International Journal of Health Care Quality Assurance

Lean Six Sigma implementation and organizational culture

Susan Knapp
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Journal of Health Care Quality Assurance, Vol. 28 Iss 8 pp. 855 - 863
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Lean Six Sigma implementation Lean Six Sigma

implementation
and organizational culture
Susan Knapp
School of Business, Kaplan University, Fort Lauderdale, Florida, USA 855
Abstract Received 9 December 2014
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Revised 23 June 2015

Purpose – The purpose of this paper is to examine the relationship between four organizational Accepted 5 July 2015
cultural types defined by the Competing Values Framework and three Lean Six Sigma implementation
components – management involvement, use of Lean Six Sigma methods and Lean Six Sigma
infrastructure.
Design/methodology/approach – The study involved surveying 446 human resource and quality
managers from 223 hospitals located in Maine, New Hampshire, Vermont, Massachusetts and
Rhode Island using the Organizational Culture Assessment Instrument.
Findings – In total, 104 completed responses were received and analyzed using multivariate analysis
of variance. Follow-up analysis of variances showed management support was significant,
F(3, 100) ¼ 4.89, p o0.01, η2 ¼ 1.28; infrastructure was not significant, F(3, 100) ¼ 1.55, p ¼ 0.21,
η2 ¼ 0.05; and using Lean Six Sigma methods was also not significant, F(3, 100) ¼ 1.34, p ¼ 0.26,
η2 ¼ 0.04. Post hoc analysis identified group and development cultures having significant interactions
with management support.
Practical implications – The relationship between organizational culture and Lean Six Sigma in
hospitals provides information on how specific cultural characteristics impact the Lean Six Sigma
initiative key components. This information assists hospital staff who are considering implementing
quality initiatives by providing an understanding of what cultural values correspond to effective Lean
Six Sigma implementation.
Originality/value – Managers understanding the quality initiative cultural underpinnings, are attentive
to the culture-shared values and norm’s influence can utilize strategies to better implement Lean Six Sigma.
Keywords Six Sigma, Lean thinking, Improvement models, Organizational culture,
Quality improvement, Change management
Paper type Research paper

Introduction
Faced with increasing costs, reduced reimbursements and a need to reduce medical
errors, hospital managers are searching for methods that reduce costs while improving
patient care. Managers in several hospitals have implemented Lean Six Sigma with the
anticipation that the approach will reduce medical errors and subsequently control costs
(Chassin, 2013). Several studies identify the significant influence culture has on
successful quality initiatives (Rad, 2006). Carnell (2004) showed that without considering
culture and without creating an organization-wide empowerment atmosphere combined
with accountability, Lean Six Sigma will be merely a rote by-the-numbers activity
performed by disinterested employees. This study’s purpose was to examine how
Lean Six Sigma implementation in hospitals, including key components such as
management involvement, statistical methods and an effective organizational
infrastructure, relates to four organizational cultural types in the Competing Values
Framework: group; developmental; rationale; and hierarchical. This research helps us to
International Journal of Health
understand what hospital staff are using to improve service quality and overall Care Quality Assurance
organizational performance, and provides an opportunity to examine the role that Vol. 28 No. 8, 2015
pp. 855-863
organizational culture has on successful Six Sigma implementation. This information will © Emerald Group Publishing Limited
0952-6862
assist hospital managers who are considering implementing quality initiatives by DOI 10.1108/IJHCQA-06-2015-0079
 IJHCQA providing an understanding of what cultural values correspond with successful Lean Six
28,8 Sigma implementation. If managers understand the quality initiative cultural
underpinnings and are attentive to the influence of culture-shared values and norms
then the initiative is more likely to succeed.

Lean Six Sigma

856 Lean Six Sigma is a comprehensive system for achieving and sustaining business
success through understanding customer needs, data discipline; adding value by
reducing waste; and diligent attention to managing and improving processes
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(Voehl et al., 2013). A key Lean Six Sigma component is top manager involvement and
support (Hann et al., 2007). Beer (2003) found top management influences Six Sigma’s
success or failure by taking actions and making decisions that are consistent with the
initiative and by creating open communication about the implementation process that will
enable learning and further change. Another Lean Six Sigma key component is statistical
and graphical analysis that is used with process scrutiny. The graphical analysis includes
process and value stream maps, Pareto charts, histograms, box plots and control charts.
These tools are used to demonstrate measurable results and to achieve financial return
from a Lean Six Sigma project (Trusko et al., 2007). A third key component is the unique
infrastructure that uses champions, black belts and green belts to lead and implement the
Lean Six Sigma initiative. Green belts and black belts are staff extensively trained in Lean
Six Sigma methods and lead improvement projects. The champion is generally a senior
manager who oversees an improvement project. Ensuring that these three components are
effective is critical to Six Sigma success (Benitez et al., 2007). This study analyzed the
relationship between cultural characteristics and three key Six Sigma components.

Organizational culture
Organizational culture can be defined as the assumptions and beliefs shared by
organization members, which influence how staff perceive, think and act (Schein, 2010).
A common theme in the definitions is shared values and beliefs that are used to make
decisions when performing duties. Values are the fundamental concepts and beliefs
that identify success within an organization. Culture also conveys meaning to
organizational members by providing a unifying purpose and sense of community.
Culture’s significance has frequently been overlooked by managers as they implement
an organizational initiative. While culture is deep seated and difficult to change, there
are several strategies that leaders can use to help influence culture; e.g., determining
what pay attention to, measure and control. Another important influence is deliberate
role modeling, teaching and coaching that is conducted by organization leaders that
helps facilitate others who are internalizing desired values. Another strategy for
influencing culture is the criteria used for allocating rewards and status. Schein (2010)
described how altering reward systems, work procedures, objectives and work teams
can influence changes in behavior. These strategies are important for ensuring Lean
Six Sigma’s successful implementation.

Competing Values Framework

The literature includes several models that have been developed to provide structure and
definition to organizational culture. A most frequently cited model is the Competing
Values Framework, which is built on two dimensions that represent the competing values
that exist in organizations. Each dimension identifies values and key performance criteria
that are opposite from the values and performance criteria at each end of the continuum.
 One dimension differentiates flexibility and discretion from stability, order and control. Lean Six Sigma
Cameron et al. (2006) found that some organizations are viewed as effective if they are implementation
changing and adapting, such as Microsoft and Nike, while other organizations are viewed
as effective because they are stable and durable, such as most universities and companies
like Coca-Cola. The other dimension differentiates a focus on internal capability and
integration from external orientation and differentiation from rivals. An internal focus
includes factors internal to the organization, such as employee morale and cohesion. 857
The external focus measures effectiveness using the staff’s ability to function well in their
environment. Cameron et al. (2006) showed that organizations, such as Dell and
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Hewlett-Packard, are characterized by harmonious internal characteristics, in contrast to

organizations that focus on challenging and competing with rivals, such as Toyota.
There two dimensions form four quadrants: group; developmental; hierarchical; and
rational. Group culture has an internal focus and an emphasis on flexibility and cohesion.
There is a sense of togetherness along with teamwork and participation in this cultural type.
There is a tendency for minimal management levels with supervisors being viewed more as
mentors rather than bosses. Leaders are assumed to be most effective through teamwork
and joint decision making. Loyalty, tradition collaboration, involvement and consensus are
highly valued. Employee involvement is emphasized and decision making is moved to the
individual performing the work. The strategic emphasis is toward developing human
resources, commitment and morale. Success is defined by the internal climate and concern
for organization members (Cameron and Quinn, 1999). Developmental culture also
emphasizes flexibility, but has an external focus. Culture is geared toward innovation, risk
taking and individuality. The challenge is to adapt quickly to new opportunities.
Organizational effectiveness is associated with entrepreneurship, vision and constant
change. Teams are quickly formed and disbanded. Members are expected to be adaptable,
flexible and creative. Power is decentralized to facilitate rapid decision making. Initiative and
freedom are encouraged to promote competitive advantage. Leaders are expected to instill
vision, take risks and be inventive. The long-term organizational goal is to use new products
and services to drive rapid organizational growth. The hierarchical culture is both control
and internal oriented and has a rigorous adherence to formal rules, procedures, structure
and authority. There is an emphasis on structural stability with member roles clearly
defined and enforced through policies and procedures. There are well-defined multiple
authority levels. Leadership strategies focus on reducing errors, outcome standardization
and consistency with an organizing and monitoring leadership style. Cameron and Quinn
(1999) point out that hierarchy cultures stress efficiency with policies and procedures being
the united force. Value results from increasing certainty and eliminating anything that
prevents regularity. Generally, these organizations do not respond well to change. The focus
is to do more of what is known rather than on seizing new opportunities (Goodman et al.,
2001). The strategic emphasis is toward stability, predictability and smooth operations.
The rational culture is control oriented, focussed externally and has an emphasis on
productivity and goal achievement. There is an emphasis on competition, fast response and
customer focus. Leaders tend to be aggressive and competitive and implement strategies
that are focussed on producing short-term profitability for stakeholders. Customers and
rapid response are the highest priorities and the strategic emphasis is toward competitive
advantage and market superiority (Goodman et al., 2001).
The four cultural types are further defined by six dimensions: dominant characteristics;
leadership style; organizational glue; organizational climate (existing work environment);
success criteria; and management style. The dominant characteristics dimension refers to
core values, such teamwork or commitment to goals. Organizational glue is the bonding
 IJHCQA mechanisms that hold an organization together, such as cohesion, commitment and loyalty.
28,8 Organizational climate is the existing work environment. The management style
dimension refers to how employees are treated, consulted and participate. Cameron and
Quinn (1999) indicated that although it appears that values located in opposite quadrants
compete or are even contradictory, they are not mutually exclusive. Organizations exist in
dynamic environments and subsequently need to operate in all four quadrants as
858 determined by existing environmental factors; e.g., effective leadership will involve
supporting team development and participatory decision making (group culture elements)
while achieving high productivity (a rational culture element). Balancing the dimensions
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ensures that staff have the capacity to respond to many environmental conditions.

Research method
The study’s independent variables were organizational cultural types, measured by the
Competing Values Framework through participant responses to 24 questions included
in the survey’s organizational culture section. The dependent variables were Lean Six
Sigma implementation key elements: senior management support; Lean Six Sigma
infrastructure; and using Lean Six Sigma methods. The scores for these variables were
calculated from responses to a questions about how respondents perceive their
organization regarding implementing each component. The scores ranged from 1
(very low utilization) to 5 (very high utilization).

Materials and instruments

Organizational culture was measured using the Organizational Culture Assessment
Instrument, which includes six sections representing six organizational culture dimensions:
organizational leadership; managing employees; organizational glue; strategic emphasis;
dominant characteristics; and success criteria. Each section includes four questions
formatted as a five-point Likert scale. Each question corresponds to one of four Competing
Values Framework cultural types. The questionnaire’s second section involved questions
related to the respondent’s view of the hospital’s quality initiative. This section involved
assessing how staff used quality methods, senior management support and infrastructure.
The scores ranged from 1 (very low utilization) to 5 (very high utilization). The researcher
consulted three quality experts to identify the key dimensions associated with Lean Six
Sigma infrastructure, senior management support and Six Sigma methods. These
dimensions were developed into 16 questions based on a five-point Likert scale.
The response options ranged from 1 to 5 (1 very low Lean Six Sigma component use and
5 very high use). The questions asked responders to report their perceptions of their
organizations’ success when implementing Lean Six Sigma implementation’s three
elements. The instrument’s third section covered demographics: respondent’s job title,
hospital size (based employee and bed count); state in which the hospital was located;
quality management program; and the quality program’s age. The instrument was piloted
to test and gather feedback on the survey. Two Lean Six Sigma master black belts and a
pilot group (two hospital quality and two human resource managers) were sent the cover
letter and survey instrument. Pilot group members were asked to review the instrument
and cover letter for clarity and completeness to they were: relevant; easy to understand; and
suggest ways to improve the cover letter and instrument.

Participants
The combined instrument was used to survey member hospital quality managers and
human resource managers in Massachusetts, Rhode Island, Maine, New Hampshire and
 Vermont hospital associations. During the study there were 223 member hospitals: 39 in Lean Six Sigma
Maine, 26 in New Hampshire, 17 in Vermont, 131 in Massachusetts and ten in Rhode Island. implementation
Therefore, the sample frame included 446 potential participants from 223 New England
hospitals. A power analysis was conducted to determine the likelihood that the statistics
would detect the independent variable’s effects. The power used was 0.8. The sample size
needed at the 0.8 level to test for the difference in the dependent variable was 98.
859
Data analysis
The first analysis stage was calculating the descriptive statistics: frequencies,
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percentages, means and standards deviations. The demographic information included

items related to the participating hospitals, such as total beds and employees.
The demographic information also related to items specific to individual responders,
such as tenure with current employer. Analysis was accomplished with SPSS.
A factorial multivariate analysis of variance (MANOVA) was conducted to evaluate the
interactions between four organizational cultural types and three Six Sigma
components. One-way analysis of variance (ANOVA) calculations determined the
interactions between three Six Sigma components. Post hoc comparisons were
conducted to study pair-wise differences among factors where results were significant.

Results
In total, 104 healthcare professionals completed the questionnaire; 55 responders were
quality managers and 49 were human resource managers. In total, 22 responses were
from Maine; 21 from New Hampshire, 11 from Vermont, 42 from Massachusetts and
eight from Rhode Island. In total, 42 percent of responders were from hospitals with one
to 99 beds; 29 percent from hospitals with 100 to 249 beds, 17 percent, 250 to 400 beds
and 12 percent from hospitals more than 400 beds. Responses-based hospital size and
employee count were 6 percent from hospitals with one to 200 employees; 26 percent,
201 to 500 employees; 30 percent, 501 to 1,200 employees; and 38 percent were
1,200 employees or more. Most hospitals (92 percent) had quality management
initiatives in place; 35 percent using a Lean Six Sigma variation. Among Lean Six
Sigma organizations, 73 percent had used Lean Six Sigma for less than two years;
22 percent, three to five years; and 5 percent more than five years.
The instrument section focussing on quality practices had questions addressing
three Lean Six Sigma components: management support, infrastructure and methods.
Three questions were specific to three components. The maximum score for each
component was 15 and the minimum was 3. The mean score for the management
support component was 10.2 with a 1.92 (n ¼ 104) standard deviation. The mean score
for infrastructure was 6.8 with a standard deviation of 2.6 (n ¼ 104) and the mean score
for methods was 8.3 with a 1.96 (n ¼ 104) standard deviation.
MANOVA was calculated to evaluate organizational cultural types the interactions
between the organizational cultural types (group, hierarchical, developmental and
rational) on the dependent (management support, infrastructure and Lean Six Sigma
method). Significant effects were found on the organizational cultural types:
Wilks ¼ 0.68, F(9, 238) ¼ 4.4, p o 0.01. The ANOVA on management support was
significant, F(3, 100) ¼ 4.89, p o 0.01, η2 ¼ 1.28. The ANOVA on infrastructure was not
significant, F(3, 100) ¼ 1.55, p ¼ 0.21, η2 ¼ 0.05. The ANOVA on Six Sigma methods
was not significant, F(3, 100) ¼ 1.34, p ¼ 0.26, η2 ¼ 0.04. The ANOVA results showing
differences in the independent variables are summarized in Table I.
 IJHCQA Research questions
28,8
RQ1. To what extent, if any, is there an interaction between group organizational
culture type (Competing Values Framework) and the Lean Six Sigma
implementation key element – management support?
The ANOVA conducted on management support was significant, F(3, 100) ¼ 4.89,
860 p o 0.01, η2 ¼ 1.28. Post hoc analysis on management support involved conducting
pair-wise comparisons to determine which cultural type had the greatest impact on this
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variable. The post hoc analysis identified the group culture as having the greatest
interaction with management support. There was a significant interaction between
group culture and senior management support. The post hoc analysis results are
summarized in Table II:
RQ2. To what extent, if any, is there an interaction between developmental
organizational culture type (Competing Values Framework) and the Lean Six
Sigma implementation key element – management support?
The ANOVA on management support was significant, F(3, 100) ¼ 4.89, po0.01,
η2 ¼ 1.28. The post hoc analysis showed that the developmental culture had an impact on
management support. There was a significant interaction between developmental culture
and management support. The post hoc analysis results are summarized in Table II:
RQ3. To what extent, if any, is there an interaction between hierarchical
organizational culture type (Competing Values Framework) and the key Lean
Six Sigma implementation element – infrastructure?
The ANOVA showed no significant main effects of organizational culture on
infrastructure, F(3, 100) ¼ 1.55, p ¼ 0.21, η2 ¼ 0.05:
RQ4. To what extent is there an interaction between rational organizational culture
type (Competing Values Framework) and the Six Sigma implementation key
element – using metrics?
The ANOVA showed no significant main effects on metrics use, F(3, 100) ¼ 1.34,
p ¼ 0.26, η2 ¼ 0.04.

Table I. Variable F p η2
ANOVA – showing
differences among Management support 4.89 0.003 1.28
the dependent Infrastructure 1.55 0.21 0.05
variables Using Six Sigma methods 1.3 0.26 0.04

Cultural type Mean SD

Table II. Group 10.76 1.72

Management Developmental 10.38 1.41
support – post hoc Rational 8.82 2.16
analysis Hierarchical 9.96 1.98
 Discussion Lean Six Sigma
The findings demonstrated a significant interaction with Lean Six Sigma management implementation
support, group and developmental cultural types. The findings did not support the
research question regarding a significant interaction between the rational culture and
Six Sigma methods. The findings did not support the research question regarding a
significant interaction with the hierarchical culture and Lean Six Sigma infrastructure.
Findings showed that organization managers who emphasized group culture were 861
more likely to initiate a successful quality initiative. These findings were consistent
with Mrowoski (2001) in a study conducted among healthcare providers. Dellana and
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Hauser (1999) also found that group culture had a positive relationship with leadership.
The group culture emphasizes flexibility and cohesion. There is a sense of togetherness,
teamwork and participation is encouraged in this cultural type. Employee involvement is
emphasized and decision making is moved to the individual performing the work. These
cultural characteristics are consistent with the assumptions built into Lean Six Sigma.
Findings support a positive interaction between developmental culture and
management support. Developmental culture and the corresponding leadership style
results in leaders from this cultural perspective pursuing a Lean Six Sigma initiative.
The developmental culture is characterized by flexibility with a focus on innovation,
risk taking and individuality. A theme is to adapt quickly to new opportunities.
Organizational effectiveness from this cultural perspective is associated with
entrepreneurship, vision and constant change. Leaders are expected to instill vision,
take risks and be inventive. These leaders are inclined to take risks associated with a
new initiative and able to adapt to the changes that Six Sigma implementation involves.
The research question that the hierarchical culture has a significant interaction with
Lean Six Sigma infrastructure was not supported. This research question was based on
the hierarchical culture’s focus on being internal and control oriented. This culture is
characterized by a rigorous adherence to formal rules, procedures, structure and authority.
There is an emphasis on structure stability with members’ roles clearly defined and
enforced through policies and procedures. This focus on control and on clearly established
roles appears to correspond with the infrastructure practices associated with Lean
Six Sigma. The research question that rational culture significantly reacts with Lean Six
Sigma methods was not supported. Rational culture is focussed on achievement,
productivity and being results oriented. These characteristics appear to be consistent with
measurement and Lean Six Sigma methods. There is also an emphasis on competition,
which might result in inconsistencies with Six Sigma methods (Hann et al., 2007).
Our findings support the important role that culture has in relationship to Lean Six
Sigma implementation. In particular, how the qualities associated with group and
developmental cultures positively relate to Lean Six Sigma implementation,
particularly management support. Our results indicate that hospital managers
implementing a Lean Six Sigma initiative would be well served to use an approach and
strategies that are consistent with group and developmental cultures.

Implications
Our study and previous studies indicate that characteristics associated with group
culture, such as collaboration, involvement and learning are key factors for an effective
Six Sigma implementation. Particularly significant is the reaction that occurred with
group culture and management support. The group culture leadership style involves
collaboration and employee involvement. Leaders are mentors who focus on developing
strong relationships with organization members. Organizational leaders considering
 IJHCQA implementing Six Sigma might be well focus on thorough employee-training
28,8 and involving them as much as logistically possible in the initiative. Frequent and
bi-directional communication about the initiative will help employees to understand
and commit to using Lean Six Sigma practices.

Limitations
862 Our study has several limitations. One involved measuring organizational culture.
Schein (2010) described organizational culture as complex and maintained that measuring
through an inventory is not easy to accomplish and that responses only reflect personal
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attitudes. Another limitation was that only two individuals were surveyed in each
hospital; i.e., one human resource and quality manager from sample organizations.
Using only two participants from each organization may not be sufficient to reflect
organization culture. The inventory’s personal attitude aspects could be a potential study
limitation. The individuals responding to the survey may have believed that quality is an
important standard to achieve and might have been actively involved in implementing
quality initiatives in their organization. Participant responses could have been skewed as
they might have wanted to reflect a positive image.

Recommendations
While culture is deep-seated and difficult to change, there are strategies that leaders can use
to help influence culture. One key way to influence culture is determining what to pay
attention to and what to measure. Another important means is deliberate role modeling,
teaching and coaching that is conducted by organization leaders. The personal example
modeled by the senior leader accompanied with teaching and coaching helps employees to
internalize the desired values. As our findings indicate, the leadership style, promoting a
shared vision, providing support and breaking down barriers in departments by promoting
cross-functional collaboration will be particularly effective throughout the process.
Developing and implementing policies on metrics use and connecting with training
and compensation helps to influence employee abilities an inclinations to use Lean Six
Sigma methods. Altering reward systems, work procedures, objectives and work teams
can influence behavior. Infrastructure and role clarity help staff to understand how
their contribution to quality improvement help to strengthen their motivation toward
quality management.
Leaders should become versed in the change process. One change theorist,
Kotter (2006), identified three phases to help ensure that change implementation
is successful. The first step involves laying the groundwork for change. This is
accomplished by conveying its need and purpose, which should be communicated
along with the benefits associated with the change. Other key ingredients are laying the
groundwork and leader commitment to the Lean Six Sigma initiative. Leaders must
create and communicate a clear and concise Lean Six Sigma vision.
The second phase Kotter (2006) identified, the action phase: empowering members
to act on the vision and to involve employees in the change. Involvement results in
greater understanding, support and commitment to implementation. It is important to
communicate progress and successes. The third change implementation phase involves
making the changes permanent by institutionalizing new approaches, including
developing and supporting Lean Six Sigma infrastructure. Leaders should align Lean Six
Sigma with other major organizational processes and practices, which help reduce the
time and costs associated with implementing a Lean Six Sigma initiative. These strategies
 (supported by our study and previous work) are more likely to result in a successful Lean Lean Six Sigma
Six Sigma implementation. Hospital managers implementing effective quality and process implementation
improvement initiatives, such as Lean Six Sigma, will more likely improve overall
performance, reduce costs and reduce medical errors.

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Corresponding author
Dr Susan Knapp can be contacted at: sknapp@kaplan.edu

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