Applicability of the 5S management method for quality improvement in health-care facilities: a review – Tropical Medicine and Health
This study identified several key factors pertaining to the context and impacts of the 5S application. They were the implementation settings, applied tools or methods, changes resulting from the 5S application, and the objective of the intervention in the context of quality improvement (Table 1). Among the 15 empirical studies, the quantitatively measurable changes are presented in the nine articles [24–32]. Changes perceived by health workers are presented in one article, too [33].
Table 1 Research articles on the empirical application of 5S to health-care facilities
Full size table
Context of 5S application for quality improvement
Our review identified service areas and geographical locations involved in the empirical 5S application. 5S was applied to primary health-care facilities [28, 33, 34] and different locations or sectors of hospitals, including a pharmacy [24]; an emergency department [25]; an operating room [26]; multiple departments (central supply, histology laboratory, ICU, medical-surgical inpatient care unit, and infusion center) of several hospitals [27]; a laboratory [29]; a surgical clinic [31]; multiple locations of hospitals (or without specific information about target locations) [32, 35–38]; and central warehouses [30]. Of the 15 studies, six were conducted in the USA [26, 27, 29–31], one in the UK [35], and eight in low- and middle-income countries, namely Brazil, India, Jordan, Senegal, Sri Lanka, and Tanzania [24, 25, 28, 32–34, 37, 38].
Depending on the studies, 5S was combined with other tools and its application was meant for different quality improvement goals. Ten of the 15 empirical studies involved the application of 5S only [27, 28, 30, 32–38], whereas the other five studies combined several tools and methods including 5S [24–26, 29, 31]. In addition, 5S was regarded as a method under the framework of lean health-care by authors in ten studies [24–27, 29–31, 33, 35, 36] and toward better quality management (or total quality management (TQM)) in three studies [32, 37, 38].
Several studies presented the perceived roles or stages of the 5S application in the quality improvement context. 5S was considered to serve as an initial step toward TQM [32], as a foundation for continuous improvement [35], as a foundation for the lean tools to establish a self-ordering, self-regulating environment of sustainable change [36], and as a solution to improve the disorderly work environment that serves as a potential bottleneck in providing adequate services [33].
Eight empirical studies focused in low- and middle-income countries, but the resource levels of the studied facilities were not necessarily described in the articles. One of them, based at a health center in Senegal, highlighted the facility’s chronic resource constraints and its extremely disorderly work environment characterized by full of unwanted items kept everywhere unattended before the 5S application [33]. However, in the remaining seven studies, it was not clear whether the health-care facilities faced the typical problems prevalent in those countries, such as financial and human resource constraints.
Impacts of 5S application to health-care facilities
Ten empirical studies (nine quantitative and one qualitative studies) presented changes resulting from the 5S application and explicitly stated the research methods in the articles reviewed (Table 1). All nine quantitative studies presented measurable changes by comparing the status before and after the interventions without adopting explicit measures to control for potential confounding factors. The qualitative study presented health workers’ views on the changes attributable to the application of 5S in their workplace, daily routines, and services provided. In cases where several tools were utilized in the intervention, it was not possible to identify the extent to which 5S contributed to the changes. One study simply focused on score increases measured for each S (sort, set in order, shine, standardize, and sustain), whereas the remaining nine studies highlighted positive changes in the quality of health-care. Based on the classification of the health-care quality dimensions proposed by the Institute of Medicine (USA) [39], these changes included measures pertaining to three areas: (a) efficiency, (b) safety, and (c) patient-centeredness.
The efficiency measures included improvements to the work processes, potential cost reductions, and increases in physical space [24–26, 29, 30, 33]. The changes resulting from the 5S application were presented as potential reductions of more than 45 % in the drug-dispensing cycle time [24]; improved process flows, increased capacity, and shorter stay for all patient classes [25]; a 70 % reduction in the number of instruments used in minimally invasive spine surgeries (from 197 to 58) and a 37 % decrease in setup times (13.1–8.2 min, p = 0.0015); potential institutional annual cost savings of US$2.8 million [26]; a reduction in the turnaround time for a typical test, an increase in the number of tests, cost savings, reductions in the dispersion of the turnaround time, and better space utilization [29]; increases in inventory turnover by 30 % in a hybrid 5S application site and 4.0 and 43.0 % in two traditional 5S application sites [30]; and a reduction in the time involved in searching for items and an improvement in their ability to move within the office after the introduction of 5S [33].
Safety measures included improved ergonomics resulting from the rearrangement and removal of items to eliminate safety violations and improved compliance with regulations [27], 52 % reduction in the post-Caesarean infection rate and 33 % reduction in the stillbirth rate over the 2-year period [32], and an improved sterilization process [33].
The assessment of patient-centeredness measures was based on the time spent on direct patient care increasing from 30 to 61 % after 30 days and improvements in patient satisfaction [31] and reduction in waiting time for patients and better directional indications for patients [33].
Adoption of 5S application as part of government initiatives
This review highlighted the application of 5S as part of government initiatives. Of the 15 research articles reviewed, five involved empirical 5S application as part of government initiatives, and these five studies were all concentrated in low- and middle-income countries. In these studies, the 5S application was initiated as part of the local governments’ programs in India [28, 34] and national strategies for health-care quality improvement spearheaded by health ministries in Senegal, Sri Lanka, and Tanzania [32, 33, 37].
Other types of publications presented case studies on the adoption of 5S as national strategies in low- and middle-income countries. The Castle Street Hospital for Women in Sri Lanka is the first documented case of 5S application to a government hospital in a low- or middle-income country [32]. Achievements at the Castle Street Hospital led to a pilot study, conducted between 2005 and 2007, to institutionalize 5S at five government hospitals in Sri Lanka [40]. In 2009, the health ministry of the Sri Lankan government initiated a project with the technical support of JICA to improve the quality and safety of health-care facilities in the whole country (Ministry of Healthcare and Nutrition, Project document: improvement of quality and safety in healthcare institutions in Sri Lanka, unpublished). The implementation of the project resulted in the adoption of 5S as part of the national strategies of the Sri Lankan government’s health ministry [41].
Starting in 2007, 5S was introduced to government hospitals in African countries under the framework of JICA’s Asia Africa Knowledge Co-creation Program (AAKCP). With the aim of applying Sri Lanka’s successful experience to Africa, the program provided assistance in introducing 5S-KAIZEN-TQM to pilot government hospitals, first in eight countries (Eritrea, Kenya, Madagascar, Malawi, Nigeria, Senegal, Tanzania, and Uganda; phase I: 2009–2013) and then in another seven countries (Benin, Burkina Faso, Burundi, the Democratic Republic of Congo, Mali, Morocco, and Niger; phase II: 2009–2013) [22, 42]. It was reported that the pilot introduction of 5S-KAIZEN-TQM in these government hospitals in the 15 African countries led to an improvement in the visual management of the workplace as well as the service delivery process [43]. These pilot initiatives led to the formulation of new technical cooperation projects that included 5S as part of the activity components in several participating countries. Those projects resulted in the adoption of 5S as a mainstream strategy for quality improvement in health-care services in Senegal and Tanzania [44–46].
