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Medical errors are the third-leading cause of deaths in the United States causing more than 250,000 deaths annually. On an average, around 58% of medical errors that were reported in the United States were preventable (Resnick, 2019) (Gowen, et. al., 2012). Over the years, hospital expenses have increased due to factors like technological advancements, aging of population, and many more. Hospitals are struggling to keep costs under control while improving quality and efficiency of care for its patients. They seek to constantly improve the quality of care by complying to 6 dimensions of healthcare quality: Safety, Effectiveness, Equity, Efficiency, Timeliness, and Patient-Centeredness (Institute of Medicine, 2001). These dimensions are a set of categories that hospitals focus on to improve their quality and productivity. Quality and productivity management aims at reducing or eliminating such sources of poor healthcare services by focusing on programs like improving patient satisfaction, reducing wait time in hospitals, reducing medical errors, and simplifying operations. It consists of well-planned strategies to “provide high standards, excellence, and the ability to meet and exceed customers’ expectations” (Langabeer & Helton, 2016). Just as people’s lifestyle changes as we move geographically, so too the healthcare expectations change as we move countries. These expectations are highly influenced by the socio-economic conditions of the area. In the United States, customer expectations revolve around making quality care more affordable for everyone, and reducing wait time for patients. However, for a developing country like India, population explosion and lack of awareness leads to very different expectations from the customers. In India, customer expectations are more about improvements in healthcare interoperability and accessibility. In order to successfully implement these initiatives, hospitals first need to understand its internal and external environment. One of the common quality improvement methods used in both, United States and India is Lean Six Sigma. This method is helpful in creating value for customers while reducing errors to solve problems and enhance customer satisfaction. This paper compares hospital operations in the United States and India by discussing various Lean Six Sigma models carried out by each country, and analyzing its future impacts.To navigate in today’s challenging healthcare environment, organizations need to respond to numerous factors in order to make it to the top. Most of these changes are required in the form of structural and functional transformations. The key forces that drive these organizational changes are internal and external environments. Internal environment; as the name suggests, refers to those elements that occur within the boundaries of the company. For example, the employees, the management, the system and structure, the internal culture, etc. These internal elements are not only responsible for influencing internal decisions and activities, but also for employee behaviors and performances. On the other side, external environment consists of elements that occur outside of the company but still affects its quality of care and service, and its performance (Mosadeghrad, 2014). Some of the external factors that are not in control of the organization are its customers, its social, cultural, political and legal environment, its resources, and other numerous influences. Both internal and external environments have a significant influence on the organization’s progress, quality and productivity, and operations. In order to monitor these changes, ‘environmental scanning’ is conducted by organizations that helps them further decide a strategic course of action. The environment and influence of each factor highly depends on the location. Table 1.1 shows some of the internal and external factors affecting hospitals in United States and India respectively. Hospitals and healthcare organizations need to come up with modified strategies to combat with their environments. Lean and Six Sigma are two such techniques that are widely used among hospitals to improve their quality and productivity. The Lean process focuses on eliminating waste (errors, wait times, etc.) from the system with a standardized, production leveling approach. Six Sigma is a technique focused on process and quality improvement by eliminating of defects (errors, re-work, etc.) (Langabeer & Helton, 2016). Even though both the approaches have similarities, they differ in fundamental concepts, implementation strategies, and outcomes (Lee et. al., 2018). Lean uses the PDSA (Plan, Do, Study, Act) method whereas Six Sigma uses the DMAIC (Define, Measure, Analyze, Improve, Control) method to achieve its goals. In addition, Lean Six Sigma was created as a combination of both the approaches to produce better outcomes. Hospitals create personalized Lean or Six Sigma improvement processes after proper environmental scanning of its factors. Healthcare professionals are the ones who take part in healing people, however, sometimes they can become the primary carrier of certain infections and diseases. It is said that around 2 million Americans contract hospital-acquired infections (HAIs) each year, causing an estimated 99,000 deaths (“Guideline for Hand Hygiene, 2002). Evidently, hand hygiene is one of the major internal factors that affects quality of care in U.S. hospitals. The Presbyterian Healthcare Services (PHS) in Albuquerque, New Mexico approached this issue with a Lean Six Sigma technique to increase its hand hygiene compliance to 90% (Carboneau, et. al., 2010). Hand hygiene guidelines are provided by organizations such as CDC, WHO, TJC, and CMS. TJC has a policy that if hand hygiene compliance is not observed for more than three instances, the hospital is cited for failure to comply. Presbyterian Healthcare Services used the DMAIC process to identify reasons for noncompliance to reduce MRSA infection rates by 51%. The process was divided into two parts. The first part was to understand the root cause of the issue followed by implementation of the solution at two hospitals in Albuquerque. The second part was to expand the implementation to six other Presbyterian Healthcare Services across the state. The solutions were implemented in three major areas: employee and physician education, positive culture change, and environmental improvements (Carboneau, et. al., 2010). Compliance to hand hygiene has been an ongoing challenge in hospitals. The problem with hand hygiene is that the monitoring process is difficult, and so, much of the data is not accurate enough. Healthcare organizations should invest in electronic monitoring devices and Artificial Intelligence to improve accuracy in recording. Electronic monitoring will be more efficient than direct monitoring as it will allow electronic auditing of hand hygiene compliance which will generate more accurate data to work with. The audited data can be then used by compliance officers and other departments to track their progress and make necessary changes to their improvement plans. Hand hygiene needs an engineered solution in the future to combat the increasing rates of hospital-acquired infections (HAIs). India is the second largest populated country in the world. Healthcare quality and process improvement is thus extremely challenging due to over population, lack of education, traditional mindset, etc. Healthcare organizations strive to provide quality of care, safety and affordability throughout the country. According to a survey conducted by the Healthcare Federation of India in 2014, India has about “0.7 doctors, 1.3 nurses and 1.1 hospital beds per 1,000 people”, instead of the WHO requirement of 1:250 ratio (Hinchageri et. al., 2017). Due to these reasons, hospitals witness difficulties in coping with patient waiting time, customer satisfaction, medication errors, mortality rates, patient recovery time, and many others. Miglani Pratima (2015) conducted a study in a corporate chain of hospitals on the reduction of medication errors using Lean Six Sigma techniques. Medication errors are preventable errors that occur during prescribing, dispensing, or directing drugs by healthcare workers to the patients. In the case study, one of the wards recorded extremely high medication error rate, contributing around 31% of missed doses, 21% or wrong doses, and 17% of doses given at wrong time. This affected patient safety and delivery of care, ultimately worsening customer satisfaction rates in these hospitals. Lean Six Sigma methods attempted to implement improvement processes such as training nurses for medication administration, monitoring of medication errors, and introduction of a medication nurse to administer the process. The average time for a nurse to administer medications was decreased from 9 minutes to 4 minutes (~ by 55%) in a span of 3 months (Miglani, 2015). As a result, patient satisfaction increased, medication errors reduced, nurses work load decreased, and work flow became smoother. Considering the amount of people seeking healthcare services, patient satisfaction becomes one of the key performance indicators for hospitals in India. Patient services can be improved by advancing technologically and implementing modern equipment and models that will reduce paper work and increase efficiency. This will not only be cost effective, but will also increase customer satisfaction as they will get better services at affordable prices. Moreover, Indian hospitals need to increase the use of analytical elements such as SWOT and PEST analysis to understand and react according to environmental requirements. Understanding data, reducing manual administration, and spreading awareness by training are some of the ways hospitals can improve their patient satisfaction rates, especially when dealing with a large population. Improving quality and productivity is the primary focus of any healthcare organization. There are several internal and external factors that influence the structure and functions of a company. Therefore, hospitals need to examine its internal and external environments in order to implement process improvement measures. The paper focuses on the application of Lean Six Sigma technique for process improvement in two countries: United States and India. In Albuquerque, New Mexico, a Lean Six Sigma model was successful in increasing hand hygiene rates by 90% and reducing hospital-acquired infection rates by 51% (Carboneau, et. al., 2010). Future recommendations to improve hand hygiene throughout the country includes the implementation of advanced electronic monitoring system that can carry out electronic audits and provide accurate data for the future. In India, a case study was performed using Lean Six Sigma applications to reduce medication errors and decrease nurse administration times by 55% (Miglani, 2015). A significant amount of hospitals in India still work with manual administration methods such as paper prescriptions and paper medical records, which can create discrepancies in medication administration. Future recommendations for such hospitals is to implement electronic health record systems to make administration efficient, which will ultimately reduce such medication errors. Lean Six Sigma methods can prove to be extremely beneficial in implementing such changes in hospitals around the world. Lean Six Sigma has a lot of potential to change the face of healthcare in terms of quality, productivity, and performance.

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