amanuel and Alert. Whereas hospitals under Addis Ababa health
bureau are GANDI, MENELIK, YEKATIT 12, RAS DESTA, ZEWDITU and TIRUNESH
Beijing. Among those hospital TIKUR ANBESA and St. PAUL gives services for highly
complicated cases. Hospitals like Alert, St. Amanuel, St. Peter give specialized services. The
researcher considers versatility as a case selection criterion so these hospitals aren’t selected as a
case for this research study.
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Figure 6: EHRIG adherences of Addis Ababa Health Bureau Hospitals for the Past four years starting from 2012
(WOLDEGEBRIEL, 2016)
The EHRIG includes 124 hospital management standards that assess 13 functions, namely,
leadership and governance, patient flow, medical records management, pharmacy services,
laboratory services, nursing care, infection-prevention, facilities management, medical equipment
management, financial and asset management, human resource management, quality management
and monitoring and reporting. By assessing those functions of the hospital, the report shows that
YEKATIT 12 Hospital has the lowest performance, which is below 75%. From the listed functions
patient flow, medical records management, facilities management and quality management are the
concerns of this research. So based on this data YEKATIT 12 hospital is selected as a case hospital.
3.2 Research phases
Research Framework
A preliminary assessment is done to have a general overview about the hospital. Following the
preliminary assessment, a problem statement is stated with an objective of investigating process
improvement in Yekatit 12 hospital through lean six sigma methodologies. The research
framework shows how this research went through starting from the preliminary assessment and
Tsinukal.B Page 23
observation to the last experimentation by arena simulation software. The framework shows how
data has been collected, analyzed and what tools are deployed for the improvement.
Figure 7: Research framework
Data collection
Both qualitative and quantitative data collection methods are employed for this research as well as
both primary data sources and secondary data sources have been employed for this research. As a
primary sources direct observation, questionnaires, semi structured interviews and time counting
are used. In addition, as a secondary data source by different literatures, journals, reviews, reports,
hospital documents and visual aids are referred.
Literature review
Different articles, reviews, journals, case studies and reports are reviewed in the literature review
to get a thorough knowledge on the research area being studied. The literature reviews mainly
focused on lean manufacturing, Six Sigma, and the importance of integrating lean and Six Sigma,
application of lean and Six Sigma in healthcare and previous studies on lean Six Sigma in
Tsinukal.B Page 24
healthcare sector. As a result, the literature gaps are being identified, areas that need further
researching and the importance of this particular research is identified.
Observation: In this part, the observed variables are how the process is organized and prioritized,
the process flow, the value stream map, number of queues, assignment of professionals, number
of beds, pharmacy stocks, laboratory supplies, and the queue structure and so on. By observing all
this variables, a value stream map is done to diagram and document the patient flow, information
flow or flow of supplies in order to see where value is being added and waste is occurring. In order
to observe some of the variables instruments like Video camera and stopwatch is used.
Interview: A semi structured interview is prepared to define the areas to be explored in the
hospital. The interviewees are patients, physicians, nurses, receptionists, laboratorians and so on.
Interview structure
A semi structured interview is prepared based on the literature review. The interviews have three
parts and they are designed to meet the first two objectives of the study.
Part I: This part of the interview is prepared to conduct general information about the hospital. It
includes questions about how the existing system of the hospital is structured, number of service
stations with in the hospital and so on. These interviews are prepared for the management
personnel’s.
Part II: This part of the interview is prepared to assess the possible areas of wasteful activities
within the hospital and it is prepared for employees of the hospital.
Part III: This part of the interview is prepared to know the reasons of patient’s dissatisfaction
based on quality of services being provided by the hospital. Needs of patients are also assessed.
Tsinukal.B Page 25
No Main objectives Interview contents

1 To know how the existing Part I
system of the hospital is o Number of employees
structured o Number of equipment’s
2 To determine wasteful Part II
activities within the o What are the wastes within the laboratory
hospital department?
o How do you measure them?
o Is there any recorded data?
3 To determine causes of Part III
patient dissatisfaction and o Responsiveness
needs of patients o Timeliness
o Delivery characteristics
Table 5: purpose of objective
Time study: The time that it takes to get served with in the care units is recorded using stop watch
in order to calculate the service time and arrival rate of patients.
No Type of data Necessity Source of data

collection
1 Observation To know how the process is organized and Different service stations
prioritized, value stream mapping, number within the hospital
of queues, arrival and service time of
patients, laboratory supplies, queue structure
2 Interview To have an overview of what the hospital is Management personnel’s,
lacking and what measures should have been patients and hospital
taken employees
To assess how the process is organized and
how operations are being carried out within
the laboratory department
Tsinukal.B Page 26
3 Questionnaire To understand the voice of Patients

patients
4 Time study To get measurements of arrival and service Patients
time of patients
Table 6: Data collection
Data analysis
Both qualitative and quantitative data analysis methods are employed for this research. The
analysis methods which are employed for this research are:
As described on the previous chapters Six Sigma’s DMAIC roadmap is used along with lean tools
for process improvement. The first stage of DMAIC is Define, with the purpose of selecting and
defining a problem. So at this stage SIPOC is used to understand the inputs, the outputs and the
process in general. In this stage the general process map of the hospital is drawn and CTQ is
defined.
The second stage of DMAIC is intended quantify and refine the problems. On this stage process
mapping, time study, Pareto analysis and value stream mapping are used. From the methodological
reviews in the previous chapter a DMAIC roadmap is framed for this research based on the
requirement of the hospital.
Those tools help to narrow down the problem and to determine value adding activities and non-
value adding activities (wastes) within the processes. Under the time study, the researcher used a
stopwatch to record the time patients are forced to spend to be served.
The third stage of DMAIC helps to understand the causes of the problems that are being identified
on the second stage from different directions. In addition, the control charts use the data from the
time study to analyze the current performance of the process in terms of process capability and
sigma level.
The fourth stage of DMAIC uses mainly lean standard tools for problem solving Under this stage,
the researcher redesigned the process in a way to insure optimal use of resources. Layout
arrangements, time standardization using time study and developing a new value stream mapping
are parts of this stage.
Tsinukal.B Page 27
Finally, at the control stage of DMAIC the researcher recommends to use control charts to measure
the process capability of the improved system. In addition, Arena simulation software is used to
measure the performance of the newly improved system in terms of time. Generally, the tools
which are used in this research are summarized on the table below.
No Data Inputs for analysis Necessity Expected results

analysis
tools
1 CTS Response of questionnaires and To understand the Patients complaints
interviews from patients voice of the patients
2 Pareto Ishikawa diagram To prioritize Definition of major
analysis problems factors of process
variation
3 SIPOC Observation of processes, To show the AS IS Problem
interview results from system (inputs and identification
management personnel’s and outputs of process,
employees and hospital patients and
documents suppliers)
4 Process Observation of the existing To clearly understand
mapping system the process under
investigation
5 Time Time recording using stopwatch To know the time it Average service rate
study takes to get served and average arrival
within different rate
service stations and
to know how much
time different
activities will take
Tsinukal.B Page 28
6 Value Observation of processes and To diagram and Definition of wastes

stream results from employees’ documented patient
mapping interview flow, information
flow and flow of
supplies
7 Cause From staff interviews results To explore possible Causes of a certain
and and value stream mapping causes of certain problem
effect problems
diagram
8 Control Time study To measure whether Process variation

Charts the process is capable
or not before and
after improvement
Table 7: Analysis used for the research
No Software’s used for analysis
1 QI Macros To generate control charts, pareto, SIPOC, fish bone diagram and
value stream mapping
2 Arena simulator Will be used to simulate the improved processing order to measure
the performance of the improved process as a qualitative way of
data analysis
Table 8: software used for the research
Discussion, Conclusion and recommendations
These parts are the final sessions of the research study. Under this session of the research study
results which are obtained from the collected and analyzed data are presented. The DMAIC
roadmap along with its tools is expected to result a well-defined and analyzed problem in the first
three stages. Those problems are quantified through time study and VSM. The time study resulted
with the average service time and average arrival rate of patients. Then control charts diagnosed
the performance of a particular process and the Pareto analysis resulted with the potential influence
factors. Under the fourth stage of DMAIC the researcher expects an optimal process setting,
reduced process complications, waiting time reduction and a new process map by using time study
Tsinukal.B Page 29
and VSM. In addition, the simulation results are expected to show the performance of the newly
improved setting. The last stage of DMAIC is expected to determine whether the process is in
control or not.
In the discussion part findings are interpreted and the significance of the findings are discussed
thoroughly and suggestions for further researches are given and the findings are logically
synthesized. Those findings helped the researcher to explore possible improvements that can be
made in order to further develop the concerns of the research, which are recommendations.
Finally, conclusion is presented with an intention of describing the contributions made by the
overall research based on the results obtained.
3.3 Sampling technique and procedures
The researcher uses purposive sampling (deliberate selection of service providers such as medical
doctors, management personnel’s and data management staffs (clerks)) this is the most commonly
used sampling method in clinical research. The sample is chosen based on the convenience of the
investigator. Often the respondents are selected because they are at the right place at the right time.
Convenience sampling is most commonly used in clinical research where patients who meet the
inclusion criteria are recruited in the study.
304 patients for interview from adult OPD, inpatient, emergency, card room and laboratory (304
patients) from each department. This means data has been collected from 1520 patients through
interview. And five peoples involved in the data collection processes including the researcher. The
inclusion criteria for this research is a person who is older than 18 years’ old and patients who
aren’t in critical health conditions.
Tsinukal.B Page 30
CHAPTER FOUR
DATA PRESENTATION AND ANALYSIS
This chapter presents the analysis and outcomes of the interview and the time measurement results.
Data is well summarized and presented based on the objectives of the research.
4.1 BACKGROUND OF YEKATIT 12 HOSPITAL
YEKATIT 12 medical college is a public hospital established on 1915E.C. The hospital is under
the ministry of health for a long time but starting from 1987 it became under Addis Ababa health
bureau. Now the hospital serves also as a medical college beside as a hospital.
YEKATIT 12 has many service stations and for all the service stations, it has 1134 employees.
Among those employees, 35 of them are laboratory technicians and laboratory Technologists. The
hospital generally has 36 service stations.
4.2 Data collection results

Data collection results are presented with tables and by pie charts and the collected data shows
interview, and time measurement results. The interview is conducted in March 2010E.C and five
individuals including the researcher are involved in the collection process. Based on the Interview
results customer complaints are categorized into six main problems. These are timeliness, layout
related, information related, documentation related, care related and others. The Table below
shows the complaints under those six main categories and the number of patients that responded
under each complaints. This preliminary data collection helps to decide on which service station
should this research focus and what the main problems of the hospital are that causes patient
dissatisfaction. Data has been collected from 1520 patients and their complaints are compiled
below on the table below.
Interview results
1520 patients have been interviewed from five service stations. Those five departments are
Laboratory, Adult OPD, emergency, cardroom and inpatient. 304 patients have been interviewed
from each department, means a total of 1520 from all five departments. Five peoples are involved
in the data collection process including the researcher. Each individual interview one department.
Tsinukal.B Page 31
Patients are asked about the service system of the Hospital, about the challenges they face in the
hospital during treatment, and they answered questions. From the patients that are involved in the
interview 90% of them complained about laboratory department as shown on the pie chart below.
Interview results
6% 4%
0%
90%
Laboratory Adult OPD emergency

card room inpatient
Figure 8: Interview Results
The interview results show that among the service stations that the hospital has patients have a
major complain in the laboratory department.
Customer complains on service

Timeliness Layout related Information related
Long waiting time (275) Path complication (72) Lack of information (32)
Medicines are not well explained
(17)
Documentation related Care related Others
Losing of cards (17) Nurses behavior (156) Sanitation (6)
Tsinukal.B Page 32
Searching for cards for a long Empathetic attitude of Confidentiality of information

time (64) Doctors (79) (2)
Compliant channel (31)
Table 9: complaints of patients
The table above shows the kind of complaints that the patients have on the service system of the
hospital. Based on the results the problems are categorized into six main groups. Among those
problems raised, most patient complaints come from a prolonged waiting time. The six categories
are namely
 Waiting time related

 Layout related
 Lack of information
 Documentation related
 Care related and others
Depending on those complaints the CTS’s are
 CTS 1-long waiting time
 CTS 2-path complication
 CTS 3- searching for cards for a long time
So the interview results show that 90% of complaints come from the laboratory department, 6%
from adult OPD and 4% from emergency department. In addition, the main problems that should
be solved to address customer complaints are prolonged waiting time, path complication and
searching for cards for a long time within the card room.
Time measurement results
Time has been measured from Adult OPD, Inpatient, Emergency, Card room and laboratory. Data
has been collected from 1520 patients from each department. Time measurement within those
departments was the very challenging part of the data collection. Because the patient that wants to
get served in one station will come to the service station and most of the time left the area until the
appointment time reaches or to pass to the next station and tracking those patients was very
challenging. All the data collectors including the researcher tried to identify the patients by
Tsinukal.B Page 33
recording their physical appearance or the kind or color of clothes they wear and so on. All five
data collectors were engaged on the time measurement session too. The areas that time
measurement were held were, Adult OPD, card, laboratory, emergency and inpatient. The results
show that patients are forced to spend an average of 122 minutes’ n Adult OPD, 92 minutes in
inpatient, 40 minutes in emergency, 36 minutes in card room and 236 minutes in laboratory.
Department Average waiting time
Adult OPD 122 minutes
Inpatient 92 minutes
Emergency 40 minutes
Cardroom 36 minutes
Laboratory 236 minutes

Table 10: Time measurement results
Service station selection: Since the hospital is too broad and too complex to understand, the
researcher is forced to select one specific area among those different service stations. Based on the
preliminary data collection results, it is safe to conclude that among the service stations in the
hospital the laboratory department has many customer complaints. As the results showed among
1520 patients 90% of said, they faced many problems in laboratory department rather than the
other stations and based on the time measurement results the laboratory department has the highest
waiting time of all, so this researcher focuses on laboratory department only.
The laboratory service station

The laboratory service station has 35 laboratory technicians and laboratory technologists. In
addition, it has many departments in it, which give different services. The departments under
laboratory service station are
Tsinukal.B Page 34
 Urinalysis
 Parasitology (stool and blood test for parasites)
 CBC
 Serology (Blood group)
 CD4
 Chemistry
 Blood bank service (cross match)
 Microbiology (sensitivity test, culturing, cell count)
 Electrolyte (identification of -ve and +ve charges)
4.2 Data analysis

As described in the methodology session one of the popular methodology that many literatures
used in lean six-sigma is the DMAIC approach. Based on the 27 literatures which are directly to
related to the case of this research the researcher reviewed each and every of them based on their
methodological approach and based on their purpose. And develops a DMAIC road map which
will fit the problems of the case under study. DMAIC road map is necessary to analyze and
improve the process within the hospital. So based on that framework detailed data is collected and
is analyzed. The framework developed for this research is shown below.
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Figure 9: DMAIC framework(Source: Author’s Analysis)
DMAIC ROAD MAP
DEFINE
As stated in the previous chapters Six Sigma’s DMAIC roadmap is used along with lean tools for
process improvement. The first stage of DMAIC is Define, with the purpose of selecting and
defining a problem. Under the define stage there is process mapping, CTS and SIPOC respectively.
Process mapping helps to understand what the existing process in the hospital looks like and
SIPOC is used to understand the inputs, the outputs and the process in general. In this stage, the
general process map of the hospital is drawn and CTS is defined.
Process mapping: The process map of YEKATIT 12 is shown below. The process map shows the
existing process starting from patient arrival until patients exit from the system. It shows the flow
and the different stations within the hospital.
Figure 10: process Map of YEKATIT 12 Hospital(Source: Author’s observation)
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As shown above on the process-mapping patients arrive to the hospital and join the queue at the
triage. In the triage, station patients are sorted out based on their case, illness or injury. After sorted
out they will go to the card room and get card and based on that they will go to different service
stations based on their cases like pediatrics, orthopedics and etc. After being diagnosed on those
service stations, they go to laboratory service station if there is any laboratory request. Then after
getting the laboratory results they will go back to the service station they came from and if
admission is necessary they will get admitted if not they will go to pharmacy to buy the subscribed
drugs and they will exit from the system. From the different processes on this map the focus of the
researcher is the laboratory service station because of the reasons and the results presented in the
previous sessions.
CTS
CTS helps to understand the critical problems that needed to be solved in order to satisfy patients.
From the preliminary data collection, the researcher identifies what the CTS’s are, which are
 CTS 1-long waiting time
 CTS 2-path complication
 CTS 3- searching for cards for a long time
This means the prolonged waiting time in the hospital is a great factor of patient satisfaction and
patients get challenged a lot because of the complicated path of the hospital and the time that the
employees in the card room for searching a card is very tiresome for the patients.
SIPOC: SIPOC is used to understand the inputs, the outputs and the process in general. Now that
we understand the existing process in general and defined the critical things to satisfaction the next
step is to focus on the specific service station which is laboratory service station. In the SIPOC
laboratory requests come from different departments such as Medical OPD, Surgical OPD and etc.
Then the receptionists receive the requests, patients will go to the preparation room to give blood
or to receive cup/container and then they will get appointed. The laboratory technologists will
perform the analysis and return the result paper to the preparation room and the results will be
returned for the patients. The outputs of the analysis are urinalysis results, stool results, sputum
results, chemistry, CBC and etc. In addition, the customers of the hospital are external patients and
staffs. The SIPOC diagram is shown below:
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Figure 11: SIPOC of laboratory department (Author’s) observation)
MEASURE
The second stage of DMAIC, which is Measure, is intended to quantify and refine the problems in
detail. As stated in the DMAIC framework the measure phase of The DMAIC stage constitutes
process mapping of the laboratory department, which aims to show how the laboratory service
station is organized. The second one is Value stream mapping which shows the value adding and
non-value adding activities in detail and in this part wastes in laboratory department are defined.
The next step of measure stage is time measurement, which is necessary to count how much time
every activity in the laboratory service station needs. Now that the process is clearly defined and
problems are well articulated then Ishikawa will come to the picture to understand the causes of
the problems. After the causes of the problems are, articulated pareto analysis will be done to
understand which problems influence the most.
Process Mapping
The figure below shows the process mapping of the laboratory service station. As shown on the
process-mapping patients will arrive to the waiting line and join the queue and the receptionist will
receive the lab request. If their request is urinalysis or stool they will get cup/container and they
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will move to the bathroom to poop/urinate if not, they will give a blood sample and get appointed
then the analysis on the requests will be performed. Then when the appointment time reaches they
will accept the results and leave the laboratory.
The process mapping of the laboratory service station shows that many departments are available
in the station. It has reception, urinalysis, parasitology, CBC, serology, CD4, chemistry, blood
bank, Microbiology and electrolyte. Those departments analyses different testes based on the
requests that they receive. The departments have many equipment’s and machines to perform the
different operations. Like CD4 analyzer, Mindray, Beckman, Microscope and so on are the
equipment’s that the station uses. Among those departments within the laboratory department the
researches chooses four only namely CBC, Chemistry, Urinalysis and stool analysis and the
selection is based on the number of requests that they receive per day which is an average from
200-50requests/day.
Figure 12: process mapping of the laboratory service station (Author’s observation)
Process mapping of urinalysis

Urinalysis is a laboratory test to detect problems from urine. The abnormality of organs like lung,
kidneys, urinary tract, skin, and bladder might affect our body on how to remove wastes and toxins.
The focus of this research is a simple urinalysis test that takes minutes to finish not culturing. The
Tsinukal.B Page 39
department has one laboratorian/ shift and the main equipment that they use is Microscope in
addition to the other small utensils. In this department, first, a patient will come to the reception
holding a request and if the request says urinalysis a cup will be given for the patient then she/he
will go to the bathroom to urinate. After urination, the patient should come back with a sample and
he/she will give the sample to the lab assistant in the preparation room that will do the labeling
and then pass it to the urinalysis department for analysis. Then the laboratorian will adjust his
microscope and will take a sample of urine and start examining. After finishing the examination,
the lab technologist will wait until he/she collect 20 results and then he/she will return the results
for the employees who will return the results and sometimes they themselves will return the papers.
Figure 13; Process mapping of urinalysis(Author’s observation)
Process mapping of stool analysis
A stool analysis is a test done on a stool (feces) sample to help diagnose certain conditions affecting
digestive tract. This might be an infection from parasites, viruses or bacteria.
Tsinukal.B Page 40
The other session in laboratory service station is stool analysis under the name of parasitology.
This department is almost similar to urinalysis. First, a patient joins the queue and when give the
request for the receptionist, the receptionist will give the patient a container, and the patient will
take the container and go to the bathroom to poop. After the poop the patient will come back with
a sample and give it to the preparation room then the laboratory assistant in the preparation room
will label the container and give the sample for the laboratory analyzer. The lab analyzer will then
adjust his /her microscope, took a sample, and examine it. After filling the results on the request
paper, the lab analyzer will then wait until the results reach to twenty and return the results for
patients. The process mapping of stool analysis is shown below. Every activity in this department
are explained in detail
Figure 14: process mapping of stool analysis(Author’s observation)
Process Mapping of CBC
CBC (complete blood count) is a test that determines if there are any increases/decreases in the blood cell
counts. The laboratory report from CBC tells whether your blood cells are normal under your age or not. It
Tsinukal.B Page 41
can help diagnose anemia, cancer etc. CBC measures red blood cells, white blood cells and platelets. just
like the other processes getting a CBC analysis has also its processes. The patient needs to join the queue
first and go to the reception to and he / she should give blood. After giving a blood sample, the sample will
get labeled and pass to the CBC analyst. The CBC analyst will then turn on the Mindray machine and will
check whether re-agents are available or not. Then sample preparation will follow and centrifuge and then
the blood will be poured from tube. Then the sample will be put inside the Mindray and results will come
out. If there is no problem on the results the result will pass and the examiner will write the results on the
computer, then on the request paper and finally return the results. The activities in CBC department are
shown below in detail.
Figure 15: process Mapping of CBC(Author’s observation)
Process mapping of Chemistry
Clinical chemistry is area of chemistry, which is generally concerned, with the analysis of body
fluids for diagnostic purposes. Chemistry is the last department under study on this research. In
order to get a chemistry analysis a patient will first join the queue and go the reception as usual.
Tsinukal.B Page 42
Then a blood sample will be taken out of his/her arm and that sample will be labeled in the
preparation room. The labeled sample will then be taken to the chemistry analyst then the
chemistry analyst will start entering data to the computer and then she will manually match the
number and enter the data. Then the Beckman machine will examine the blood and the laboratory
technologist will fill the results on the computer and on the request paper. Then finally give the
results back for the patients. The figure below shows the detailed activities of chemistry
department.
Figure 16: process mapping for Chemistry(Author’s observation)
Value stream Mapping (VSM): value stream mapping (VSM) is a map that clearly shows a value
adding activities and non-value adding activities in process clearly. It is a widely used lean tool,
which highly helps in identification of wastes within different activities or processes.
VSM of chemistry
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Value stream mapping shows the value adding activities and the non-value adding activities. The
VSM of chemistry starts with giving requests in the reception and ends with delivering laboratory
results for patients.
Non-value adding activities in Chemistry: placement of reagents, which is far from the machine.
the examiner start examining when the number of requests reaches 40 which takes a longer waiting
time and filling data manually in filling the data on computer. The cycle time in chemistry
department is 157.5minutes.
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Figure 17: VSM of chemistry (Author’s observation)
Tsinukal.B Page 45
VSM of urinalysis
Value stream mapping of urinalysis: the value stream mapping of urinalysis shows the process
starting from when a patient goes to reception until a result is delivered for patients. The non-value
adding activities in this map is only the laboratory technologist waits to deliver results until 20
requests are examined which in turn creates a prolonged waiting time. The cycle time of urinalysis
is 53.5 minutes.
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Figure 18: VSM of urinalysis (Author’s observation)
Tsinukal.B Page 47
VSM of stool analysis

Value stream map of stool analysis: the value stream map of stool analysis shows the value adding
activities and the non-value adding activities in the stool analysis session, which is under
parasitology department. The non- value adding activity in stool analysis is the time that the
examiner took to return the result papers until it reaches to twenty. The other non-value adding
activities consumes time they can’t be avoided. The cycle time in stool analysis is 50minutes.
Tsinukal.B Page 48
Figure 19: VSM of stool analysis (Author’s observation)
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VSM of CBC: The value stream map of CBC shows the value and non-value adding activities in CBC. The non-value adding activities
in CBC are manual and matching of sample and requests, which takes unnecessary time. Entering number manually, and the Beckman
machine only takes only one sample at a time and the examiner waits until she collects three results in order to return results for the
patient.
The cycle time in CBC is 40.5 minutes.
Figure 20: VSM of CBC (Author’s observation)
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Time measurement:
The hospital’s recorded time shows the average time that patients spent in urinalysis, stool
analysis, CBC and chemistry. In addition, in order to check whether the recorded times are going
accordingly with the time standard or not the researcher checked company documents to know the
standard of he processes. The time has been shown on the table below
Note: source of standard time is the hospital
Process Existing time Standard time Wastes
CBC 40 minutes 5 minutes 35 minutes
Chemistry 150 minutes 60 minutes 90 minutes
Urinalysis 40 minutes 15 minutes 25 minutes
Stool Analysis 35 minutes 15 minutes 20 minutes
Table 11: standard and existing time of laboratory processes
Ishikawa diagram
Ishikawa diagram (cause and effect) diagram analyses the causes of the problems with in the
laboratory department. From the previous data’s the main problem within the service station is
high waiting time. The causes of these problems are analyzed by interviewing the laboratory
technicians and by observing the process. And also from the hospital time measurement results
Tsinukal.B Page 51
there is high deviation of time from the standard and the actual. In order to get answers for these
questions laboratory staffs are interviewed and observations were made. Some of the causes for
this problem are process complications, lack of automation, discharging by batch and etc.
Figure 21: Ishikawa diagram
Pareto chart
In order to analyze which causes of prolonged waiting time are more influencing a Pareto diagram is done.
This diagram is done based on an educated guess by the laboratory Technologists.
Pareto for stool analysis
The pareto is done based on an expert opinion from laboratory staffs. They made an educated guess in order
to assume the severity of the problems with in the departments. So based on that educated guess the main
cause for longer waiting time in stool analysis department is patients queue jumping. The patients that jump
queues are inpatients and staff of YEKATIT 12 Hospital.
Tsinukal.B Page 52
Stool Analysis problems

100.0%
91.5% 90.0%
50
80.0%
74.6%
70.0%
waste of time
40
60.0%
30 24 50.0%
40.7% 20
40.0%
20 30.0%
10
20.0%
10 5
10.0%
0 0.0%
inpatients Queue Highworkload Return results by Not a conducive
jumping batch environment
Figure 22: Pareto for stool
Pareto for CBC problems: The Pareto for stool is made by educated guess and expert opinions in stool
analysis department. Based on the expert’s opinions the main cause for prolonged waiting time in CBC is
lack of automation.
35 CBC problems 97.1% 100.0%

90.0%
30 85.7%
80.0%
25 71.4%
Pareto Chart
70.0%
20 18 60.0%
51.4% 50.0%
15 40.0%
10 7 30.0%
5 4 20.0%
5 1 10.0%
0 0.0%
Categories
Figure 23: Pareto for CBC
Pareto for chemistry: There are different reasons that caused in chemistry department. The main
causes of long waiting time which is based on The Pareto analysis made based on the experts
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opinion is process takes long time because of sample error, equipment problems and lack of
automation.
Chemistry problems 94.4%

100.0%
80 87.6% 90.0%
70 78.7% 80.0%
Pareto Chart
60 67.4% 70.0%
60.0%
50 40 50.0%
40 44.9%
40.0%
30 20 30.0%
20 10 20.0%
8 6 5
10 10.0%
0 0.0%
Figure 24: Pareto for chemistry
Pareto for urinalysis problems: Based on the expert’s opinion made by laboratory staffs a Pareto
analysis is made for the causes of prolonged waiting time in urinalysis department. The main cause
for that is examiners return results by batch until they reach to twenty, which hurts the patient who
was in the first queue. In addition, high workload is a problem. There is only one examiner per
shift and 400-500patients might come per day.
Urinalysis problems
95.8% 100.0%
87.5% 90.0%
20
Pareto Chart
15 75.0% 80.0%
70.0%
15 62.5% 60.0%
50.0%
10 40.0%
3 3 30.0%
5 2 1 20.0%
10.0%
0 0.0%
Categories
Figure 25: Pareto for urine
Tsinukal.B Page 54
ANALYZE
In this stage, control charts are used to check the process variation. Control charts helps to know
whether the process is under the control limits or not. These control charts are sigma tools.
Control charts for CBC: the control charts in CBC shows that all variables are under control. Even
if the values fluctuates from the mean, it is still under control. The values in the control chart are
observations made on waiting time.
XbarR Chart - for CBC

USL 103.02
120.0 LSL -22.82
UCL 103.0 N 200
100.0
80.0
waiting time
60.0 CL 58.0
40.0
20.0 LCL 12.9
0.0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
observation days
Table 12: control chart for CBC
Control charts for CBC:
Waiting times are observed for twenty days to understand the variation. In chemistry department
some values are under and below the upper and lower control limits. This means that there is
variation with in these departments. The reason for this variation is that the examiner waits until
requests reach 40 to start examining that means the first request and the 40th got their results with
almost the same time but the waiting time for the first patients and the last patient is completely
different.
Tsinukal.B Page 55
USL 237.76
LSL -58.49
N 200
Table 13: control charts for chemistry
Control chart for urinalysis: Waiting times are observed for twenty days to understand the
variation. In urinalysis department, some values between the upper and the lower control limit.
Therefore, that means the variation in this department is normal.
Tsinukal.B Page 56
XbarR Chart -Urinalysis

56.2
UCL 53.3 USL 80.81
51.2 LSL 1.79
N 200
46.2
waiting time
CL 41.7
41.2
36.2
31.2 LCL 30.1
26.2
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
observation days
Table 14: control charts for urinalysis
Control chart for stool analysis:
Waiting times are observed for twenty days to understand the variation. In stool analysis
department some values are under and below the upper and lower control limits. This means that
there is variation with in this department. The reason for this variation is that the examiner waits
until results reach to twenty that means there is a long time difference between the first patient
inline and the last patient in line. The other reason for this variation is that queue jumping from the
inpatients and staffs. That means they will affect the outpatients who were in the line and get results
way very soon before them.
Tsinukal.B Page 57
USL 77.17
LSL -5.79
N 250
Table 15: control charts for CBC
IMPROVEMENT: The fourth stage of DMAIC is Improvement. The existing process is

improved and a new value stream map is designed to improve the process.
Improved VSM for CBC: In improved VSM of CBC, the Beckman machine is adjusted to examine
five samples at a time instead of one. In addition, the writing and matching values value are omitted
by adding a bar code reader on The Beckman machine. In addition, a printer is added for printing,
which in turn reduces the time to record results. The cycle time of CBC analysis is reduced to 16
minutes.
Tsinukal.B Page 58
Figure 26: Improved VSM of CBC
Tsinukal.B Page 59
Improved value stream map of chemistry: In improved VSM of chemistry. The examiner
waits until requests reach 40 to start examining. That process is now omitted and when five
requests arrive, the examining will start. In addition, a printer is added for printing, which in turn
reduces the time to record results. The cycle time of chemistry analysis is reduced to 44minutes.
Tsinukal.B Page 60
Figure 27: Improved VSM for Chemistry
Tsinukal.B Page 61
Value stream map of stool analysis: The non-value adding activity in this process was the examiner holds results until they reach
twenty and that process is now omitted and one request will be returned at a time. In addition, the cycle time is now reduced to 22
minutes.
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Figure 28: Improved VSM for Stool Analysis
Value stream map of urinalysis: The non-value adding activity in this process was the examiner holds results until they reach twenty
and that process is now omitted and one request will be returned at a time. In addition, the cycle time is now reduced to 19 minutes.
Figure 29: Improved VSM for urinalysis
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Simulation of the new VSM: The simulation results of the improved VSM shows that the
performance of the newly improved system is better than the before. The simulation is done by
simulating the newly improved value stream mapping. The patient arrival data is used by the
previously collected data and the distribution is made by input analyzer whereas the other
processes are defined by a constant distribution and the values of the process are constant too.
Simulation of Urinalysis:
The simulation results of the newly improved value stream map
Process name Improved cycle time Simulation results

Urinalysis 19 minutes 25.93minutes
Table 16: Simulation results of Urinalysis
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Figure 30: Simulation of Urinalysis
Tsinukal.B Page 65
Figure 31: Simulation results of Urine
Tsinukal.B Page 66
Simulation results of chemistry: The simulation of chemistry is done by simulating the newly
improved system. In addition, the contribution of patient arrival is done by previously collected
data
Process name Cycle time of the newly Simulation results

improved VSM
Chemistry analysis 44.5 minutes 72.87 Minutes
Table 17: Simulation results of Chemistry
Figure 32: Simulation results of chemistry
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Figure 33: Simulation of Chemistry
Simulation of stool analysis:
The simulation of Stool analysis is done by simulating the newly improved system. In addition,
the contribution of patient arrival is done by previously collected data.
Process Name Cycle time of the improved Simulation results

VSM
Stool Analysis 22 minutes 23.17 minutes
Table 18: Simulation results of stool analysis
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Figure 34: Simulation results of stool Analysis
Figure 35: Simulation of stool Analysis
Simulation of CBC:
The simulation of CBC done by simulating the newly improved system. In addition, the
contribution of patient arrival is done by previously collected data.
Tsinukal.B Page 69
Process Name Cycle time of the improved Simulation results

VSM
CBC 15 minutes 15.72 minutes
Table 19: Simulation results of CBC
Figure 36: Simulation of CBC analysis
Figure 37: Simulation results of CBC
Tsinukal.B Page 70
4.2 Discussion
Data has been collected from different service stations in the hospital and the station with highest
waiting time and customer complaints is laboratory department. Data has been collected from 1520
patients in five departments 90% of them complained about laboratory department. Besides that,
from time measurement results in laboratory service station patients are forced to spend an average
of 236 minutes in laboratory, which is a high waiting time from the remaining four service stations.
After the preliminary data collection leads to laboratory department the researchers focus on the
process of laboratory department, which are CBC, chemistry, stool analysis and urinalysis. The
DMAIC road map is experimented on these departments. On the define stage of the roadmap
process mapping and SIPOC are done to understand and define the problem.
In the measurement stage of DMAIC VSM has been done and from the maps different non value
adding activities are sorted out such us collecting results for a specific number of time without
passing the results for patients, lack of automation, holding requests until they reach to 40 to start
examining and etc. (discussed in detail in Analysis part).
Those non value-adding activities are omitted and a new VSM is developed and cycle time has
been reduced in each departments
Name of Cycle time Cycle time after DMAIC Simulation results

process before
DMAIC
CBC 40.5minutes 15minutes 15.72Minutes
Chemistry 157.5minutes 44minutes 72.87 minutes
Urinalysis 53.5minutes 19minutes 25.93minutes
Stool analysis 50minutes 22minutes 23.17 minutes
Table 20: cycle time of the before and the after
The simulation results show that the newly improved system can improve the waiting time in the
laboratory. Generally, DMAIC is a remarkable methodology to understand variation and wastes
in hospitals and to improve processes.
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CHAPTER FIVE
CONCLUSION AND RECOMMENDATIONS
5.1Conclusion
In a competitive world like this it is must for service providers to satisfy the customers that they
are serving. Quality of service in healthcare has different attributes by standard key performance
indicators and based on the patient’s requirement too. In Ethiopia the healthcare services do not
reach the whole population not just that but the available healthcare services have so many
problems starting from the shortage of resources (labor and material) to inefficient and ineffective
quality of service. And the hospitals aren’t that active in exploring different ways to improve the
existing process and to improve the quality of healthcare especially in public hospitals.
This research study experiments different possibilities to improve the healthcare service by
addressing the requirement of the patients through lean six sigma. To do so a case hospital is
selected based on the performance report of the EHRIG. Based on the report Yekatit 12 hospital
has a low performance and data has been collected from different departments within the hospital.
Finally, from the results of the collected data laboratory department is selected as a case area.
Laboratory service station was the case area selected for this research and there are many
departments under this service station. The existing system of the service station is analyzed by
the DMAIC methodology of LSS. Based on the collected data laboratory service station faces a
prolonged waiting time and there is variation in some of the process within the services station.
LSS clearly identifies what the problems and based on the results a new process developed by
VSM to minimize those problems. The existing process and the newly improved process is
simulated by arena simulation software.
In the value stream mapping the value adding activities and the non-value adding activities are
clearly identified and the control charts showed some processes are out of control and there is
Tsinukal.B Page 72
variation within the processes. Waiting until results reach to some specific numbers in stool
analysis and urinalysis, the lack of automation and lack of printers and unnecessary processes in
CBC and Chemistry are avoided. By avoiding those problems and non-value adding activities a
new Value stream map is developed. And the cycle time is reduced from 53.5minutes to 19minutes
in urinalysis, from 50 minutes to 22 minutes in stool analysis, from 157.5 minutes to 44minutes in
chemistry and from 40.5minutes to 16minutes in CBC. And the results from the VSM are checked
on arena simulation and the simulation results shows that the performance of those departments
can be improved by the newly designed value stream mapping.
Timeliness is one of the requirement and health care sectors should seriously consider the delivery
time of their services. Finally, the researcher concluded that integrating lean and six-sigma can
really improve processes in hospitals and DMAIC methodology should be applied in health
sectors.
Tsinukal.B Page 73
5.2 Recommendations
From findings and data collections results of this research, the researcher recommends the
following suggestions
 The Beckman Machine can be automated with few adjustments, which as a result will ease
the process by avoiding unnecessary activities. The bar code reader will avoid the data
entry manually and connecting it to a printer reduces the time that the laboratorians take to
write on computes and on papers.
 The adjustment on Beckman Machine will also help to take samples in a batch instead of
one at a time so that will improve the waiting time that patients spend waiting and it will
also increase the number of patients treated per day within the hospital.
 The inpatients and the staffs should need to have another waiting line instead of jumping
in the queues. Because the jumping of the queues is one of the reasons that create variations
between the waiting times.
 One additional laboratory assistant should be employed to deliver results for patients
especially in urinalysis and stool analysis. In the current case, the laboratory technologists
hold the results until the results reaches 20 and this creates a prolonged waiting time so a
laboratory assistant should be hired and give results one by one.
5.3 Future Study area

This research considers the use of automated machines and adding a human resource in order to
minimize the prolonged waiting time in the Laboratory department but it did not consider the cost
that deploying this resources will take incurs so as a future study area the researcher suggests cost
benefit analysis should be any side with the process improvement.
Tsinukal.B Page 74
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Tsinukal.B Page 79
ANNEX
Interview questions Quality improvement of healthcare through lean six-sigma
Dear Participant,
Addis Ababa Institute of Technology is conducting MSC research entitled “Quality improvement
of healthcare through lean six-sigma.” TSINUKAL BEZABIH carries out this research under the
supervision of AMEHA MULEGETA (PHD). The study aims to investigate process improvement
in YEKATIT 12 hospital through lean six-sigma methodology. This semi structured interview
aims mainly to assess how processes are being carried out in this hospital, which activities have
wastes and to assess causes of patient dissatisfaction.
We would like to reassure you that responses given will solely be used for academic purpose and
aggregate results will be disclosed in the study report. Answers provided will be analyzed
anonymously and your specific information will not be revealed in any way.
Your participation in this study is voluntary. You are free to withdraw your consent to participate
in this study any time. Refusal to participate or withdrawal will not affect you in anyway. You
have been given the opportunity to ask any questions regarding the research and to receive answers
concerns areas you did not understand.
It takes approximately only 20 Minutes to fill out the questionnaire, and I am kindly requesting to
answer the interview questions in a professional manner with utmost honesty, at a suitable time.
Thank you in advance for your cooperation and professionalism in answering the questions.
For any inquiry, please contact TSINUKAL BEZABIH at 0912374068 or email
[email protected].
Concerns about any aspect of the study may be referred to AMEHA MULUGETA (PHD), Thesis
advisor, email [email protected] and phone number 0911- 94-80-14.
I voluntarily consent to participate in this study. In this signing form I certify that I am 18 years of
age and older. I will be given a copy of this consent form.
Tsinukal.B Page 80
Signature of participant Date
I certify that I have presented the above information to the participant.
Signature of the investigator Date

Patient ID Number
Age
This semi structured interviews are designed for patients of YEKATIT 12 hospital
1. Were you served in this hospital before this time?

YES NO
2. If your answer is no what is the reason?
3. If your answer is yes, how many times did you served in this hospital?
4. In which service stations were you served?
5. In which service station did you spend more time?
6. What was the path you followed?
Tsinukal.B Page 81
7. Do you think the system is easily understandable?

YES NO
8. What problems did you encounter at the time of your service?
9. Compared to other health services, this hospital’s service is relatively.

GOOD BAD VERY GOOD EXCELLENT
10. Among the problems you encountered during your stay at the hospital, which problems
are severe?
Semi structured interview questions for the laboratory department
1. Describe the type of services you deliver in this department.

2. What types of equipment’s are used to deliver your services?
3. Describe the method used to coordinate patient/material movements from each service
station to the service stations.
4. Per service range, how many hours of a day is productive and how many are idle?
What is to be observed?
 Delivery time for patients in each service stations

 Flow process steps from patient entry to exit
 The range of times (fastest to slowest) taken to make/provide services in each service
station from entry to exit?
Tsinukal.B Page 82
 The layout of every service stations within the hospital
Summary
The semi structured interviews, which are prepared for the laboratory department aims to identify
wastes within the service stations. Finally, a waiting time waste and patient flow is quantified by
observation and time study.
Tsinukal.B Page 83
No Title Author Objective Methodology Outcome
1 Decreasing the Improving

Yara L. Basta Quality Of Health
To dispatch 90% of Service Through
DMAIC Lean Six-Sigma After implementation, 90.6% of the
dispatch time of et.al medical reports on the day reports were dispatched on the day
medical reports sent of the patient’s visit by of the visit.
from improving the logistic
hospital to primary process.
care with Lean Six
Sigma
2 Lean Six Sigma: a G. Improta et To show that Lean Six DMAIC (Define, Measure, Analyze, The average
new approach to the al. Sigma represents an Improve, Control) roadmap length of stay was reduced from
management of appropriate methodology 18.9 to 10.6 days (−44%).
patients undergoing for the development of a
prosthetic hip clinical pathway which
replacement surgery allows to
improve quality and to
reduce costs in prosthetic
hip replacement surgery.
3 The application of Emma Montella The application of the Lean Data on more than 20 000 patients who 20% reduction in the average
Lean Six Sigma et.al Six Sigma (LSS) underwent a wide range of surgical number of hospitalization
methodology to methodology to reduce the procedures between January 2011 and days between pre intervention and
reduce the number of patients affected December 2014 were control phases, and a decrease in the
risk of healthcare– by sentinel bacterial collected to conduct the study using the mean (SD) number of days of
associated infections infections who are at risk departmental information system and hospitalization amounted to 36
in surgery of HAI. DMAIC roadmap (15.68), with a data distribution
departments around 3 σ.
Tsinukal.B Page 84
4 Reducing Patient E. V. Gijo and To reduce the longer DMAIC roadmap, cause and effect diagram, The average waiting time
Waiting Time in Jiju Antony waiting time by using LSS value stream map and statistical tools reduced from 57 min to 24.5 min
Outpatient methodology and the standard deviation was
Department Using reduced to 9.27 from 31.15 min.
Lean Six Sigma
Methodology
5 Applying lean six H.Long et.al Application of LSS to DMAIC, value stream mapping and cause Cycle time of the
sigma to improve improve the medical and effect diagram improved door-to-balloon process
healthcare process of acute decreased by 58.4%, Process cycle
myocardial infarction. efficiency increased from 32.27 to
51.81% and average days of the
hospital got decreased by three
days.
6 Application of Lean- Suman.K et.al To identify the DMAIC, failure mode analysis, cause and 50% improvement is made in
Six Sigma to Improve current challenges being effect diagram, value stream mapping and capacity, 36% in idle time and 31%
Quality in faced by health care pareto chart in utilized time.
Healthcare Industry industry and
ways to tackle them using
Lean-Six Sigma
7 Axiomatic Design of Dominik T et.al To discuss a Axiomatic design framework A holistic optimization of hospital
a Framework for the comprehensive, system- patient flows, by reducing the
Comprehensive based approach to achieve complexity of the system.
Optimization of a factual holistic
Patient Flows in optimization of patient
Hospitals flows.
8 Applying lean Six Sandy L. To apply the Lean Six Six Sigma DMAIC (Define-Measure improve the key linen operational
Sigma to reduce linen Furterer1 Sigma problem solving Analyze-Improve-Control) problem solving metric, soil to clean linen ratio by
loss in an acute care methodology and tools to approach. 16% and saved $77,480 for the first
hospital improve the linen year
processes.
9 Using Six Sigma J. De la Lama Reduce the variability Data of hospital stays, occupancy rates and The delay is minimized
tools to improve et.al scheduling pre-anesthesia discharges were studied.
internal processes in consultations, (2) reduce
a hospital center absenteeism of outpatients
through three pilot and reduce delays, and (3)
projects increase the efficiency of
Internal Medicine
Rehabilitation ward.
Tsinukal.B Page 85
10 Improvement of Alicja Maleszka To evaluate the impact of DMAIC Reduced wastage and cost reduction
management process and Magdalena Lean Six Sigma tools on FMEA
by using lean six Linke the certain management Pareto chart
sigma tools in some process to eliminate or Value stream mapping
big organization of reduce wastage Regression and correlation
food industry TPM
Hypothesis tests
Visualizations
Poka- yoke
SMED
11 Performance Barnabè et.al Discuss the potentials of House of quality Deduced that applying LSS in
Enhancement and LSS in healthcare, Design for six sigma hospital can able to reduce cost,
Continuous highlight the factors DMAIC waste reduction and it can increase
Improvement in enabling a LSS Pareto chart efficiency
Healthcare: intervention in a Cause and effect diagram
How Lean Six Sigma Healthcare setting and to
“Hits the Target” evaluate performance
improvement in a hospital
12 Applying lean six Berna Umut To Value stream mapping Risk minimization
sigma improvement and Peiman increase catheterization Root cause analysis Waiting time reduction
methodology to Alipour Sarvari laboratory efficiency Process improvement actions Efficiency maximization
increase
catheterization
laboratory efficiency
13 Formation of Six Tolga et.al To reduce the number of DMAIC Areas that caused the complications
Sigma Infrastructure complications occurring Failure mode effect analysis has been identified
for the Coronary during coronary stent Root cause analysis
Stenting Process insertion process
14 Application of Lean Matthew G.et.al To Value stream mapping Block utilization is increased
Sigma to the improve audiology Schedule utilization and lead time were Lead time is reduced
Audiology Clinic at a scheduling and utilization measured for five months Booked appointment is increased
Large Academic in a large tertiary care
Center referral center
15 Integration of Six Celil.G et.al To evaluate the Pareto chart Causes of the complications are
Sigma Methodology complications occurred SIPOC identified and improvement actions
to Reduce during and after the Trainings are taken
Complications Hemodialysis sessions Total count of complications
in a Private Hemo made in a private
dialysis Center Hemodialysis center in
terms of their sigma levels
Tsinukal.B Page 86
and
severity.
16 Process Improvement Jeroen.M et.al Develop a unifying and Breaking down Opportunities for
in Healthcare quantitative conceptual work into micro processes, tasks, and process improvement are identified
framework for healthcare resources from a diagnosis of the process
processes from the under study. By providing
viewpoint of process conceptual models
improvement and practical templates for process
diagnosis, the framework relates
many disconnected strands of
research and
application in process improvement
in healthcare to the unifying pursuit
of process improvement.
17 Process improvement A. Ahmed, J. To improve and DMAIC Six sigma methodology along with
based on an Page and J. control processes, reduce AnyLogic simulation AnyLogic simulation can able to
integrated approach Olsen non-value-added activities reduce defects in a process
of DMAIC and multi- and support decision-
method simulation making by using Six
Sigma’s
methodology alongside
Any Logic; using agent-
based, discrete event, and
system dynamics models
18 Application of Lean Nabeel. M et.al To DMAIC Reduction of patient length of stay
Six Sigma tools to streamline processes and Value stream mapping in hospital
minimize enhance productivity of a
length of stay for hospital’s ophthalmology
ophthalmology day department.
case surgery
19 Improving Gloria J.et al To increase the efficiency DMAIC Total process time is reduced
Timeliness and the timeliness Cause and effect diagram
and Efficiency in the Control charts
Referral Process for
Safety
Net Providers
20 Risk management Andrea To understand whether DMAIC Reduction of capital
and cost Chiarini Lean Six Sigma tools are FMEA Improved safety
reduction of cancer useful to reduce Value stream mapping Improvements are made in terms of
safety and health risks to motion and transportation
Tsinukal.B Page 87
drugs using nurses and physicians who

Lean Six Sigma tools manage cancer drugs and
to analyze economic
improvements reached by
the means of lean six
sigma
21 Deployment of Lean Susan.E et al To describe SIPOC It can able to reduce avoidable
Six Sigma in a systematic approach to Cause and effect diagram readmissions
Care Coordination the discharge process
aimed to improve
transitions of care from
hospital to post–
acute care, utilizing Lean
Six Sigma methodology
22 Impact on integration G.Muthukumar To present the concept on Computer and Google searches towards Lean six sigma can bring a dramatic
of Lean an et.al how to merge lean and six- lean, six sigma and lean six sigma change in any industrial process and
Manufacturing and sigma in industries to it can able to improve the quality of
Six Sigma in improve quality of a a product
various applications product and to reduce
process variability
23 Evaluation of Patrícia.O et.al To analyze sustainable Process Mapping with the identification of Reduction of 74.8% of chemical,
environmentally actions from an problems, Brainstorming, 5 Why’s, Impact infectious and sharps waste, an
sustainable actions in environmental point of Effort Matrix and Effect Cause Matrix increase of 33.3% of common
the medication view in the medication recyclable and 20% of common
process process, from the reception non-recyclable
of the prescription of the In nursing, there was a reduction of
pharmacy to waste discard 22.5% of chemical, infectious and
by nursing sharps waste, an increase of 22.9%
of common recyclable and an
increase
of 20% of common non-recyclable
24 The application of Rahul. P et.al To provide an example of Collecting baseline data 60% reduction in idle time
Lean Six Lean Six Sigma (LSS) Value stream mapping
Sigma to the application in DMAIC
configuration research and development Pareto chart
control in Intel’s (R&D) organizations to FMEA
manufacturing eliminate waste and
R&D environment improve systems based on
available
Tsinukal.B Page 88
data that in turn improves

the innovative environment
25 Observational study DAVID.V To use a data driven Surveys Non value added time is reduced by
using the tools of CHAND approach to eliminate Observation 64% per patient
lean six sigma to examples of waste and DMAIC Pre rounding process is eliminated
improve the variation identified in T-test
efficiency of the resident rounding using
resident rounding lean six sigma
process methodology
26 Lean Six Sigma, Sara O. Salem Aims to describe the A computer searches of PubMed, OvidSP, Lean, Six Sigma, LSS, and RCA are
Root Cause Analysis et.al principles and objectives of and Google Scholar (2000-2016) were made powerful quality improvement tools
to Enhance LSS and RCA using keywords such as Lean, or Six Sigma that prevent adverse events, produce
Patient Safety in tools with a special focus or lean six sigma or medication errors better quality services and result in
Healthcare on their diverse roles in (MEs) or adverse drug events or RCA enhancing patient satisfaction and
Organizations: A healthcare organizations. which retrieved thousands of references but safety. These quality tools also
Narrative Review, only 110 articles were decrease costs, work performance
2000-2016 included in this paper variance, waste and increase
customer satisfaction and the work
performance of healthcare
professionals
27 The Applicability of Sharon A. Concerned on the potential Available literatures involving applications Lean and Six Sigma process
Lean and Six Sigma Schweikhart, use of Lean of Lean and Six Sigma to improvement methodologies are
Techniques to and Allard.E and Six Sigma to improve health care, laboratory science, and clinical well suited to help
Clinical Dembe the processes involved in and translational research are reviewed achieve NIH’s goal of making
and Translational clinical and translational clinical and translational research
Research research more efficient and cost-effective,
enhancing the quality of the
research, and facilitating the
successful adoption of biomedical
research
findings into practice.
Tsinukal.B Page 89

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ADDIS ABABA UNIVERSITY

ADDIS ABABA INSTITUTE OF TECHNOLOGY

SCHOOL OF MECHANICAL AND INDUSTRIAL ENGINEERING

INDUSTRIAL ENGINEERING CHAIR

QUALITY IMPROVEMENT OF HEALTHCARE THROUGH LEAN SIX

ADDIS ABABA, ETHIOPIA

A THESIS SUBMITTED TO SCHOOL OF GRADUATE STUDIES OF ADDIS ABABA

ADDIS ABABA UNIVERSITY

ADDIS ABABA INSTITUTE OF TECHNOLOGY

SCHOOL OF MECHANICAL AND INDUSTRIAL ENGINEERING

INDUSTRIAL ENGINEERING CHAIR

ADVISOR: AMEHA.M (PHD)

CO-ADVISOR:GEZAHEGN.T(PHD) Oct, 2019

ADDIS ABABA INSTITUTE OF TECHNOLOGY

SCHOOL OF MECHANICAL AND INDUSTRIAL ENGINEERING

INDUSTRIAL ENGINEERING CHAIR

QUALITY IMPROVEMENT OF HEALTHCARE THROUGH

APPROVED BY BOARD OF EXAMINERS

Dr. YILMA TADESSE …………………… ……………………...

DEAN, SMIE SIGNATURE DATE

DR. AMEHA MULUGETA ……………………. …….……………….

ADVISOR SIGNATURE DATE

Dr. GEZAHEGN TESFAYE ……………………. ……………………..

CO ADVISOR SIGNATURE DATE

DR. ERMIAS TESFAYE ……………………. ……………………..

INTERNAL EXAMINER SIGNATURE DATE

DR. EPHREM GIDEY ……………………. ……………………..

EXTERNAL EXAMINER SIGNATURE DATE

Tsinukal Bezabih Signature Date

Dr.Ameha Mulugeta Signature Date

Dr. Gezahegn Tesfaye Signature Date

This research aims in experimenting the possibilities of process improvement opportunities in

List of figures ................................................................................................................................. iv

List of tables ................................................................................................................................... vi

List of Abbreviation’s ................................................................................................................... vii

CHAPTER ONE ............................................................................................................................. 1

INTRODUCTION AND BACKGROUND ................................................................................... 1

1.1 Introduction ........................................................................................................................... 1

1.2 Problem Statement ................................................................................................................ 3

1.3 Research Questions ............................................................................................................... 4

1.4 Objectives of the Research .................................................................................................... 4

1.5 Scope ..................................................................................................................................... 4

1.6 Significance of the Study ...................................................................................................... 5

CHAPTER TWO ............................................................................................................................ 6

LITERATURE REVIEW ............................................................................................................... 6

2.1 Introduction ........................................................................................................................... 6

2.2 Definition and History of Lean manufacturing ..................................................................... 7

2.3 History and Definition of Six Sigma ..................................................................................... 8

2.4 Why Lean Six Sigma............................................................................................................. 9

2.5 Lean Six Sigma in service industry ..................................................................................... 11

2.6 Previous researches on lean six sigma in health sectors ..................................................... 14

3.1 Introduction ......................................................................................................................... 21

3.2 Research phases................................................................................................................... 23

3.3 Sampling technique and procedures .................................................................................... 30

CHAPTER FOUR ......................................................................................................................... 31

DATA PRESENTATION AND ANALYSIS .............................................................................. 31

4.1 BACKGROUND OF YEKATIT 12 HOSPITAL ............................................................... 31

4.2 Data collection results ......................................................................................................... 31

4.2 Data analysis ....................................................................................................................... 35

4.2 Discussion ........................................................................................................................... 71