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Int J Health Care Qual Assur. 2016;29(2):192-208. doi: 10.1108/IJHCQA-05-2014-0058.

Lean and Six Sigma in acute care: a systematic review of reviews.

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Health Technology Assessment Unit, Centre hospitalier de l'Université de Montréal (CHUM), Montréal, Canada.



The purpose of this paper is to present a systematic review of literature reviews, summarizing how Lean and Six Sigma management techniques have been implemented in acute care settings to date, and assessing their impact. To aid decision makers who wish to use these techniques by identifying the sectors of activity most often targeted, the main results of the interventions, as well as barriers and facilitators involved. To identify areas of future research.


A literature search was conducted, using eight databases. The methodological quality of the selected reviews was appraised with AMSTAR. A narrative synthesis was performed according to the guidelines proposed by Popay et al. (2006). Data were reported according to PRISMA.


The literature search identified 149 publications published from 1999 to January 2015. Seven literature reviews were included into the systematic review, upon appraisal. The overall quality of the evidence was poor to fair. The clinical settings most described were specialized health care services, including operating suites, intensive care units and emergency departments. The outcomes most often appraised related to processes and quality. The evidence suggests that Lean and Six Sigma are better adapted to settings where processes involve a linear sequence of events.


There is a need for more studies of high methodological quality to better understand the effects of these approaches as well as the factors of success and barriers to their implementation. Field studies comparing the effects of Lean and Six Sigma to those of other process redesign or quality improvement efforts would bring a significant contribution to the body of knowledge.


Lean and Six Sigma can be considered valuable process optimization approaches in acute health care settings. The success of their implementation requires significant participation of clinical personnel from the frontline as well as clinical leaders and managers. More research is needed to better understand the factors of success and the barriers to their implementation, as well as their long-term impact.


This is the first broad systematic review of reviews, synthesizing data pertaining to implementation issues and results in acute care settings, to be published. It will benefit health care managers assessing the potential of these approaches and the potential drawbacks associated with their implementation. Moreover, it identifies directions for future research.


Acute care settings; Lean thinking; Literature review; Process efficiency; Quality management; Six Sigma

[Indexed for MEDLINE]

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