Section 2 Lean and Six Sigma

#### **Chapter 2**

## Perspective Chapter: A Renewed Perspective on Lean Six Sigma in Healthcare – People and Performance

*Relinde J. de Koeijer, Jaap Paauwe, Mathilde M.H. Strating and Robbert Huijsman*

#### **Abstract**

The Lean Six Sigma (LSS) approach has taken a central role in healthcare quality management, and many studies report positive effects of the method on performance of healthcare organizations. However, LSS in healthcare is also unbalanced because the human side of the method is undervalued. A more balanced application of LSS in healthcare includes an interrelated approach of both "soft" and "hard" LSS practices, broad perspective on employee well-being, "soft" HR approach related to LSS, and "soft" climate for LSS. This leads to a renewed perspective on LSS in healthcare that considers both people and performance and where the interplay between "hard" and "soft" factors is addressed.

**Keywords:** lean, six sigma, healthcare, performance, employee well-being, HRM, climate

#### **1. Introduction**

In the past 20 years, since the Institute of Medicine [1] defined the concept of quality of care, it has become increasingly clear that healthcare is a clashing vessel of values. Values such as good quality of care and safe and accessible care are important. But also, effective and efficient care because healthcare must also remain affordable. The Covid-19 pandemic has highlighted the struggle with bringing the different values together within healthcare systems across the globe [2]. Changed circumstances lead to different value trade-offs. For example, during the coronavirus crisis we started to look differently at lean approaches to organizing care, using as few supplies as possible (also called just-in-time management) [3]. Other existing issues were put on edge by the crisis. For example, Covid-19 did not create the healthcare staffing shortage, but the impact is worsened because of it, visible in current high levels of burnout among healthcare professionals [4]. In addition, consider the challenges of access to healthcare services and of enhancing the quality of care and patient safety while reducing costs [5]. These existing challenges, amplified during the Covid-19 pandemic, emphasize

the importance of operations management for healthcare for years to come. Moreover, it demands a renewed perspective on commonly applied operations management methodologies in healthcare, such as Lean Six Sigma (LSS), which integrates values regarding people and performance. In this chapter, in which we, among other things, use PhD work done before [6], we will start with a short history of LSS in healthcare, followed by identifying gaps in the application of this method based on current literature, leading to proposed renewed perspective on LSS, the scientific and managerial relevance of this perspective, and a research agenda for the upcoming years.

#### **2. A brief history of lean six sigma in healthcare**

The LSS approach has taken a central role in healthcare quality management. LSS follows a long history of system management and quality improvement, starting at the beginning of the twentieth century through mass production affected by among others, Henry Ford, followed by the Toyota Production System (TPS) in the Japanese automotive industry and adopted as Lean Management (LM) in the Western world since 1980 [7]. Around the same time that LM was embraced, many large companies, including Motorola and General Electric, implemented Six Sigma (SS) with a focus on reducing errors and minimizing variability [8]. LSS as a combination of Lean Management and Six Sigma is seen as the most effective process improvement that it is widely implemented in the top performing organizations [9], also in healthcare settings [2, 10]. Although the integration of Lean Management and Six Sigma is still relatively rare in healthcare [11], more and more studies report positive effect of LSS on outcomes. For example, Bhat et al. [12] explore the successful deployment of LSS in the Indian healthcare sector and found improvements in patient registration cycle time and reductions in average waiting time, queue length, and staff utilization. Antony et al. [13] report the use of LSS in reducing medication errors in the Norwegian public healthcare context. The Mayo Clinic Rochester in the USA increased their process efficiency and financial performance by applying LSS [14]. A recent study by De Koeijer et al. [15] shows strong positive effects of LSS on internal process and financial performance in university hospitals in the Netherlands. These studies illustrate that in healthcare, LSS is commonly applied with the aim to improve process efficiency, thereby improving quality and reducing costs [7]. Given these positive reports of LSS and given the ever-increasing costs in healthcare, it is very likely that the application of LSS will grow rapidly in healthcare. However, the Covid-19 pandemic has taught us that a narrow focus on specific values of care, such as safety and efficiency, can lead to neglect of other crucial values of care, such as humanity and taking care of healthcare personnel. And this risk is also apparent for LSS. In the next paragraph, we will discuss why LSS, in its current form, is likely to be insufficiently equipped to tackle the multifaceted challenges that healthcare systems are facing, including rising costs, growing expectations from patients, demographic changes, and growing burn-out rates among healthcare professionals.

#### **3. Lean six sigma in healthcare: unbalanced?**

From the beginning, criticism has been part of LSS in healthcare. Some researchers and practitioners object to the notion of industrialized healthcare delivery. They argue that tensions may arise between the need to demonstrate efficiency and achieve performance targets (derived from governmental financial pressure) and the need

*Perspective Chapter: A Renewed Perspective on Lean Six Sigma in Healthcare – People... DOI: http://dx.doi.org/10.5772/intechopen.106875*

to invest time and resources in continuous improvement. Moreover, some state that with these increasing administrative burdens and productivity targets, the intrinsic motivation of healthcare employees is suffering [16]. LSS is controversial from the perspective of employees. Proponents argue that healthcare organizations that embrace LSS to improve performance can simultaneously foster employee well-being. Opponents, however, say that LSS leads to higher performance yet lower employee well-being. LSS is not a neutral and value-free activity, and the debate about relationship between LSS and employee well-being is crucial in the light of the workforce shortage in healthcare combined with current high levels of burn-out among healthcare professionals. One of the explanations for this ongoing debate could be that LSS, in its current form, is unbalanced in several ways.

First, the application of LSS in healthcare is accompanied with a heavy focus on tools and techniques at the expense of the human side [17]. The LSS toolbox that healthcare organizations deploy tends to be filled with "hard" LSS practices focusing on process improvements. Henrique and Filho [18] state in their systematic review that the most common techniques used in healthcare are VSM, Standardization of Work, and Visual Management. Also, LSS practices such as "focus on metrics" (the use of quantitative metrics to measure quality and process performance and to set improvement goals) and "process management" (e.g., statistical process control and error-proof process design) illustrate the dominant "hard" focus of LSS practices. Due to this single-minded focus on process improvement, LSS initiatives risk being perceived as cost-cutting efforts at odds with the values of healthcare and therefore risk the withdrawal of staff and potential resistance. Moreover, the outcomes of healthcare organizations depend, on the one hand, on routine and standardized processes and, on the other hand, on employees with the right customer mindset and ability to anticipate changing demands from their customers [15]. "Hard" and "soft" LSS practices should thus go hand in hand: a singular focus on a "hard" approach to optimizing processes neglects the human factor, while a one-dimensional focus on a "soft" approach complicates the attainment of performance outcomes. Therefore, this chapter contains a balanced interrelated approach of LSS practices in healthcare (see **Table 1**) that consists of both "hard" practices, which are focused on practices for improving processes (quality information, process management, structured improvement procedure, focus on metrics) and "soft" practices aimed at employees and relationships (top management support, customer relationship, and supplier relationship). This interrelated approach of LSS makes it possible to empirically examining the effects of multiple dimensions on outcomes.

Second, although many healthcare organizations state that both efficiency and employee goals are drivers for applying LSS, the conceptualization of employee goals is very limited compared with efficiency and quality targets [7, 19, 20]. Where recent research in healthcare agrees on two core performance dimensions of LSS: internal process and financial, employee well-being is poorly defined. For example, a study by Niemeijer et al. [21] of almost 300 LSS projects in Dutch hospitals describes concrete aims of LSS initiatives regarding reducing costs, improving safety, and increasing revenue; however, employees' outcomes are not characterized. And when employee goals are mentioned in studies on LSS, this is mostly done in terms of workers satisfaction [22, 23]. It is important to create a more balanced perspective of employee well-being, since there is no agreement on the effect—positive, negative, or nonexistent—of LSS on employee well-being [24]. For example, studies by Graban [25], Stamatis [26], and Collar et al*.* [27] mention improved levels of commitment and satisfaction related to LSS initiatives. However, a large study by the Saskatchewan Union of Nurses [28]


#### **Table 1.**

*LSS interrelated systems approach of both "hard" and "soft" practices.*


### **Table 2.**

#### *Perspective Chapter: A Renewed Perspective on Lean Six Sigma in Healthcare – People... DOI: http://dx.doi.org/10.5772/intechopen.106875*

showed that LSS had an overall negative effect on worker satisfaction, and studies by Angelis et al. [29] and White et al. [30] discuss negative effects of LSS on worker commitment. Reviews of studies that focus on trusting relationships and health effects of LSS report mainly negative effects [31]. Since most healthcare organizations claim that employee goals are part of the LSS approach, it is wise to define these goals to determine the effect—positive, negative, or nonexistent—of LSS on employee well-being. A broad perspective on employee well-being supports healthcare organizations in monitoring these goals, and based on recent literature [15, 32], this chapter contains the following balanced conceptualization of employee well-being, related to LSS, which includes three components: happiness (satisfaction and commitment), trust, and health (workload and need for recovery) (see **Table 2**).

#### **4. The human side of lean six sigma in healthcare – HRM and climate**

Although employees' issues related to LSS are substantial, since LSS in healthcare commonly focuses on organizational challenges that have to do with work (re)design in a complex and dynamic environment, the attention for management of employees is limited. LSS initiatives are a result of collective efforts and require engaging a multitude of actors (e.g., clinicians, nurses, and administrators) and LSS project members operate as "liaison officers" between professional groups, between organizational "layers," and between the internal and external worlds of the healthcare organization. To fulfill their role successfully, LSS project members need specific abilities, motivation, and opportunities. Also, given potential conflicts of interest between different stakeholders, management decisions are needed to shape employment relationships that are aimed at achieving specific (LSS) goals. The employees' issues as described above show the importance of strategic Human Resource Management (HRM) related to LSS; however, especially in healthcare HRM is still considered as a more operational or tactical concept within the larger framework of LSS [33]. For example, Antony et al. [34], and Honda et al. [35] state that training is crucial when implementing LSS. Buestan et al. [36] and Ahmed et al. [37] argue that successful implementation of LSS depends on the participation of healthcare staff. While these separate HR practices are indeed relevant, there is a need for a more coherent, and strategic perspective on HRM that is in sync with LSS. For example, cross-functional teams could help to generate ideas for science-based, systematic quality initiatives [38]. Performance appraisal and rewards could also function as morale boosters and encourage employee engagement [9, 39, 40]. In addition, training and development are crucial to getting skilled and motivated people to work on LSS projects [41, 42]. Employee participation and engagement in decision-making and problem-solving can also help inspire commitment to organizational excellence [43]. If LSS can be imagined as a dance within healthcare organizations, then HRM is its matching dance partner and together they make sure that the dance is balanced on "hard" and "soft" issues. Therefore, this chapter provides a more balanced union between LSS and HRM by including a separate strategic HRM approach (see **Table 3**). By constructing LSS and HRM separately, it provides an approach that does justice to both perspectives [15], and it supports investigating effects and relationships of these two approaches combined and separately.

In addition, the narrow focus on the "hard" side of LSS has led healthcare to neglect activities that encourage employees to develop shared perceptions of LSS. These shared perceptions are important for the internalization of LSS interventions [44]. For the effects of LSS to become visible and measurable, a process of


#### **Table 3.**

*HRM systems approach.*

routinization must take place in which professionals adopt these new work practices and adapt their existing organizational routines accordingly. However, there is a dearth of research investigating the organizational patterns (routines) that LSS implementation may enable [13]. Adopting LSS in such a way that it becomes a permanent part of the organization's daily routine can be described as internalization [45]. New routines cannot be sustained in a setting that does not support and enable their performance, however. For example, unless the LSS climate reflects employees' belief in the real value of LSS for their organization, there is a significant risk that LSS will never be internalized [46]. This risk is particularly acute in healthcare because healthcare professionals fear that adopting LSS will lead to over-standardization [47] and that LSS redirects clinical practice away from patient care toward more administrative and management tasks [48]. Shared perceptions support employees in their drive to sustain quality improvement initiatives [49] and in their commitment to accomplishing organizational excellence [43, 50]. Creating a climate for LSS that reflects positive shared perceptions of employees about LSS practices and their commitment to them is therefore crucial to the internalization of LSS [45]. Climate is consistently conceptualized as employees' shared perceptions about the nature of their organization in terms of events, policies, practices, and procedures [51, 52]. Internally, climate is often considered actionable, i.e., management can try to shape climate to pursue organizational goals and influence performance [53, 54]. Many scholars of operations management have attempted to define a climate for LSS, most of them by drawing on the experience

*Perspective Chapter: A Renewed Perspective on Lean Six Sigma in Healthcare – People... DOI: http://dx.doi.org/10.5772/intechopen.106875*

of organizations that have implemented LSS successfully [55]. Bhat et al. [2] argue that an integrated LSS strategy ensures a climate of continual improvement in the healthcare setting. Goodridge et al. [56] state that LSS seeks to create an environment in which mistakes are opportunities for learning, with consistent application of no-blame approaches to mistakes and errors. Ambekar and Hudnurkar [57] claim that people with a positive attitude and critical-thinking capability innovate and ideate solutions. While researchers agree that a successful LSS implementation will aim to achieve climate change and succeed, they fail to agree on the specific characteristics of such a climate for LSS. This chapter highlights a "soft" climate for LSS that reflects employees' perceptions regarding the extent to which the organization emphasizes specific LSS values, goals, expected behaviors, and contributions at work, related to quality, innovation, and efficiency [15, 58].

#### **5. A renewed perspective on lean six sigma in healthcare: people and performance**

In the above paragraphs, we discussed different lines of thought on supporting a more balanced application of LSS in healthcare: by embracing an interrelated approach of both "soft" and "hard" LSS practices, by adopting a broad perspective on employee well-being and by developing the human side of LSS in healthcare by constructing a "soft" HR approach related to LSS, and by adapting a "soft" climate for LSS. This brings us a renewed perspective on LSS in healthcare that considers both people and performance and where the interplay between "hard" and "soft" factors is addressed, contrary to earlier research [59].

When focusing on the interplay between "soft" and "hard" factors, there are a few relationships that need to be considered. For example, it is important not to pick and choose from the LSS toolbox [60, 61], healthcare organizations may benefit the most from LSS, when applied as a systems approach of LSS practices. Also, the relationship between LSS, performance, and employee well-being is worth discussing. Healthcare organizations that adopt LSS to improve organizational performance may assume based on the more classical view (see **Figure 1a**) that LSS will also benefit or at least not harm employees. However, recent research [6] shows that the situation might be more complex and that LSS is suitable for improving performance and

**Figure 1.** *a: Classic view on LSS in healthcare. b: Renewed perspective on LSS in healthcare: People and performance.*

unsuitable for increasing employee well-being. In fact, they show that performance and well-being are at odds with each other: when well-being increases, performance decreases and vice versa. This may lead to a new perspective on the ongoing discussion whether LSS positively or negatively impacts employees. In this chapter, we argue that LSS is simply not designed to improve employee well-being. Although this may seem obvious, systematic reviews by D'Andreamatteo et al. [23] and Moraros et al. [22] mention both efficiency and employee goals as drivers for applying LSS in healthcare organizations. However, the driver for improving employee well-being is not visible in the way LSS is designed: especially in healthcare LSS is often applied as a set of "hard" practices, concerning tools and techniques for improving processes. Therefore, our renewed perspective on LSS in healthcare reserved a special place for HRM (see **Figure 1b**). Not only does research show that HRM is essential to improve employee well-being [15, 62], previous studies have confirmed that HRM plays a vital role in shaping climate and thereby internalizing LSS [63]. HRM is crucial for creating shared perceptions among employees and, consequently, a climate for LSS [6]. In this context, HRM can be seen as a signaling system that constantly sends messages to employees stressing the attitudes and behaviors desired within the organization. For example, hospital management can use HR practices to create a desired climate where LSS initiatives take root by communicating to employees that quality improvement is important, that improvement initiatives and innovative behavior are expected and rewarded, and that attaining organizational excellence is encouraged [43, 50]. Where LSS practices are more generic, HR practices are developed specifically for employees. For example, quality management training can be tailored to specific employee groups and their educational backgrounds. Following this line of thinking, it can be said that HRM boosts employee engagement and involvement in continuous quality improvement [43, 64]. Finally, by adapting a climate for LSS, employee well-being is improved [15]. Given the ambition of hospitals to maintain higher standards of both organizational performance and employee well-being, it is crucial that hospitals that adopt LSS should also foster a climate for LSS by combining LSS and HRM, thereby internalizing LSS. Employees interpret management activities as indicative of organizational support and care and reciprocate accordingly with commitment, satisfaction, and trust [65]. In that sense, healthcare employees may experience HRM as a form of recognition and concern, creating a climate for LSS and affecting their well-being.

Summarizing, with the renewed and balanced perspective on LSS in healthcare that encompassed people and performance (see **Figure 1b**), healthcare organizations can create mutual gains and sustainable outcomes for both the organization and employees. With this renewed perspective, healthcare organizations can face multifaceted challenges related to both performance (for example rising costs and growing expectations from patients) and people (for example retaining highly dedicated and competent employees and growing burn-out rates among healthcare professionals).

#### **6. Managerial and practical implications**

Many healthcare organizations that struggle with both challenging efficiency targets as well as increasing personnel shortages have tried to find one cure for all their problems by embracing LSS. However, despite promising (sales) stories about LSS, for example, that it leads to happy employees who have more time for the work they are passionate about, this chapter shows that LSS in healthcare is unbalanced. The heavy

#### *Perspective Chapter: A Renewed Perspective on Lean Six Sigma in Healthcare – People... DOI: http://dx.doi.org/10.5772/intechopen.106875*

focus on tools and techniques at the expense of the human side, the poorly conceptualization of employee goals, the limited attention for management of employees, and a climate for LSS may lead to suboptimal results, which will not be conducive to establishing a fully-fledged quality philosophy [43]. One could argue that LSS should be used for those processes where the financial pressure is high. But the danger is that LSS will become a concept that is not that attractive for healthcare professionals, since performance will not be at the core of their profession. How can a healthcare organization stay financially sustainable and deliver good quality without happy, healthy, and trusting employees? The systematic review by Hall et al. [66], for example, shows that low levels of well-being of healthcare workers are correlated with poorer patient safety. Fortunately, from a management perspective, we see that adopting a balanced approach of both "soft" and "hard" LSS and HR practices allows healthcare organizations to capitalize on their synergies for internalizing LSS, performance, and employee well-being. Management can use HRM to shape a climate for LSS conducive to the pursuit of organizational goals and the well-being of employees. Therefore, healthcare organizations should involve their HR departments right from the start when introducing LSS programs to ensure that a HRM systems approach is in place. In many healthcare organizations, HRM—unlike LSS—is a consistent component, covering all employees. There is a fundamental different pace of HRM and LSS. Where LSS in healthcare is focused on improving short-term efficiency through short-cycle improvement projects [67, 68], HRM is present constantly. HR practices are practical and can be tailored to specific employee groups and their educational backgrounds. For example, HR practices such as teamwork, participation, and training involve employees at different levels in continuous quality improvement. Management can use these HRM practices to create a desired climate in which LSS initiatives can take root. It is important that managers are consistent in communicating to employees what is valued and considered important in the organization and the kind of behaviors and attitudes that are expected and rewarded [69, 70]. For example, they should emphasize the importance of continuous improvement and of achieving quality outcomes and discuss with employees how they can contribute in practical terms.

It is vital for healthcare executives to acknowledge the fundamental dichotomy between the process-oriented tasks required to provide health services and human factors [71]. Where most literature on LSS so far has argued for the inclusion of HR practices in an LSS systems approach, this chapter enlightens that LSS and HRM should be viewed as two different things. Separating LSS and HRM could be an opportunity for healthcare organizations, since a critical challenge that faces LSS implementation is a lack of belief that it will work [14]. Employees might perceive LSS as something new and be hesitant to embrace the method [72], also due to the increasing internal and external pressure to work more efficiently. When the resistance to apply LSS is growing, healthcare organizations can be flexible in reframing the method, while at the same time can be tenacious in applying HRM systems approach. This conclusion also has impact on the positioning of LSS in healthcare organizations. As LSS is meant to continuously improve performance and not employee well-being, it makes much more sense to make LSS part of the quality and safety department. HRM departments have a separate and equal important task to continuously foster the health, happiness, and trusting relationships of the employees of their healthcare organizations. Still, LSS and HRM require constant alignment and should be managed integrally. In practice, this could mean that when healthcare executives share the "why" of LSS within the organization, they should emphasize both performance improvements and higher levels of employee well-being. Another recommendation

is to monitor progress in LSS integrally by focusing not only on the number of LSS initiatives and their progress but also on the happiness, health, and trusting relationships of employees, and by explicitly including performance indicators in the "LSS dashboard." In addition, since direct supervisors play a prominent role in transmitting values and climate [73], they should actively support their employees with a balanced approach that incorporates both "hard" and "soft" factors into the improvement process [74]. For example, appraisal interviews should not only focus on "hard" key performance indicators, but also on improvement efforts and more narrative input. This may also mean that employee productivity would temporarily decline to allow time for improvement projects or quality training.

Concluding, in recent years, a great deal has been invested in LSS in healthcare: belts have been trained, improvement teams have been formed, and LSS improvement approaches have been widely embraced. This chapter demonstrates an optimistic view about LSS in healthcare, if applied balanced and with a focus on people and performance (see **Figure 1b**). With this renewed perspective, where HRM is strategically aligned with the goals of LSS, healthcare organizations can create mutual gains and sustainable outcomes for both the organization and employees.

#### **7. Agenda for future research**

To acquire a deeper understanding of the causal relationships in our renewed perspective on LSS, future research should apply a longitudinal and intervention design (including control settings). Such research could, for example, examine a potential spiraling positive or negative effect, i.e., that the more LSS in combination with HRM is adopted, the more LSS is internalized and the more performance and employee well-being improve, and vice versa. Longitudinal research could also verify whether the relationships as discussed in this chapter, for example, between LSS and performance, HRM, climate, and well-being, are cause-and-effect relationships.

In addition, it is interesting to investigate whether the renewed perspective on LSS is generic for different types of healthcare organizations (e.g., hospitals, elderly, and disabled care) or that a specification for each subsector is needed. Also, the current inpatient and specialty-oriented view of healthcare professionals will develop into more disease path- and care chain focused ways of working, in (regional) teams with common integral responsibility for each other's functioning [75]. Therefore, it is interesting to conduct future research into multidisciplinary teams, consisting of healthcare professionals from different healthcare institutions that work together on LSS initiatives.

Finally, we need a broader definition of performance in relation to LSS, as well as a more comprehensive set of performance measures. The definition of performance related to LSS, namely "value for customers while optimizing resources" [76] could benefit from a more contemporary and healthcare-specific clarification. Recent debates have focused on how performance in healthcare should be defined and measured [77]. For example, is performance about costs, efficiency (e.g., shorter waiting times, improved utilization), customer satisfaction, quality, health-related outcomes, or all of the foregoing [78, 79]? In light of these recent debates, we argue that the definition of performance in relation to LSS should be updated and clarified specifically in the context of healthcare. In addition to this chapter setting out a wide range of perceived improvements (e.g., internal processes, customer satisfaction, and financial results), we propose incorporating objective outcome measures into any future research.

*Perspective Chapter: A Renewed Perspective on Lean Six Sigma in Healthcare – People... DOI: http://dx.doi.org/10.5772/intechopen.106875*

#### **8. Conclusion**

The LSS approach has taken a central role in healthcare quality management, and many studies report positive effects of the method on performance of healthcare organizations. However, LSS in healthcare is also unbalanced in several ways. First, the application of LSS in healthcare is accompanied with a heavy focus on tools and techniques at the expense of the human side. Second, although many healthcare organizations state that both efficiency and employee goals are drivers for applying LSS, the conceptualization of employee goals is very limited compared with efficiency and quality targets. In this chapter we discuss different lines of thought on supporting a more balanced application of LSS in healthcare: by embracing an interrelated approach of both "soft" and "hard" LSS practices, by adopting a broad perspective on employee well-being and by developing the human side of LSS in healthcare by constructing a "soft" HR approach related to LSS, and by adapting a "soft" climate for LSS. This brings us a renewed perspective on LSS in healthcare that considers both people and performance and where the interplay between "hard" and "soft" factors is addressed, contrary to earlier research [59]. With the renewed and balanced perspective on LSS in healthcare that encompassed people and performance (see **Figure 1b**), healthcare organizations can create mutual gains and sustainable outcomes for both the organization and employees.

#### **Author details**

Relinde J. de Koeijer1 \*, Jaap Paauwe1,2, Mathilde M.H. Strating1 and Robbert Huijsman1

1 Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands

2 Human Resource Studies, Tilburg University, The Netherlands

\*Address all correspondence to: rkoeijer@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 3**

## Integrated Lean Safety Model to Develop Organizational Safety Culture

*Pal Pandi Ammavasi, Kallarpiran Arumugam and Anbu Meenakshi Sundram*

#### **Abstract**

The basic purpose of any business organization is to operate it with minimum risks and accidents. These contexts maintain safety culture in the organization in order to improve performance. The integration of Lean and Six Sigma along with existing safety practice may build a more effective safety culture, which may engage the entire workforce proactively seeking a healthy and hassle-free work environment considerably and notably reducing risks and accidents and mitigate the stress of workforce. This prompted the present authors to develop an integrated Lean Safety Management model (ILSM) for improving safety in workplaces. ILSM is an integration of Lean Thinking, Six-Sigma (DMAIC) and Behaviour Based Safety Management. The purpose of this chapter is to bring out the salient features of ILSM through SMILE approach and its credibility in meeting out the needs of the stakeholders regarding industrial safety and occupational health aspect.

**Keywords:** safety culture, behavioral based safety, lean six sigma, ILSM model, SMILE Approach

#### **1. Introduction**

Though, the concept of industrial safety is widely practiced in Western and few other developed countries, its predominant presence in India is yet to be seen except the manufacturing industries having foreign collaborations and some large manufacturing industries having well defined inclusive infrastructure. The chemical and cement industries are very much vulnerable to the risks of accidents. The health of employees is at risk as they are exposed to dangerous chemical activities and exhumation of dusts. This prone to severe health hazards in employees at long run. Therefore, safety is inclusively concerned with the employees as well as the workplace. The malfunctioning of machineries in the workplace may cause accidents. The leakages of chemicals or oil, in case of chemical and oil industries have direct adverse impact on employee's safety. It could be seen that few big Indian construction industries have taken the advantages of the safety concept in their workplace but not in full fledged manner. "Safety has been defined as a condition where nothing goes wrong or a condition where the number of occurrence of accident, risk of injury, loss and danger to persons, property and environment is acceptably small" [1]. Rene [2] has pointed out that technical breakdown and human errors cause unsafe situation. The safety is considered to be very important in the sense that reducing risk of accidents and avoiding careless handling of machineries may pay a good dividend in terms of performance excellence and financial benefits to the organization. Besides, it helps boost the morale and activate the positive motivation among the employees. Safety is very much concerned with employees' health and incepts care on their family in all welfare aspects. Further, it is very essential that creating and maintaining a safe working environment ensures high health levels among the workers, protecting the workers from the risk of accidents, illness or discomfort in the workplace and increase the efficiency of wok processes, improves employee perceptions of their working environment and leads to higher recruitment attractiveness [3]. The above context clearly emphasizes the safety concept in manufacturing and services organizations give more importance to the employees than the machineries. In the context of importance given to employees, their behavior and attitude form base in implementing safety culture in organization. To keep the safety culture permanent and perennial in organization, it is very important to induct the safety culture among the employees by transforming their behavior and attitude. This thought of imbibing the importance and benefit of safety among employees lead to the concept of "Behavioral Based Safety (BBS)" management for maintaining safe work environment in organization. The both lean thinking and BBS concept helps proliferate safety in organization by eliminating the unwanted and non value added activities and streamlining the processes in all aspects. Lean Thinking and Six Sigma (DMAIC Methodology) are viewed as formidable strategic weapons to succeed in performance excellence. Therefore, the authors felt the need of an appropriate comprehensive integrated lean safety model (ILSM) to ensure safety practices and enrich safety and health performance in the industry by reducing the risk of accidents. Since, ILSM is a practice of accident prevention system; the authors suggest that the top management must initiate holistic implementation of ILSM to attain safety culture sustainability in the organizations.

#### **1.1 Objectives**

Following are few important objectives for this study


#### **2. Review of literature**

The Review of Literature has been presented in eight major sections. The first section would bring out the studies related to safety, the second section has been marked to review studies on culture, in the third section, the authors try to highlight the studies on safety culture, the fourth one detail about BBS, the fifth and the sixth describe factors attributing to workplace accidents and benefits of BBS respectively. The Seventh and the eighth sections highlight the linkage of Lean and Six-Sigma with BBS.

• Safety

"Safety has been defined as a condition where nothing goes wrong or a condition where the number of occurrence of accident, risk of injury, loss and danger to persons, property and environment is acceptably small" [1]. Rene [2] has pointed out that technical breakdown and human errors cause unsafe situation.

• Culture

Culture is the product of the interaction between human psychological, work behavioral, and organization situational [4]. According to Reason [5], culture is the 'engine' that drives the organization towards the goal of sustaining the maximum resistance towards hazards. Organizational cultures are rooted within community expectations and intersect with national cultures [6].

• Safety Culture

Safety culture in the organizational set up includes the 'health' as an important one. Therefore, in most of the literature it has been referred as 'Health and Safety' (H&S) culture. Accordingly, based on Hale and Hovden [7] who in their study classified H&S in three ages, Hudson [8] has suggested following three stages in the evolution of H&S culture. In the first stage, Technology was given importance (technical age), then in second stage, more emphasize has been given on H&S management systems (human factors' age) and in the third the H&S is seen through cultural aspect (safety culture age). Reason [5] suggests that 'an abiding concern for failure' would be the key component of a good safety culture. Therefore, organizations having good safety culture are sensitive and responsive to signals of danger.

Before going into detail discussion, understanding the definitions of SC is more important. The cultural drivers of Health and Safety comprises of social forces within organizations that shape organizational members' assumptions, beliefs, values and actions [9]. Few of the identified important factors of SC are; management [10], individual and behavioral [4], Worker's knowledge on safety. In this regard, the stakeholder role in safety culture and safety performance has been discussed by Althaqafi and Abunar [11]. A broad thinking is that the social forces are the main cultural drivers which shape organizational members' assumptions, beliefs, values and actions [9]. In line with the social phenomenon, Richter and Koch [12] define safety culture as the shared and learned meanings, experiences and interpretations of work and safety-expressed particularly symbolically – which guide peoples' actions towards risk, accidents and prevention.

#### • Levels of SC

Hudson [8] has identified five levels in SC namely, Pathological-unless we experienced we will not think and cares about safety; Reactive-safety is important in the sense that when we do a lot every time we have to meet an accident; calculative-there is system in place to manage all hazards; Proactive-trying to anticipate safety problems before they arise and generative-health and safety show how the business is going on. According to theory of SC, following four levels have been identified that are; physical culture, institutional culture, behavior culture and spiritual culture. Further it has been defined as "the sharing of safety values, attitudes, ethics and code of conduct" (State Administration of Work Safety, 2009 a&b).

SC being an important part of organization management system, it improves the quality and operation mode of safety management level which could prevent major accidents, reduce accident rates and improve safety performance.

• Behavioral Based Safety (BBS) Management

Employee awareness of safety plays crucial role in maintaining safety standards in organizations. Poor awareness of safety indicates a poor safety climate which decreases the health and safety of employees. Behavioral Based Safety (BBS) is a process within which employees of organizations have been enveloped to follow the safety procedures in their work situation where by to learn more on safe and unsafe activities towards transformation of their behavior and attitude to avoid unsafe work environment, loss of life, get injured and loss of time and financial remuneration. Therefore, BBS focuses on what people do, analyses why they do it and then applies a research supported interventional strategy to improve what people to do. It is an approach based on human behavior used to prevent workplace injuries. BBS is one of the approaches to make employees to aware safety in workplace to improve safety performance and decrease the number of accident cases at the workplace and incorporated with safety management system towards safety and health performances and improvements [13] and is not a program, but an integrated management "process" [14]. The important role of human components in organizations accelerates the risk of accidents wherein, the attitude and behavior of workers have to be carefully considered at the workplace to avoid the untoward incidents. In this exercise, the organization has the compelling responsibility and the duty to make the worker to understand to work safe in the safe environment. Therefore, it is the behavior and the attitude of the worker to follow the norms of the safety in workplace. So, organization should come forward to instill among workers the positive behavior towards safety and has the responsibility to activate and motivate the worker to abide to the strategic plans and related training programs of organization. This is otherwise called as the behavior based safety management. The sustenance of the safety systems management is possible only when the BBS has been transformed to be a culture of the organization, since it wholly relied on human resources.

• Factors Attributing to Workplace Accidents

Cox has defined BBS as the intervention that focused on people and Connor suggested to develop a list of human factors that influence workplace safety. The workplace accidents are caused by unsafe behavior [15] and unsafe act [16], unsafe working conditions and false acts, inadequate safety performance, improper

#### *Integrated Lean Safety Model to Develop Organizational Safety Culture DOI: http://dx.doi.org/10.5772/intechopen.107002*

housekeeping, low tool maintenance, supervisory fault [17] and unsafe act or unsafe conditions. Any act that deviates from generally recognized safe procedure laid down to do the job may be considered as unsafe act [18]. In spite of organizations having well managed safety management with good safety policy, significant accidents occur [19] and this may be due to unsafe or careless employees which can easily be resolved by closely monitoring and changing the behaviors of workers [20].

• Lean Thinking Aligning with Safety Management System

Lean Manufacturing (LM) is a business concept; its goal is to minimize processing time, resources and other activities in the manufacturing process and by eliminating wastages to achieve performance excellence and sustainability. The 5S process (Sort, Set in order, Sweep, Standardize, and Sustain) is the basis for an effective lean implementation. The 5S process is a structured program to systematically achieve total organization, neatness, cleanliness, standardization and discipline in the workplace [21]. LM process gives importance to the worker safety by informing, empowering the workers to be active with knowledge, skills and create opportunity to act safely in the workplace in order to eliminate or reduce hazards or risk of accidents.

Anvari et al. [22] have attempted to evaluate an approach aligning Lean Manufacturing with Safety Management Systems and tried to establish relationship between them. In compliance with the above, the above authors have talked about the 6th S that is Safety along with the existing 5S of Lean Manufacturing since safety strategies are considered crucial to world-class competitiveness. Because, the 6S process simplifies the work environment, reduces waste and non-value activities while improving quality of efficiency and safety [22]. The 5S were drawn from Toyota Management System (TMS) and the 6th S has been added by Universal Coordinated Time to emphasize safety in the workplace [23]. The 6th gets prominence since; it is the first method the companies often implement before implementation of Lean process because it serves as the foundation of future continual improvement effort [24]. When safety (6S) is aligned with the Five Ss it creates a culture of continual improvement and employee engagement that is essential for successful implementation of Lean. The 6S helps other lean methods such as cellular manufacturing, onepiece flow and JIT production for easy implementation. In the context stated above, 6S that is Safety can strongly be considered as one of the tools of LM. It strongly enables for employees and enables people to be free of aggravations that hinder their work and it acts as a positive way to involve people in improving their own work settings [25]. Health and Safety hazards in organization are created due to employees de-motivation, lack of or unclearly defined working procedure and tasks, lack of control, lack of instruction or appropriate training, unsafe worker behavior, low management commitment to safety, no consensus on what Safety Management System (SMS) exactly is and on corresponding scope [26] all those could be controlled by LM process. The errors of total productive maintenance (one of the LM component) contribute to accidents in complex systems [27]. Sourin et al. (have) found the relationship between the Lean tool Poka-Yoke and SMS. Fernandez et al. and Bottani et al., [28] have suggested that creation of all types of hazards controlled in LM environments. It could be concluded that there is a perfect correlation and relationship between all the SMS policies and practices and the LM/6S. It could be concluded that all the dimensions of safety culture are used in LM [29]. Increasing diffusion between organizations in respect of Safety Management Systems have been felt by Bottani et al. [28] this is because of the major shortcoming in most of the safety

culture models due to lack of integration [15]. Therefore, Fernandez-Muniz et al. [30] suggest that safety must be integrated into all the organization's decisions and actions, and the prevention must be more organizational and strategic than material, since human component plays an important role in the causal chain of workplace accidents. When two or more systems are integrated into one model, the level of compatibility increases resulting potential tangible and intangible gains with added value to the organization [31]. Several authors for example, Karapetrovic and Jonker, [32]; Beckmerhagen et al. [33]; Jergensen et al. [34] and Rebelo et al. [35] have extensively studied the integration of Safety with other management systems (like various quality and environmental management systems) for efficient management and excellent performance of organizations.

Following the efforts taken by the above mentioned authors, the present authors have developed a new conceptual model like ILSM and established SMILE approach in behavior based safety system.

• Six Sigma Aligning with Safety Management System

Rehman and Ateekh-ur-Rehman [36] have evolved the possibility of managing safety through Sig Sigma approach and found that the DMAIC approach was effective in reducing the safety hazards. Kehinde et al. [37] have conducted a study in a food processing industry on managing safety using Six Sigma Technique. The Sigma level of safety was estimated using DMAIC method. Further, Failure Mode Effect Analysis (FMEA) was used and the Risk Priority Number (RPN) for various departments was also calculated. This study helped to contain safety hazards at present and in future. Stricoff and Seymour [38], Bahadir and Ivan [39], and Ng et al. [40] have endorsed the above findings.

#### **2.1 Gap**

Safety Management System (SMS) is familiar with all types of industries in countries abroad. BBS is one of the safety concepts in SMS. The Indian scenario is seemed to be different, particularly, in Southern most part of India that is Tamil Nadu, the Safety practice industries still yet to be taken off. It was observed from field visit that few big industries of various types around Chennai, the capital of Tamil Nadu follow few elements of SMS but not in full. Particularly, the lean oriented BBS concept in most of the industries in India, particularly in Tamil Nadu is still to be practiced. The reason being, the negligence of organizations to adapt lean oriented BBS concept and the less interest of employees to understand the salient features of the system and failed to understand that despite giving benefits to the organization, it forms basis for the health and welfare of the workers. Further, very few literatures are available on industries with regard to implementation of BBS in associate with Lean Six Sigma.

#### **2.2 Reasons and need**

The industries are looking forward to achieve financial benefits through increasing performance. This could be achieved by the relentless contribution of workers. Therefore, workers should be given a healthy and accident free work environment. This warrants change of behavior and attitude. Thus the organizations must keep workers more informative of the work environment and to make them aware of their responsibility in discharging the task in a prescribed way of operation. The holistic

implementation of BBS may help organizations to successfully face challenges from similar organizations and the national and international market volatilization.

#### **2.3 The main focus of the study**

This study may help to maintain safe work conditions through principled practice of discipline through BBS practice among employers and employees. This cultivates the safety culture in order to reap benefits like, reduction of cost of product in all aspects, eliminate cost of worker's compensation claims and to reduce costs related to employee medical leave and absenteeism.

#### **3. The proposed model**

On extensive deliberations about the integration of Lean, Six Sigma (DMAIC) and BBS, the authors have developed the following SMILE approach in working environment and new conceptual model to be implemented in organizations for attaining safety culture. The robust implementation of lean oriented BBS (SMILE approach) and integrated lean safety model in an organization may definitely help harvest good benefits in terms of accidents free organization, performance excellence and huge financial benefits (**Figure 1**) (**Table 1**).

**Figure 1.** *A conceptual model of safety culture environment.*

#### *Six Sigma and Quality Management*


**Table 1.**

*SMILE approach - lean oriented behavior based safety system.*

#### **4. Findings and discussion**

Various past studies have brought out the importance of implementing Safety Management System in manufacturing, construction and related organizations. The studies have also underlined several benefits like, keeping and improving employee's health and welfare, changing behavior and attitude of employees towards positive and safe work environment and thus motivating them to work in risk and accident free environment. Therefore, the organizations could reap financial benefits by reducing compensation paid to employees due to accidents, improve quality and production due to increased performance excellence, and could stand out as unbeatable competitor in the market. The Six Sigma technique also reduces the process output variation to six standard deviation which lies between the mean and the nearest specification limit to 3.4 defections per million opportunities. Peter et al. [41] have stressed the need of Six Sigma for continuous improvement in the workplace.

The integration of various managements systems with SMS further fillip to the Safety processes in organizations. The basic and the main concept of Lean is the reduction of space, time, manufacturing processes and other non-value added activities, resources and the various types of wastes. The 5S tool of Lean has been structured to systematically achieve total organization, neatness, cleanliness, standardization and discipline in the workplace [21] which result the reduction of risk of accidents through safer and more efficient productive operation. Stricoff and Seymour [38] have suggested that Six Sigma could be applied for the purpose of organizational safety. Staryarsky and Whitfield [42] have identified few constraints in applying Six Sigma in manufacturing organization towards "World Class" safety performance. In spite of the constraints, several authors have studied the utilization of Six Sigma in various

types of organizations, for example, ship Management and safety [39]; to explore injury rate of an international waste disposals firm [41] and reduce hazards among cargo handlers working in cargo container [40].

#### **5. Conclusion**

Especially manufacturing and construction industry have become an important sectors in promoting economic growth. However, the accident cases in the manufacturing sector and construction industries are always higher than other sectors. In order to reduce the accident cases, safety culture is the long term solution that creates consistent patterns of safety behaviors, beliefs and values in the organization by practice of effective leadership support, management commitment (Management must be sensitive towards safety issues and committed to challenge unsafe behaviors without fail) and effective safety management system. Safety has a significant role in industrial organizations. Lean is built on the central idea of reducing or eliminating wastes from the system. Since accidents are fundamentally a waste, lean inherently includes safety concerns within its scope.

The conclusion arrived here at is purely a hypothetical based on a number of related studies by various authors and according to their findings. Anvai et al. [22] have found the perfect relationship between lean management and safety management system and most of the attributes of lean management positively and significantly correlated with the SMS process. Several authors have stressed the employee awareness of safety has been considered to be an important in quality outcome in the organizations [43] because poor awareness would result in poor safety climate which would be detrimental to the employee as well as organization. The safety concept is mainly and wholly related to human component. Therefore, it is very important a change in the behavior and attitude of worker to be instituted for a complete transformation in the safety concept to be followed in organization. Therefore, the safety culture should be given equal attention like other important elements such as quality and productivity. Safety Culture could be attained through effective implementation of SMILE approach and integrated lean safety model in industry. The authors suggest that top management (safety monitoring authority committee) must initiate practice of ILSM with support of 'SMILE' approach to reduce the occurrences of accidents in all aspects of the company by sustainable safety culture.

#### **5.1 Implementation**

Though, different approaches in implementation of BBS process could be observed from various studies, those were mainly based on case study approach. Faridha et al. [19] after reviewing various studies by Killimett [44], Wirth et al., [45], Geller [46], DePasquale and Geller [47] and Smith, have seen a common and consistent approach which has been included in the following four steps as suggested by Dejoy [20] and Krause et al. [48]. Step 1 Identify critical safety behavior that contributes to injuries and losses; Step 2 Observation over sometime period of identified behavior; Step 3 Reinforcement is applied to increase desired behavior and Step 4 Findings and Feedback on the performance is presented for continuous improvement. The White Paper published by SoBran-Bio Science suggests the following four steps for implementation. Those are; establish a need for change, create a plan of action, plan for implementation and put energy into implementation and sustainability. The robust

implementation of Lean oriented BBS (SMILE approach) and Integrated Lean Safety Model in an organization may definitely help harvest good benefits in terms of accidents free organization, performance excellence and huge financial benefits.

### **6. Implications**

Implications can be classified into two. One is theoretically impacted and another one is practically experienced. The paucity of studies on lean six sigma oriented behavior based safety management under Indian environment could be fulfilled with this endeavor. In practical, this paper may feed some useful information on the importance of safety aspects in various types of industries which are very much prone to all types of risks. The present model may be an eye opener to those industries which are still in early stage of implementing safety procedure and for the industries still not yet been implemented. Those types of industries vulnerable to different types of risks, accidents and social ill-health may recoup their industries process with risks and accidents free with the help of this model and thus could achieve performance excellence.

#### **6.1 Limitations and scope for future studies**

This study is purely a theoretical one based on the findings of various research studies done by different authors in different environment and different types of industries. The present conceptual model developed based on new approach called 'SMILE'. This new model needs empirical validation to confirm its authenticity. This paper has been developed having taken in mind the Indian industrial environment. However, universal applications of this approach may give greater dividend to all types of industries that are prone to risks, accidents, since the nucleus of this study centered on 'Safety Culture' which is an universal entity.

#### **Author details**

Pal Pandi Ammavasi<sup>1</sup> \*, Kallarpiran Arumugam<sup>2</sup> and Anbu Meenakshi Sundram<sup>3</sup>

1 Mechanical Engineering, Bharath Niketan Engineering College, Tamilnadu, India

2 Seed for Safety Private Limited, Chennai, Tamilnadu, India

3 Department of Information Technology, St. Joseph's College of Engineering, Chennai, Tamilnadu, India

\*Address all correspondence to: drapandi@gmail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Integrated Lean Safety Model to Develop Organizational Safety Culture DOI: http://dx.doi.org/10.5772/intechopen.107002*

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#### **Chapter 4**

## Perspective Chapter: The Lean Approach in Waste Management – A Case Study

*Roberta Pinna and Giovanni Senes*

#### **Abstract**

This work presents a manufacturing case study focused on reducing waste in a corrugated paperboard packaging company located in Italy. Corrugated paperboard is the primary material used in transporting, distributing, and storing many products, particularly food productions. The project started in September 2020 with the aim of identifying the causes of some waste along the production process and the consequent planning of actions to reduce them. This project was implemented following the logic of lean manufacturing through the use of the PDCA (Plan-Do-Check-Act) methodology. The quality control tools for continuous improvement of the manufacturing process are used. The results achieved by the plant are significant in terms of economic and environmental sustainability. From an economic point of view, the measures implemented have allowed the plant to achieve, in the period between September 2020 and March 2021, a decrease from 10% to 9% of the percentage of the waste with a cost reduction approximately of € 17,000 for each of the first three months of 2021. From an environmental point of view, waste reduction is one of the objectives underlying the sustainability strategy adopted by the company, which has long been committed to the responsible management of its production processes to reduce its environmental impact.

**Keywords:** lean production, PDCA, waste reduction, continuous improvement tools, sustainability

#### **1. Introduction**

Four years after the adoption of the 2030 Agenda by the 193 member countries of the United Nations, including Italy, there is a growing awareness worldwide of the need for an integrated approach to address complex economic, social, *and* environmental challenges in order to shift to a sustainable development model. The sustainability approach, a set of principles, tools, and practices oriented toward sustainable development, is progressively establishing as a new paradigm in the activities and processes management of all organizations [1]. In particular, among the factors that more than others have given a strong impetus in the direction of a profound change in the management models and tools adopted, the joint search for efficiency, effectiveness, and sustainability represents the most significant. In fact, organizations that

develop sustainable strategies may have a competitive advantage in terms of higher productivity, better products, and considerable cost savings [2]. In literature, there is a consensus that sustainable development involves improvements in different aspects, such as energy consumption, reduction of emissions to air, water, and soil, environmental impacts of the products, reduction of waste and better efficiency in the use of rawmaterial, health and worker safety [3–5], and the implementation of lean or Six Sigma approach in the business organizations can improve productivity and environmental sustainability.

In the manufacturing sector, as well as in the cardboard packaging production sector, the management of waste and the efficiency in the use of raw materials represent one of the most critical situations that companies have to manage. The corrugated cardboard production sector, with almost 7 billion m<sup>2</sup> of produced area, 150 thousand employees, and almost 500 plants in Europe, has become over the last decades the most requested material in the production of eco-friendly and robust packaging to contain, protect and transport. Thanks to its recyclability and biodegradability, it has fostered the birth of green packaging industry, whose main prerogative is the reduction of environmental impact. In Italy, the sector is worth about 4 billion euros and counts on a supply chain that employs 15 thousand people for an annual production that in 2018 exceeded 7 billion m2 (an increase of 3.62% compared to 2017). According to the Italian Corrugated Cardboard Manufacturers Group (GIFCO), this is a sector that records continuous growth thanks also to the push of e-commerce. Italy is the second European producer of corrugated cardboard used in packaging after Germany, followed by France and Great Britain. In the last decade, corrugated paperboard companies are under pressure in order to improve productivity and quality while reducing costs. In addition, the need to promote the long-term sustainability of the natural resource, such as wood fiber, which is the single largest input to the manufacturing of paper products, become strategic the efficient use of renewable natural resources, thus reducing waste and improving the circularity of the manufacturing processes. Today, corrugated boxes are made from a high percentage of recycled paper, such as corrugated boxes, cartons, or newspapers. The re-use of such items means corrugated offers a number of environmental benefits. In other words, the adoption of a sustainable strategy allows more efficient use of resources, better cost results, and reduces adverse impacts on people and the environment. There are several methods that facilitate sustainable practices, one of these is lean production [6–10]. It is a methodology that aims at maximum efficiency through eliminating all those activities with no added value and that are a source of waste and costs.

The objective of the present study carried out in a corrugated cardboard industrial company, was to implement a lean production system based on the PDCA (Plan-Do-Check-Act) method to identify and reduce wastes in the production process of the firm. The orientation toward sustainability has become one of the cardinal principles of company policy, for this, it is important to become more efficient in the use of resources through a reduction of the waste in the production process; thus, enabling the increase of economic benefits. This has led the company to make a strong commitment to improve the environmental impact of all its plants and promote the sustainability of the company for the benefit of future generations. For this reason, since 2020 the management of the company has implemented a lean production approach, with the aim to reduce waste by 0.75% in 2021. To achieve the proposed objectives, a methodology based on the PDCA cycle was implemented.

*Perspective Chapter: The Lean Approach in Waste Management – A Case Study DOI: http://dx.doi.org/10.5772/intechopen.106744*

#### **2. Lean production and waste management in manufacturing**

The term *Lean production* was coined by researchers in the International Motor Vehicle Program at the Massachusetts Institute of Technology to describe the way in which production operations were organized at the Toyota Motor Company in Japan during the 1980s. The goal of lean production is doing the same number of outputs by reducing the number of inputs, through the elimination of waste in order to give customers what they want and satisfying their expectations. In other words, this management approach allows for improving the operational efficiency, quality, and flexibility through the elimination of waste [7, 10]. The elimination of waste is the primary goal of any lean system. The term waste or *muda* is anything that consumes resources without creating value for the customer. Studies conducted in the manufacturing sector [11–13] have confirmed the existence of seven types of waste (**Table 1**) and how they negatively impact time, cost, and product quality. In particular, with specific reference to defects, some research [14, 15] has shown that these represent the main cause of damage or bad quality of products. In this case, bad quality or defects do not only result in customer dissatisfaction, but also in waste due to additional costs and time to repair the defect, resulting in a slowdown in production and increasing lead time. In the manufacturing sector, as well as in the cardboard packaging manufacturing sector, the presence of defects in raw materials are one of the most critical situations that companies in this sector must manage. Waiting time is another particularly important type of waste. For example, employees are not doing their work, as they are unproductively waiting for the elimination of the defect and restarting the machine.

Over the years the lean production model has been refined, taking on other designations as well, such as lean organization, lean manufacturing, lean service, lean office, lean enterprise, and even lean thinking, indicating its nature as an industrial "philosophy" that inspires essentially all methods and techniques. Numerous studies [16–20] have demonstrated the effectiveness of this approach in terms of cost reduction, improved quality, and flexibility through the elimination of all non-value-added activities and waste.

#### **2.1 Continuous improvement and PDCA cycle**

Implementation of lean production may be facilitated by the use of quality tools, among which the Plan-Do-Check-Act (PDCA) method can be applied to the implementation of waste reduction programs and sustainable management strategies. This methodology initially was developed in 1930 by Walter A. Shewhart. However, it was William Edward Deming who developed this method with the purpose of providing a tool for product quality control [2, 21]. It quickly became an industry, a useful tool that can support the development of process improvements at the organizational level [22]. This cycle is a sequence of actions necessary not only for pursuing the goal of continuous improvement but also for solving quality-related problems and implementing new solutions. Some authors [23] show that continuous improvement tools, such as PDCA, are often used in change management processes, in the implementation phases of new solutions, or when a new process has to be designed. Thanks to its versatility, this tool can be used successfully in any company and in any sector of activity, such as health and education sectors. The Deming cycle is divided into four phases:


**Table 1.**

*Seven types of waste.*


*Perspective Chapter: The Lean Approach in Waste Management – A Case Study DOI: http://dx.doi.org/10.5772/intechopen.106744*

• ACT: At this phase, the new actions will be standardized, and identify other opportunities for improvement.

Numerous studies conducted in different industrial contexts [24–27] show that different applications of PDCA methodology have been implemented with positive results in terms of reduction of waste and costs, as well as improving the quality of processes and products. Some authors [28] investigated how to reduce defects that minimize the rework rate through the PDCA methodology. In another work [29] the PDCA cycle was used for continuous quality improvement in a dairy laboratory. The results showed a significant reduction from the initial 368 to 85 samples of contaminated UHT milk. This reduction resulted in an increase in efficiency from 68.02% to 74.06% and ineffectiveness from 88.95% to 96.85%. So, the PDCA methodology allowed a reduction in the incidence of errors, making the processes more efficient. The effective implementation of PDCA requires the use of appropriate techniques and tools that can support each of the phases of the cycle, especially in the problem analysis and in the definition of the actions that must be implemented. The seven basic tools are flowcharts, control charts, histograms, Pareto analysis, Fishbone diagram, check sheet, and scatter diagram. Through the synergistic use of these tools and techniques, it is possible to identify the problems that are at the origin of the waste, select the main one, show the relationships between different variables, search for all potential causes, and then get to select the real ones. Numerous researches [30–35] have confirmed the effectiveness of quality tools in continuous improvement projects. In addition to the seven basic quality tools, some authors [2, 15, 36] also mention the following main ones: Six sigma, the 5S method, A3, failure mode analysis and effects (FMEA), quality function deployment (QFD), single-minute exchange of die (SMED).

#### **3. The case study**

This study was conducted in a large multinational company producers of fiberbased packaging and pulp. In Italy, this organization has four plants responsible for the production of corrugated boxes, offering customized packaging solutions for fruit and vegetables, poultry, and industrial segments. The research was carried out in an Italian plant responsible for the production of corrugated packaging solutions for agricultural, consumer goods, and industrial applications. This plant occupies an area of 30,000 m2 and employs about 170 people, with an annual production capacity of 150 million m<sup>2</sup> of cardboard. The flow of materials goes through the following unit:


#### **3.1 Methodology**

Since 2020 the management of the company has implemented a lean production approach, with the aim to reduce waste by 0.75% in 2021. To achieve the proposed objectives, a methodology based on the PDCA cycle was implemented. In the first phase, data collections were carried out weekly in order to quantify the forms of waste. At the same time, the flow diagrams of the various processes under analysis were created with the aim of highlighting those that have occurred in a higher amount [37]. Based on these data, through Pareto chart and Fishbone diagram, it was possible to identify the main causes of waste. In this way, opportunities for improvement were identified [15, 28]. In the second phase, based on the analysis carried out in the previous step, improvement opportunities were implemented. Subsequently, during the third phase, the results of each action implemented were evaluated. Finally, in the fourth phase, on the basis of the evaluation carried out previously, the new measures were standardized.

#### **3.2 Results and discussions**

#### *3.2.1 Results of phase PLAN*

In this phase, the current situation of the waste in the different production unit was identified through the manageable waste KPI (MW KPI). In order to identify all forms of waste, it was necessary to analyze the overall production process, from the paper reels arrived at the plant, until they were shipped to the final customer. To do this, a flowchart of each department was developed. At this stage, it was important to engage the employees in order to understand exactly where, when and under what conditions the problem occurred. In addition, direct observation of the tools and machinery used in the production process it was important in order to identify problems and defects. During the various meetings with improvement groups, it was decided to focus on the corrugator cardboard manufacturing line where the largest amount of waste was generated. A corrugator cardboard machine is a set of machines designed to bring together three, five, or seven sheets of paper to form single, double, or triple wall board in a continuous process. In order to identify the most frequent causes of waste, the Pareto diagram was used (**Figure 1**).

Pareto diagram highlighted that the most important causes of waste in the corrugator cardboard manufacturing line were the downtime, peel, and paper residual around the core of the roll. The analysis of MW KPI pointed out that the high number of defective cardboard boxes was due to the frequent downtime of the corrugator, which had suffered a productivity decrease in recent years. This important type of waste was caused by defects and blocks recurring in the corrugator machine. The results in **Figure 2** show that the main causes of downtime of the machine were paper breaking and blocks.

*Perspective Chapter: The Lean Approach in Waste Management – A Case Study DOI: http://dx.doi.org/10.5772/intechopen.106744*

#### **Figure 1.**

*Pareto diagram—causes of waste.*

**Figure 2.**

*Pareto diagram—causes of downtime.*

To analyze the causes of this phenomenon, the Ishikawa diagram was used. This tool is a result of brainstorming of the working team of the corrugator department, consisting of employees of the Ondulator Department, manufacturing manager, and process improvement manager. As a result, of brainstorming, it emerged that breaking paper was mainly due to mistakes made by employees during the creation of the couplings. Indeed, the breaking paper was caused by wrong operations, wrongs in paper reel peels, paper reel wrong, uncontrolled paper reel, and damaged paper reel.

The same analysis has been made for the block machine. The team identified three main groups of causes: method, machine, and people (see **Figure 3**). In the "machine" group, the main cause was the incorrect adjustment of belts, causing their premature wear.

The next group of causes "Method" and "People" specified causes, such as lack of right scheduling interventions, failure reporting, incorrect frequency of lubrication activities, and wrong procedure

After identifying the causes which might have affected the problems, the improvement continuous team, through continuous interaction with the employees of the corrugator unit, identified potential solutions, based on the cost-effectiveness of the solution, its effectiveness, reliability, and technical complexity. With reference to each solution, the person responsible for the action itself, the deadline, and goals were then identified.

**Figure 3.** *Ishikawa diagram.*

#### *3.2.2 Results of phase DO*

The aim of this phase is to implement the action plan in order to make changes and eliminate the causes of problems in the production process. Among the implemented improvements were the following:


#### *3.2.3 Results of phase check*

At this phase, the results of the implementation of actions for each type of problem are analyzed. It is necessary to ask whether the problems identified in phase 1 have disappeared, or at least diminished. This activity, with a view to continuous improvement, was very important because it is possible to highlight any deviations from the planned objective, and it is possible to identify other opportunities for improvement.

Regarding the breaking paper, **Figure 4** shows a decrease in downtime after the implementation of the actions planned.

#### *3.2.4 Results of phase act*

Based on the findings of the check analysis and verified the sustainability and effectiveness of the implemented actions, it was necessary to proceed with standardization of improvement. Standardization is a key element in the lean approach, as

#### **Figure 4.**

*Downtime for breaking paper after the implementation of the action plan.*

standards define best practices for process implementation. What was tried within a single team, what was tried in a single process, the change that was made in a single machine, all of this must be extended to become the new standard to be followed and becomes the basis for subsequent further improvements. Since the purpose of the standard is to enable activities to be carried out without error and waste, it must contain a precise description of the sequence of activities and how these activities should be carried out correctly in order not to generate waste.

#### **4. Conclusion**

Lean management is nowadays one of the most dominating management approach, both in industrial and service environments. One of the reasons for such success is its simplicity. The whole concept is based on a common-sense idea of socalled "waste." Removing it is the very essence of Lean Management. The measures implemented in the Italian plant in the period between September 2020 and March 2021 have allowed sto significantly reduce waste and costs. The waste associated with breaking paper and blocks were reduced from 10% to 9%, with a cost reduction of 17.000 euros. This is an important achievement considering that the company's competitive position depends on many factors, including price, cost, product, and service quality. In addition, the implementation of the lean methodology has enabled the company to make the overall corrugated cardboard production process more efficient through better organization of the work. This means that in order to improve the process and reduce waste, it is necessary to encourage employees to analyze the problems and identify the opportunities for improvement. The plant's achievements are also particularly important in terms of sustainability. In fact, waste reduction is one of the goals underlying the sustainability strategy adopted by the company, which has long been committed to the responsible management of its production processes in order to reduce their environmental impact. Environmental protection and responsible production practices are two fundamental aspects of the company's way of operating.

For this reason, the efficient use of paper in the corrugated board production process and the consequent reduction of wastes represent important goals for the company and which are, therefore, continuously monitored.

### **Author details**

Roberta Pinna1 \* and Giovanni Senes2

1 Department of Economics and Business, University of Cagliari, Italy

2 Process Improvement Analyst, Italy

\*Address all correspondence to: pinnar@unica.it

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Perspective Chapter: The Lean Approach in Waste Management – A Case Study DOI: http://dx.doi.org/10.5772/intechopen.106744*

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### Section 3
