A realist evaluation of the contribution of Lean Six Sigma to person-centred cultures in a university hospital
Background: Lean Six Sigma, a quality improvement methodology, has been used in healthcare since 2001. Person-centred approaches to healthcare improvement are now widely advocated in political, policy and practice discourse. Literature shows quality improvement practitioners are often unaware of or pay little attention to Lean Six Sigma’s philosophical roots, seeing it less as an organisational philosophy but more as a quality improvement tool for continuous improvement. A lack of fidelity to Lean Six Sigma’s philosophical roots can create a division between person-centred approaches to transforming care experiences and services, and quality improvement methods focusing solely on efficiency and clinical outcomes. There is little research into, and a poor understanding of, the mechanisms and processes through which Lean Six Sigma education influences healthcare staff’s person-centred practice. Aim: To address the question: whether, to what extent and in what ways, Lean and Six Sigma in healthcare contribute to person-centred care and cultures. Design and methods: Realist review identified three potential Context, Mechanism, Outcome configurations (CMOcs) that explained how Lean Six Sigma influenced practice, relating to staff, patients and organisational influences. A realist evaluation explored how staff interacted with a Lean Six Sigma education programme (the intervention). Specifically, the CMOc relating to staff was adjudicated by study participants to determine whether, to what extent and in what ways it influenced person-centred care and cultures. Data collection was informed by person-centred principles and took place through a series of workshops and semi-structured interviews, followed by a review of research participants’ improvement projects outcomes. Findings: Three focused CMOcs, Aspects of Organisational Culture, the Organisation’s Receptivity and Participants’ Self-perception, emerged from the adjudication of the CMOc relating to staff, illuminating the contextual factors (C) that facilitated the outcomes (O) that arose from the underlying mechanisms (M) that were active when the contextual factors (C) were present. Synergies (respect for persons, voice of the customer, staff empowerment and observational studies), an influencer (quality) and divergences (core values, standardisation and first principles) between participants’ Lean Six Sigma practice and person-centred care and cultures were also revealed. Discussion: A return to Lean Six Sigma’s philosophical roots facilitates coherence in the philosophy, intention, methods and outcomes between Lean Six Sigma and person-centred approaches. Their combined use is not only possible but may also be desirable, enabling Lean Six Sigma practitioners to work in ways that support the development of quality, person-centred care that takes account of the outcomes for, and experiences of, patients, their families and staff. Incorporating person-centred principles into the research design, whilst adhering to the principles and rigour of realist evaluation, resulted in a new way of adjudicating CMOcs and novel methods of working with research participants. This study contributes to the evidence base on the study of quality improvement beyond the effectiveness of interventions alone. The findings will be of interest to researchers, policymakers and practitioners globally. Keywords: Lean, Six Sigma, Lean Six Sigma, Process improvement, Person-centredness, Person-centred care, Person-centred cultures, Kaizen.