Revista Meta: Avaliação

DMAIC is a Six Sigma methodological framework that has attracted the attention of researchers in the field of health (REIS et al., 2021). It is noticed that DMAIC has been used in several processes in health services, such as dispensing medication, hospital discharge and patient admission. Lean Six Sigma, based on the association of DMAIC with lean, brought important and valuable results in the context of health care, such as reducing the length of stay (LOS) in services, increasing patient satisfaction and reducing employee satisfaction. This study aims to evaluate how Lean Six Sigma/DMAIC has been implemented in the health area and its impacts on patient health care processes.

AHMED, S. Integrating DMAIC approach of lean six sigma and theory of constraints toward quality improvement in healthcare. Reviews on Environmental Health, Berlin, v. 34, n. 4, p. 427-434, 2019. DOI: 10.1515/reveh-2019-0003. Available in: https://pubmed.ncbi.nlm.nih.gov/31314742/. Access in: 13 dec. 2020.

AHSAN, K. B. et al. Emergency department resource optimisation for improved performance: a review. Journal of Industrial Engineering International, Tehran, v. 15, p. 253-266, 2019. DOI: https://doi.org/10.1007/s40092-019-00335-x. Available in: https://link.springer.com/article/10.1007/s40092-019-00335-x. Access in: 16 june 2020.

AL KUWAITI, A. Application of six sigma methodology to reduce medication errors in the outpatient pharmacy unit: a case study from the King Fahd University Hospital, Saudi Arabia. International Journal for Quality Research, Kragujevac, v. 10, n. 2, p. 267-278, 2016. DOI: 10.18421/IJQR10.02-03. Available in: https://www.proquest.com/docview/2555371898?pq-origsite=gscholar&fromopenview=true. Access in: 12 aug. 2020.

AL KUWAITI, A.; SUBBARAYALU, A. V. Reducing patients’ falls rate in an Academic Medical Center (AMC) using six sigma “DMAIC” approach. International Journal of Health Care Quality Assurance, Bingley, v. 30, n. 4, p. 373-384, 2017. DOI: 10.1108/IJHCQA-03-2016-0030. Available in: https://pubmed.ncbi.nlm.nih.gov/28470136/. Access in: 9 sept. 2020.

AL-ARAIDAH, O. et al. Lead-time reduction utilizing lean tools applied to healthcare: the inpatient pharmacy at a local hospital. Journal for Healthcare Quality, Chicago, v. 32, n. 1, p. 59-66, 2010. DOI: 10.1111/j.1945-1474.2009.00065.x. Available in: https://pubmed.ncbi.nlm.nih.gov/20151593/. Access in: 7 sept. 2020.

ALEEM, S. et al. Depression screening optimization in an academic rural setting. International Journal of Health Care Quality Assurance, Bingley, v. 28, n. 7, p. 709-725, 2015. DOI: 10.1108/IJHCQA-01-2015-0012. Available in: https://pubmed.ncbi.nlm.nih.gov/26241092/. Access in: 1 sept 2020.

ALLEN, T. T. et al. A. Improving the hospital discharge process with six sigma methods. Quality Engineering, New York, v. 22, n. 1, p.13-20, 2010. DOI: 10.1080/08982110903344812. Available in: https://www.tandfonline.com/doi/abs/10.1080/08982110903344812?journalCode=lqen20. Access in: 1 sept. 2020.

ANTONY, J. et al. Six sigma in healthcare: a systematic review of the literature. International Journal of Quality & Reliability Management, Bingley, v. 35, n. 5, p.1075-1092, 2018. DOI: 10.1108/IJQRM-02-2017-0027. Available in: https://www.researchgate.net/publication/318876629_Six_Sigma_in_Healthcare_A_Systematic_Review_of_the_Literature. Access in: 1 sept. 2020.

ARAFEH, M. et al. Using six sigma DMAIC methodology and discrete event simulation to reduce patient discharge time in King Hussein Cancer Center. Journal of Healthcare Engineering, London, v. 2018, p.1-18, 2018. DOI: https://doi.org/10.1155/2018/3832151. Available in: https://www.hindawi.com/journals/jhe/2018/3832151/. Access in: 1 sept. 2020.

ARAMAN, H.; SALEH, Y. A case study on implementing lean six sigma: DMAIC methodology in aluminum profiles extrusion process. The TQM Journal, Bingley, v. 35, n. 2, p. 337-365, 2023. DOI: https://doi.org/10.1108/TQM-05-2021-0154. Available in: https://www.emerald.com/insight/content/doi/10.1108/TQM-05-2021-0154/full/html. Access in: 6 june 2023.

BARROS, L. B. et al. C. Lean healthcare tools for processes evaluation: an integrative review. International Journal of Environmental Research and Public Health, Basel, v. 18, n. 14, 2021. DOI: 10.3390/ijerph18147389. Available in: https://pubmed.ncbi.nlm.nih.gov/34299840/. Access in: 6 june 2023.

BHAT, S. et al. Lean six sigma for the healthcare sector: a multiple case study analysis from the Indian context. International Journal of Quality & Reliability Management, Bingley, v. 37, n. 1, p. 90-111, 2020. DOI: https://doi.org/10.1108/IJQRM-07-2018-0193. Available in: https://www.emerald.com/insight/content/doi/10.1108/IJQRM-07-2018-0193/full/html. Access in: 9 sept. 2020.

BHAT, S.; GIJO, E. V.; JNANESH, N. A. Application of lean six sigma methodology in the registration process of a hospital. International Journal of Productivity and Performance Management, Bingley, v. 63, n. 5, p. 613-643, 2014. DOI: https://doi.org/10.1108/IJPPM-11-2013-0191. Available in: https://www.emerald.com/insight/content/doi/10.1108/IJPPM-11-2013-0191/full/html. Access in: 9 sept. 2020.

BHAT, S.; JNANESH, N. A. Application of lean six sigma methodology to reduce the cycle time of out-patient department service in a rural hospital. International Journal of Healthcare Technology and Management, Geneva, v. 14, n. 3, p. 222-237, 2014. DOI: https://doi.org/10.1504/IJHTM.2014.064257. Available in: https://www.inderscienceonline.com/doi/abs/10.1504/IJHTM.2014.064257. Access in: 9 sept. 2020.

BLACK, J. R.; MILLER, D. The Toyota way to healthcare excellence: increase efficiency and improve quality with lean. 2. ed. Chicago: Health Administration Press, 2016.

CHAVES, S. M. A. et al. Fast track in emergency services an integrative review. In: DOLGUI, A.; BERNARD, A.; LEMOINE, D.; CIEMINSKI, G. von; ROMERO, D. (ed.). Advances in production management systems: artificial intelligence for sustainable and resilient production systems: part II. Nantes: Springer International Publishing, 2021. p. 241-249. Available in: https://link.springer.com/chapter/10.1007/978-3-030-85902-2_26#:~:text=It%20was%20concluded%20that%20Fast,performance%20in%20the%20emergency%20services. Access in: 4 dec. 2021.

CHEUNG, Y. Y.; GOODMAN, E. M.; OSUNKOYA, T. O. No more waits and delays: streamlining workflow to decrease patient time of stay for image-guided musculoskeletal procedures. Radiographics, Easton, v. 36, n. 3, p. 856-871, 2016. DOI: 10.1148/rg.2016150174. Available in: https://pubmed.ncbi.nlm.nih.gov/27163595/. Access in: 9 sept. 2020.

CHIARINI, A. From total quality control to lean six sigma: evolution of the most important management systems for the excellence. Milan: Springer, 2012.

COUGHLIN, K.; POSENCHEG, M. A. Quality improvement methods: part II. Journal of Perinatology, New York, v. 39, n. 7, p. 1000-1007, 2019. DOI: https://doi.org/10.1038/s41372-019-0382-1. Available in: https://www.nature.com/articles/s41372-019-0382-1. Access in: 15 sept. 2020.

CUDNEY, E. A.; FURTERER, S.; DIETRICH, D. (ed.). Lean systems: applications and case studies in manufacturing, service, and healthcare. Boca Raton: CRC Press, 2013.

DANG, A. et al. Using process improvement tools to improve the care of patients with neutropenic fever in the emergency room. Journal of Oncology Practice, Alexandria, v. 14, n. 1, p. 73-81, 2018. DOI: 10.1200/JOP.2017.026054. Available in: https://pubmed.ncbi.nlm.nih.gov/29324209/. Access in: 15 sept. 2020.

DELLIFRAINE, J. L.; LANGABEER II, J. R.; NEMBHARD, I. M. Assessing the evidence of six sigma and Lean in the health care industry. Quality Management in Health Care, Philadelphia, v. 19, n. 3, p. 211-225, 2010. DOI: 10.1097/QMH.0b013e3181eb140e. Available in: https://pubmed.ncbi.nlm.nih.gov/20588140/. Access in: 16 july 2020.

DREACHSLIN, J. L.; LEE, P. D. Applying six sigma and DMAIC to diversity initiatives. Journal of Healthcare Management, Chicago, v. 52, n. 6, p. 361-367, 2007. Available in: https://pubmed.ncbi.nlm.nih.gov/18087977/. Access in: 31 may 2020.

FERNANDES, H. M. de L. G. et al. Lean healthcare in the institutional, professional, and patient perspective: an integrative review. Revista Gaúcha de Enfermagem, Porto Alegre, v. 41, 2020. DOI: https://doi.org/10.1590/1983-1447.2020.20190340. Available in: https://www.scielo.br/j/rgenf/a/NXrNmFCz8cSkcswKH7XDBqt/?lang=en. Access in: 6 june 2023.

GEORGE, M. L. Lean six sigma for service: how to use lean speed and six sigma quality to improve services and transactions. New York: McGraw-Hill, 2003.

GIJO, E. V. et al. Reducing patient waiting time in a pathology department using the six sigma methodology. Leadership in Health Services, Bingley, v. 26, n. 4, p. 253-267, 2013. DOI: https://doi.org/10.1108/LHS-02-2012-0004. Available in: https://www.emerald.com/insight/content/doi/10.1108/LHS-02-2012-0004/full/html. Access in: 15 sept. 2020.

GOH, T. N. et al. Six sigma: a SWOT analysis. International Journal of Six Sigma and Competitive Advantage, Geneva, v. 2, n. 3, p. 233-242, 2006. DOI: https://doi.org/10.1504/IJSSCA.2006.011116. Available in: https://www.inderscienceonline.com/doi/abs/10.1504/IJSSCA.2006.011116. Access in: 15 sept. 2020.

GOH, T. N.; XIE, M. Statistical control of a six sigma process. Quality Engineering, New York, v. 15, n. 4, p. 587-592, 2003. DOI: https://doi.org/10.1081/QEN-120018391. Available in: https://www.tandfonline.com/doi/abs/10.1081/QEN-120018391. Access in: 15 sept. 2020.

HENRIQUE, D. B.; GODINHO FILHO, M. A systematic literature review of empirical research in Lean and Six Sigma in healthcare. Total Quality Management & Business Excellence, London, v. 31, n. 3-4, p. 429-449, 2018. DOI: https://doi.org/10.1080/14783363.2018.1429259 Available in: https://www.tandfonline.com/doi/full/10.1080/14783363.2018.1429259. Access in: 23 july 2021.

HOLWEG, M. The genealogy of lean production. Journal of Operations Management, Amsterdam, v. 25, n. 2, p. 420-437, 2007. DOI: https://doi.org/10.1016/j.jom.2006.04.001. Available in: https://www.sciencedirect.com/science/article/abs/pii/S0272696306000313. Access in: 25 may 2020.

IMPROTA, G. et al. Improving performances of the knee replacement surgery process by applying DMAIC principles. Journal of Evaluation in Clinical Practice, New York, v. 23, n. 6, p. 1401-1407, 2017. DOI: 10.1111/jep.12810. Available in: https://pubmed.ncbi.nlm.nih.gov/28948662/. Access in: 15 sept. 2020.

IMPROTA, G. et al. Lean six sigma in healthcare: fast track surgery for patients undergoing prosthetic hip replacement surgery. The TQM Journal, Bingley, v. 31, n. 4, p. 526-540, 2019a. DOI: 10.1108/TQM-10-2018-0142. Available in: https://www.ingentaconnect.com/content/mcb/tqm2/2019/00000031/00000004/art00001. Access in: 15 sept. 2020.

IMPROTA, G. et al. Lean six sigma: a new approach to the management of patients undergoing prosthetic hip replacement surgery. Journal of Evaluation in Clinical Practice, New York, v. 21, n. 4, p. 662-672, 2015. DOI: 10.1111/jep.12361. Available in: https://pubmed.ncbi.nlm.nih.gov/25958776/. Access in: 23 sept. 2021.

IMPROTA, G. et al. The application of six sigma to reduce the pre-operative length of hospital stay at the hospital Antonio Cardarelli. International Journal of Lean Six Sigma, Bingley, v. 11, n. 3, p. 555-576, 2019b. DOI: https://doi.org/10.1108/IJLSS-02-2019-0014. Available in: https://www.emerald.com/insight/content/doi/10.1108/IJLSS-02-2019-0014/full/html. Access in: 15 sept. 2020.

ISLAM, K. A. Developing and measuring training: the six sigma way. San Francisco, CA: Pfeifeer, 2006.

KWAK, Y. H.; ANBARI, F. T. Benefits, obstacles, and future of six sigma approach. Technovation, Essex, v. 26, n. 5-6, p. 708-715, 2006. DOI: 10.1016/j.technovation.2004.10.003. Available in: http://www.inf.ufsc.br/~joao.dovicchi/pos-ed/pos/gerti/resenhas/Anbari_Research_Benefits_Obstacles_Future_Six_Sigma.pdf. Access in: 15 sept. 2020.

LIMA, A. da C. et al. Potential of continuing education in health of improvement practices in urgency and emergencies in emergency care units – UPA-24h. IFAC-PapersOnLine, Luxenburg, v. 55, n. 10, p. 906–909, 2022. DOI: https://doi.org/10.1016/j.ifacol.2022.09.417. Available in: https://www.sciencedirect.com/science/article/pii/S2405896322017037. Acess in: 17 april 2023.

LINDEN, M. C. C. van der; UFFORD, H. M. E. J. van; LINDEN, N. N. van der. The impact of a multimodal intervention on emergency department crowding and patient flow. International Journal of Emergency Medicine, [S. l.], v. 12, n. 1, 2019. DOI: 10.1186/s12245-019-0238-7. Available in: https://pubmed.ncbi.nlm.nih.gov/31455260/. Access in: 15 sept. 2020.

MAHANTI, R.; ANTONY, J. Confluence of six sigma, simulation and software development. Managerial Auditing Journal, Bradford, v. 20, n. 7, p. 739-762, 2005. DOI: 10.1108/02686900510611267. Available in: https://ideas.repec.org/a/eme/majpps/02686900510611267.html. Access in: 5 june 2023.

MCDERMOTT, O. et al. Lean six sigma in healthcare: a systematic literature review on motivations and benefits. Processes, Basel, v. 10, n. 10, 2022. DOI: https://doi.org/10.3390/pr10101910. Available in: https://www.mdpi.com/2227-9717/10/10/1910l. Access in: 5 june 2023.

MITTAL, A. et al. The performance improvement analysis using six sigma DMAIC methodology: a case study on Indian manufacturing company. Heliyon, Cambridge, v. 9, n. 3, p. 1-11, 2023. DOI: https://doi.org/10.1016/j.heliyon.2023.e14625. Available in: https://www.sciencedirect.com/science/article/pii/S2405844023018327. Access in: 6 june 2023.

MOHER, D. et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med, San Francisco, CA, v. 6, n. 7, 2009. DOI: 10.1371/journal.pmed.1000097. Available in: https://pubmed.ncbi.nlm.nih.gov/19621072/. Access in: 4 aug. 2020.

MOUSLI, H. M. et al. Improving VTE prophylaxis in ward and ICU surgical urology patients: a six-sigma DMAIC methodology improvement project. The TQM Journal, Bingley, 2023. DOI: https://doi.org/10.1108/TQM-09-2022-0281. Available in: https://www.emerald.com/insight/content/doi/10.1108/TQM-09-2022-0281/full/html. Access in: 4 june 2023.

NIÑEROLA, A.; SÁNCHEZ-REBULL, M. V.; HERNÁNDEZ-LARA, A. B. Quality improvement in healthcare: six sigma systematic review. Health Policy, Armsterdam, v. 124, n. 4, p. 438-445, 2020. DOI: 10.1016/j.healthpol.2020.01.002. Available in: https://pubmed.ncbi.nlm.nih.gov/32156468/. Access in: 2 feb. 2021.

PANDE, P. S.; NEUMAN, R. P.; CAVANAGH, R. R. The six sigma way team fieldbook: an implementation guide or project improvement teams. New York: McGraw-Hill, 2002.

PEPPER, M. P.; SPEDDING, T. A. The evolution of lean six sigma. International Journal of Quality & Reliability Management, Bingley, v. 27, n. 2, p. 138-155, 2010. DOI: http://dx.doi.org/10.1108/02656711011014276. Available in: https://ro.uow.edu.au/commpapers/1706/. Access in: 2 feb. 2021.

PEREIRA, M. G.; GALVÃO, T. F. Extração, avaliação da qualidade e síntese dos dados para revisão sistemática. Epidemiologia e Serviços de Saúde, Brasília, DF, v. 23, n. 3, p. 577-578, 2014. DOI: 10.5123/S1679-49742014000300021. Available in: http://scielo.iec.gov.br/pdf/ess/v23n3/v23n3a21.pdf. Access in: 3 june 2021.

PEREIRA, N. N. et al. Monitoring patient flow in the one emergency care unit (UPA) in São Paulo Brazil. IFAC-PapersOnLine, Laxenburg, v. 55, n. 10, p. 561-565, 2022. DOI: https://doi.org/10.1016/j.ifacol.2022.09.453. Available in: https://www.sciencedirect.com/science/article/pii/S2405896322017438?via%3Dihub. Access in: 17 april 2023.

PRASHAR, A. Six sigma adoption in public utilities: a case study. Total Quality Management & Business Excellence, Abingdon, v. 27, n. 5-6, p.479-506, 2015. DOI: https://doi.org/10.1080/14783363.2015.1014782. Available in: https://www.tandfonline.com/doi/abs/10.1080/14783363.2015.1014782. Access in: 2 june 2023.

PYZDEK, T.; KELLER, P. A. The six sigma handbook: a complete guide for green belts, black belts, and managers at all levels. 3. ed. New York: McGraw-Hill, 2010.

RAVAL, S. J.; KANT, R.; SHANKAR, R. Revealing research trends and themes in lean six sigma: from 2000 to 2016. International Journal of Lean Six Sigma, Bingley, v. 9, n. 3, p. 399-443, 2018. DOI: https://doi.org/10.1108/IJLSS-03-2017-0021. Available in: https://www.emerald.com/insight/content/doi/10.1108/IJLSS-03-2017-0021/full/html. Access in: 2 apr. 2020.

REIS, M. et al. (ed.). Advances in production management systems: artificial intelligence for sustainable and resilient production systems: part II. Nantes: Springer International Publishing, 2021. p. 269-279. Available in: https://link.springer.com/chapter/10.1007/978-3-030-85902-2_29#:~:text=The%20main%20motivators%20for%20the,in%20user%20and%20team%20satisfaction. Access in: 22 dec. 2021.

RICCIARDI, C. et al. Fast track surgery for knee replacement surgery: a lean six sigma approach. The TQM Journal, Bingley, v. 32, n. 3, p. 461-474, 2020. DOI: https://doi.org/10.1108/TQM-06-2019-0159. Available in: https://www.emerald.com/insight/content/doi/10.1108/TQM-06-2019-0159/full/html. Access in: 16 sept. 2020.

RICCIARDI, C. et al. Lean six sigma approach to reduce LOS through a diagnostic-therapeutic-assistance path at A.O.R.N. A. Cardarelli. The TQM Journal, Bingley, v. 31, n. 5, p. 657-672, 2019. DOI: 10.1108/tqm-02-2019-0065. Available in: https://www.semanticscholar.org/paper/Lean-Six-Sigma-approach-to-reduce-LOS-through-a-at-Ricciardi-Fiorillo/9b28548cacdda11cddd8ca21e1aa7df8a4d81975. Access in: 16 sept. 2020.

ROSA, A. et al. Lean six sigma to reduce the acute myocardial infarction mortality rate: a single center study. The TQM Journal, Bingley, v. 35, n. 9, p. 25-41, 2023. DOI: https://doi.org/10.1108/TQM-03-2022-0082. Available in: https://www.emerald.com/insight/content/doi/10.1108/TQM-03-2022-0082/full/html. Access in: 5 june 2023.

SAMANTA, A. K.; VARAPRASAD, G.; GURUMURTHY, A. Implementing lean six sigma in health care: a review of case studies. International Journal of Lean Six Sigma, Bingley, v. 14, n. 1, p. 158-189, 2023. DOI: https://doi.org/10.1108/IJLSS-08-2021-0133. Available in: https://www.emerald.com/insight/content/doi/10.1108/IJLSS-08-2021-0133/full/html. Access in: 5 june 2023.

SANTOS, A. B. et al. Application of the enterprise diagnosis method in healthcare: an evaluation study in three emergency care units in the state of São Paulo - Brazil. Meta: Avaliação, Rio de Janeiro, v. 13, n. 41, p. 884-900, 2021. DOI: http://dx.doi.org/10.22347/2175-2753v13i41.3755. Available in: https://revistas.cesgranrio.org.br/index.php/metaavaliacao/article/view/3755. Access in: 20 dec. 2022.

SCALA, A. et al. Lean six sigma approach for reducing length of hospital stay for patients with femur fracture in a university hospital. International Journal of Environmental Research and Public Health, Basel, v. 18, n. 6, 2021. DOI: 10.3390/ijerph18062843. Available in: https://pubmed.ncbi.nlm.nih.gov/33799518/. Access in: 4 june 2023.

SILICH, S. J. et al. Using six sigma methodology to reduce patient transfer times from floor to critical-care beds. Journal for Healthcare Quality, Chicago, v. 34, n. 1, p. 44-54, 2012. DOI: 10.1111/j.1945-1474.2011.00184.x. Available in: https://pubmed.ncbi.nlm.nih.gov/23552174/#:~:text=Conclusions%3A%20The%20Six%20Sigma%20approach,to%20a%20critical%20care%20area. Access in: 20 sept. 2020.

SINGH, A. et al. Application of six sigma and 5 S to improve medication turnaround time. International Journal of Healthcare Management, London, v. 14, n. 4, p.1279-1287, 2021. DOI: https://doi.org/10.1080/20479700.2020.1757873. Available in: https://www.tandfonline.com/doi/abs/10.1080/20479700.2020.1757873?journalCode=yjhm20#:~:text=However%2C%20hospitals%20can%20always%20strive,%2C%20which%20is%20almost%2043%25. Access in: 20 sept. 2020.

SNEE, R. D. Lean six sigma - getting better all the time. International Journal of Lean Six Sigma, Bingley, v. 1, n. 1, p. 9-29, 2010. DOI: https://doi.org/10.1108/20401461011033130. Available in: https://www.emerald.com/insight/content/doi/10.1108/20401461011033130/full/html. Access in: 1 oct. 2020.

SORDAN, J. E. et al. Characterization of lean six sigma projects in healthcare settings: empirical research. Benchmarking: an International Journal, London, 2022. DOI: https://doi.org/10.1108/BIJ-03-2022-0183. Available in: https://www.emerald.com/insight/content/doi/10.1108/BIJ-03-2022-0183/full/html. Access in: 4 july 2023.

STAMATIS, D. H. Essentials for the improvement of healthcare using lean and six sigma. New York: Productivity Press, 2011.

SUNDER, M, V.; GANESH, L. S. Summary and conclusions. In: LEAN SIX SIGMA IN BANKING SERVICES. Future of business and finance. Singapore: Springer, 2020. DOI: https://doi.org/10.1007/978-981-15-3820-9_7. Avaible in: https://link.springer.com/chapter/10.1007/978-981-15-3820-9_7. Access in: 10 june 2020.

TANER, M. T.; SEZEN, B.; ANTONY, J. An overview of six sigma applications in the healthcare industry. International Journal of Health Care Quality Assurance, Bingley, v. 20, n. 4, p. 329-340, 2007. DOI: https://doi.org/10.1108/09526860710754398. Available in: https://www.emerald.com/insight/content/doi/10.1108/09526860710754398/full/html. Access in: 20 june 2020.

TLAPA, D. et al. Effects of lean healthcare on patient flow: a systematic review. Value in Health, [S. l.], v. 23, n. 2, p. 260-273, 2020. DOI: 10.1016/j.jval.2019.11.002. Available in: https://pubmed.ncbi.nlm.nih.gov/32113632/. Access in: 24 may 2020.

TRAKULSUNTI, Y. et al. Reducing medication errors using lean six sigma methodology in a Thai hospital: an action research study. International Journal of Quality and Reliability Management, Edinburgh, v. 38, n. 1, p. 339-362, 2021. DOI: 10.1108/IJQRM-10-2019-0334. Available in: https://researchportal.hw.ac.uk/en/publications/reducing-medication-errors-using-lean-six-sigma-methodology-in-a-. Access in: 15 sept. 2020.

TUFAIL, M. M. B. et al. Implementation of lean six-sigma project in enhancing health care service quality during COVID-19 pandemic. AIMS Public Health, Springfield, v. 8, n. 4, p. 704-719, 2021. DOI: 10.3934/publichealth.2021056. Available in: https://pubmed.ncbi.nlm.nih.gov/34786430/. Access in: 4 june 2023.

ULUSKAN, M. A comprehensive insight into the six sigma DMAIC toolbox. International Journal of Lean Six Sigma, Bingley, v. 7, n. 4, p. 406-429, 2016. DOI: https://dx.doi.org/10.1108/IJLSS-10-2015-0040. Available in: https://earsiv.anadolu.edu.tr/xmlui/handle/11421/20862. Access in: 2 june 2022.

VIJAY, S. A. Reducing and optimizing the cycle time of patients discharge process in a hospital using six sigma DMAIC approach. International Journal for Quality Research, Kragujevac, v. 8, n. 2, p. 169-182, 2014. Available in: http://www.ijqr.net/journal/v8-n2/3.pdf. Access in: 1 oct. 2020.

YAMAMOTO, J.; ABRAHAM, D.; MALATESTINIC, B. Improving insulin distribution and administration safety using lean six sigma methodologies. Hospital Pharmacy, Saint Louis, v. 45, n. 3, p. 212-224, 2010. DOI: https://doi.org/10.1310/hpj4503-212. Available in: https://journals.sagepub.com/doi/10.1310/hpj4503-212. Access in: 1 oct. 2020.

ZIMMERMANN, G. dos S.; SIQUEIRA, L. D.; BOHOMOL, E. Lean six sigma methodology application in health care settings: an integrative review. Revista Brasileira de Enfermagem, Brasília, DF, v. 73, sup. 5, 2020. DOI: https://doi.org/10.1590/0034-7167-2019-0861. Available in: https://www.scielo.br/j/reben/a/g6J7PjGpT4T8VmKwHbvPtnp/?format=pdf〈=pt. Access in: 6 june 2023.