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BIJ
26,3 Improving customer satisfaction
of a healthcare facility: reading
the customers’ needs
854 Marvin E. Gonzalez
Department of Supply Chain and Information Management,
Received 10 January 2017
Revised 31 August 2017 School of Business, College of Charleston, Charleston, South Carolina, USA
21 June 2018
Accepted 28 June 2018
Abstract
Purpose – Customer satisfaction refers to the extent to which customers are happy and satisfied with the
products and services provided by a business. The purpose of this paper is twofold: first, to integrate lean tools
in the analysis of customer satisfaction and, second, to examine its implications for research and practice.
Design/methodology/approach – The author proposes the combination of three lean tools in order to
design a service quality system that has customer expectations (CEs) as the first input. These tools are quality
function deployment (QFD), Hoshin Kanri planning process (HKPP) and benchmarking. The author uses a
case study to show the functionality of these tools and the final design of a service quality system for a
medical center.
Findings – Interaction between the service provider and the customer is the primary core activity for service-
oriented businesses of different natures. A key relationship between trust in service quality and customer
satisfaction cannot be ignored in interpersonal-based service encounters. However, there is a gap in the
literature in terms of standardized lean-based procedures or methodologies that lead to improved customer
satisfaction that are based directly on CEs.
Research limitations/implications – Given the variety of the population, the authors developed several
methodologies to standardize the customer responses. Using several total quality management tools, the
standardization allows the authors to separate the different CEs. The gathering of customers’ expectations
(voice of the customers) allows the companies to focus on the real problems expressed by the users of the
service, increasing their loyalty and, most importantly in the field under study, the customer’s satisfaction
with the service received.
Practical implications – For practitioners, this study helps with the use of lean tools such as QFD,
benchmarking and HKPP and attempts to bridge such a gap with an evidence-based real case.
Social implications – With the incorporation of all the customer needs, additional elements must be
considered in the design of new services. Availability for all and sustainability play an important part of the CEs.
Originality/value – This paper presents a real application of QFD and Hoshin Kanri and how they may help
the service organizations with future development.
Keywords Benchmarking, Quality function deployment, Customer satisfaction, Hoshin Kanri, Lean tools
Paper type Research paper

Benchmarking: An International
Journal
Vol. 26 No. 3, 2019
pp. 854-870
© Emerald Publishing Limited
1463-5771
DOI 10.1108/BIJ-01-2017-0007
Introduction
The healthcare industry, like many other areas of business, has been impacted by the
noteworthy increase in the local and international competition in the last decade. The tough
global economy has motivated the organizations to change their operational standard
procedures. As highlighted in previous research, it is critical to listen to customer
expectations (CEs) in order to effectively satisfy the customer; such expectations can be
obtained from the basic feelings of the market (Friesner et al., 2009; Yufeng and Lihong,
2014; Roger, 1996; Jaakkola et al., 2015; Jeong and Oh, 1998). Hospitals all across the USA are
facing a growth in demand and must provide superior customer service and operate
efficiently if they intend to maintain or increase their level of customers (Bazzoli et al., 2003).
This increase in demand is leading to the development of more hospitals, but also smaller,
specialized doctor’s offices and urgent care facilities that directly compete with the
hospitals. Medical centers (MCs) have come a long way in improving the level of care and
the quality of the patient experience (Anil, 2011; Gaucher et al., 1991; Garver, 2012; De Felice
and Petrillo, 2011). Any action executed for the purpose of customer satisfaction will
increase levels of loyalty and higher profits (Iqbal et al., 2014; Chieh-Peng et al., 2015; Improving
Einspruch, 2006; Pimentel and Major, 2016). customer
Process improvement entails further investigating operational areas in which quality satisfaction
needs enhancement. For example, in hospital satisfaction surveys, quality is measured
regarding three different areas: patients’ perception of the value of the outcome of treatment,
tools and facilities practitioners used in the treatment and process by which the treatment
took place (Friesner et al., 2009). Some of these variables are measured via questions 855
concerning whether the customer feels better, for example: the customer perceived the
facility as clean, and the customer felt that waiting times were acceptable. These aspects are
constituted as the main CEs, as we will see in our study.
The healthcare industry has increased substantially in recent years. Many reasons for
this growth include higher numbers of chronic diseases, overpopulation, increase of elderly
population and the lack of healthy lifestyle choices. According to medical device +
diagnostic industry, the world’s population will increase from 7bn in 2010 to 9bn in 2050. By
2050, the elderly population will increase by 146 percent. The latter will have a dramatic
effect on the healthcare industry because the elderly use a greater amount of medical
services and supplies. Another factor to consider is that the life expectancy in the world’s
top 29 countries is over 80 years old and many scientific studies show that this number will
continue to raise (Frakt, 2013; He and Mellor, 2012).
Hospitals have a great challenge ahead of them because now they must compete with
smaller urgent care clinics, physician’s offices and specialist’s offices. Hospitals need to
re-evaluate their strategies to focus on administrative and operational efficiency, customer
service and growth management (Pimentel and Maria, 2016; Anderson and Fornell, 2000).
The purpose of this research is to fill a research gap that has been broadening in the
customer service area, that is, to create a standardized strategic procedure for listening to
and satisfying the customers’ expectations by taking such expectations into
consideration, rather than focusing solely on the competitiveness problem. During the
development stages, the author used quality function deployment (QFD) to capture the
CEs, benchmarking to compare with practices and competitors and Hoshin Kanri to set up
the strategy for the coming years.

Literature review
This study explores three Lean tools, evaluating each of them in the service area and explain
in the following section. QFD has proven a successful way to organize and develop a better
method of making products more customer-focused. The Japanese created the basics of QFD
in the 1960s. Mizuno and Akao wanted to develop a methodology that could help to produce
a product that will fully satisfy the customers’ expectations before it were produce (Akao,
1972; Hauser and Clausing, 1988; Zafar et al., 2015).
QFD is used to determine customer needs, prioritize the customers’ needs, translate these
needs into process, and then to develop targets to meet these requirements (Hauser and
Clausing, 1988; Zafar et al., 2015). The first step in the QFD is to create the house of quality
(HOQ) matrix. The purpose of this matrix is to allow you to see the correlation between the
customer’s needs and the engineering process and requirements. By realizing this
correlation, we can determine what modifications are required in the process. Additionally,
we are able to compare the organization’s attributes and performance with their
competitors’ (Hauser and Clausing, 1988). Some QFD studies in the area of healthcare had
been applied such as Einspruch (2006), Gaucher et al. (1991), Gonzalez et al. (2005), Jeong and
Oh (1998), but none of them explain in detail a process to apply the QFD.
The findings from the customers will then be translated into processing and operational
requirements. This is where we determine what the company needs to do differently in order
to supply the customer with exactly what they are demanding (Timothy et al., 2015;
BIJ Einspruch, 2006). QFD is especially helpful to service entities because they rely on customer
26,3 satisfaction for the prosperity of their business (Lee et al., 2015).
Hospitals are a service provider and therefore will benefit greatly from the use of QFD,
by utilizing this tool, hospitals can determine what kind of procedures, services and
supplies are important to their patients (De Felice and Petrillo, 2011; Frakt, 2013).
By knowing this information, hospitals can focus on the specific needs and wants of
856 patients and can cut back on the unnecessary excess (reduce waste). This knowledge can
also help reduce costs and save time for hospitals and their patients. Though 40 percent of
hospitals have studied total quality management in the USA, the patient satisfaction rate
in the USA is still very low (only 251 hospitals received a 5-star rating on patient
satisfaction, out of 3,500 US hospitals surveyed). This is attributed to the lack of
understanding on the hospital’s administrations part in terms of what the customers
really want.
The Hoshin Kanri planning process (HKPP) is extensively used in Japanese and western
companies for strategy planning and performance measurement in the manufacturing and
service sectors. The fundamental premise of the HKPP is that the best way to obtain the
desired result for an organization is for all employees to understand the long-term direction
and participate in designing the practical steps to achieve the results. The intention of this
method is to engage people that work directly in the process with the specific problem and
to empower them to come up with a potential solution. The process used in HKPP is based
on the four stages of the plan-do-check-act principle (Butterworth and Witcher, 2001;
Witcher and Chau, 2007; Nicholas, 2016).
The MC can utilize QFD to determine what their patients’ needs and wants are to insure
that they are on the right path to success. Additionally, MC can also attempt to predict
what would be the patients’ needs in the future. One of the most practical benefits of QFD
is that it provides a tool that shows organizations how to better compete with their rivals.
This information will be a great asset to MC because they are currently ranked 12 out of
all of the hospitals in the Charleston area (among facilities near Charleston, SC). When
rankings are viewed according to Outstanding Patient Experience Award, MC is not
present because they have not received this achievement. This award can be a great
incentive to implement the continuous improvement process proposed in this paper, and
to later apply for it.
Benchmarking is a tool to help organizations with the foundation for their continuous
improvement initiatives as part of their lean implementation (Parast and Adams, 2012).
Essentially, benchmarking allows an organization to develop strategic action plans based
on their performance in relation to a particular standard or best practice (Hokey et al., 1997).
Benchmarking results are used to identify, quantify and prioritize improvement
opportunities offering the greatest potential return, while highlighting areas at risk due
to under-spending. Benchmarking may be a one-off event, but it is often treated as a
continuous process in which companies continually seek to challenge their practices
(Talebi et al., 2014; Malhotra et al., 2015, 2013; Pang et al., 2009; Palm et al., 2016). The author
uses benchmarking in this paper to compare best practices in three different MCs that are
available for the same population of people.

Purpose of the study

The purpose of this study is design a strategy that allow us to evaluate the customers’
expectations, using as initial tool, QFD, producing the elements to build a long-term strategy
in the company. In spite of the application of QFD is common in service industry, the
approach using QFD and benchmarking and linking the results with Hoshin Kanri, which is
a long-term planning, is unique and constitutes in a contribution for the academia and the
area of healthcare, incorporating the CEs in the long-term process.
Methodology Improving
As were stated previously, the objective of this research is to identify, understand and customer
incorporate into corporate strategy the customer needs and the way to satisfy them in a satisfaction
medical facility, thus improving the responsiveness and effectiveness of the MC in the areas
that the customers consider strategic. The methodology used in this paper is known as
action-research, the study was developed in a medical facility (in a prior agreement with the
company, the firm name will not be revealed). We applied action-research approach 857
(the author participated in the development, training and implementation of the method).
All the information collected from the facility under study, as well as the other two facilities,
was collected using participant–observer format; therefore, the reliability, construct validity
and internal validity are much stronger than found in a typical case study.
Figure 1 shows the methodology used in this study.

Step 1: survey design

A questionnaire based on previous literature was developed. This questionnaire included items
from multiple sources in the literature, including some items from SERVQUAL in order to
obtain CEs. SERVQUAL proposes ten determinants of service quality, from which we used the
six more relevant for the case of MCs: competence, courtesy, credibility, access, communication
and knowing the customer (Parasuraman et al., 1985, 1988). These dimensions had been tested
through different research in a wide range of areas, as can be seen in the studies of Altuntas
and Yilmazc (2012), Babakus and Boller (1992), Babakus and Mangold (1992), Bahadori et al.
(2011), Buttle (1996), Carman (1990), Çerri (2012) Parasuraman et al. (1988). In the questionnaire,
we aimed to identify the different customer’s needs and the customer’s perceived rating of
those needs in the different MCs, the information obtained in this part was used in the
benchmarking analysis. The questionnaire was divided in three sections: demographics of the
sample, measurement of the service received and expectations for improving the process.

Step 2: survey application

The survey was distributed to customers at the MC. A total of 183 CEs were collected. The
analyzes are presented in the following section. The methodology of the QFD starts with

Step 2
Survey Application

Step 1 Step 3
Survey Design Final Step What’s definition
Design an strategy
to satisfy
Customer needs

Step 5 Step 4
HOQ Analysis How’s definition Figure 1.
Methodology used in
the medical center
BIJ collecting the voice of the customer (VOC), which is done with specific items in the
26,3 questionnaire, along with open-ended questions that allows the customer to indicate needs
that are not in the already listed expectations as part of the questionnaire. Therefore, the
number of CEs is larger than the number of items in the survey.

Step 3: WHAT’s definition

858 The WHAT’s in the QFD jargon refers to the CE after they have been reduced using a
systematic approach. The CEs start as raw material to the QFD in the tertiary level, meaning
that they are expressed just like the customer expresses them, in the customer’s own words.
Then, the next level (secondary level) is developed by the use of a tool called “affinity
diagrams” to reduce the number of CEs and to group the ones that are similar. In this process,
we went from 183 CEs to 46. Then, the last level in the reduction process is the main level,
which is the final CEs as they are entered in the first room of the HOQ, and they become the
WHAT’s. In this last step, we used two lean tools together: affinity diagrams and
interrelationship diagrams. There were a total of 23 CEs in the main level. The rationale is that
if we meet the attributes on the main level, we will meet the secondary and tertiary expectations
as well. Therefore, we will satisfy most of the original customer attributes found in step 2.

Step 4: HOW’s definition

The second room of the HOQ is contains the translation of the WHAT’s into technical
process requirements (HOW’s) (Mazur et al., 1995; Hauser and Clausing, 1988; Einspruch,
2006; Gonzalez et al., 2005). An interdisciplinary team within the organization will work on
process specifications that will meet the customer requirements (CEs) defined in step 2.
Therefore, there is a clear translation of the VOC into the design of the process.

Step 5: HOQ analysis

QFD has many matrixes that help in the design of customer-oriented processes. In this
paper, we focus on the first matrix, the HOQ. In the results stage, we explain in detail the
construction of this matrix, and how it is analyzed to assure that there will be improvements
in the technical requirements (HOW’s) that are more important and relevant in the
satisfaction of the customer requirements.
As part of the QFD analysis, a room is dedicated to the benchmarking analysis. Based on
these results (the QFD and the benchmarking), the HKPP was developed. As defined by
Hauser and Clausing (1988), “QFD is a product development methodology whose objective
is to ‘deploy’ the Voice of the Customer.” Therefore, it is critical to identify the CEs because
they are the cornerstone of the research.
The results of this survey were used to establish the level of administrative efficiency the
patient expects when they visit the hospital/MC for treatment. For the benchmarking part of
the analysis, we used hospital rankings and patient rankings for Charleston area hospitals
that are available online at Health Grades. This provided the necessary information on
competitors among the local hospitals. By reviewing these other hospitals, we determined
what differences exist between their strategies and that of the MC (MC under study). In terms
of the evaluation of the customers on each of the CEs, we conducted a survey with the specific
items and distributed it to customers of the competitors during a week of data collection.

Results: the QFD process

Administrative efficiency and customer service categorization
In order to apply this QFD to both of these aspects, we will combine them into one category
or concept. We can consider customer service as the result of administrative efficiency.
Therefore, the more efficient a hospital is and the greater level of customer service they
provide, the greater their level of customer satisfaction will be. In order to understand the Improving
final matrix (Figure 6), it is important an explanation of the different rooms of the HOQ. customer
Figure 2 shows the different rooms that the planning matrix in QFD use. satisfaction
VOC identification and segmentation
The first stage in implementing QFD is to gather the VOC (VOC, room 1), also known as the
CE. In this stage, the researchers collect the customer’s wants and needs. As we mentioned 859
previously, we collected the VOC by distributing surveys to real customers at the MC.
We collected over 183 CEs. The next stage is to reduce these “raw” CEs to a manageable
number to analyze, without losing important information.
The CE reduction process that we follow is a standard method where CEs go from
tertiary level to main level (Gonzalez et al., 2005; Seok and Jae Kim, 2000; Forrester, 1962).
There are three levels in this process: tertiary (raw CEs), secondary and main (see Figure 3).
In the tertiary level, the initial CEs are vague and are considered general concerns about the

Technical requirements
(HOW’s)

1 Customer
expectations Correlation Matrix Benchmark
(WHAT’s)

5 Figure 2.
Objectives Quality function
deployment rooms

Main variable Secondary Tertiary

Access to the location
Free parking
Easy access to the facility
Parking Availability
Public buses availability
Easy access to the facility
Handicap facilities

Flexible appointment system

Convenient to use Appointment system Enough appointments available
Specialist availability
Friendly system
Internet system available (for appointments)

Figure 3.
Clear map directions
Reduction process of
Easy to find Accessible from main streets the customer
Safe place expectations (CEs)
Be in downtown or close areas
BIJ issue under study without any filters or changes to the original information gathered from
26,3 the customer (183 CEs). We then used affinity diagrams to organize the 183 CEs into
similarity groups (making sure that the meaning is the same but said in different words).
Once the groups have been identified (the tertiary section), we proceeded to form a secondary
level of expectations, reducing the initial number of CE’s from 183 to 46. We carefully
denominated the secondary CE’s with a name that covered all the attributes inside the tertiary
860 level. For the last step, we used both affinity diagrams and interrelationship diagrams to
group the secondary variables by similarity of meaning and thereby generate the main
customer attributes (CE’s), which are the ones incorporated into the HOQ. Using this reduction
process, we generated 23 final CEs that are the main input of the WHAT’s room of the HOQ.
Figure 2 depicts an example of the reduction process.
The final variables in the main level (23 CE’s) can be summarized in five categories:
convenient to use, patient communication, patient confidence, financial issues and
environment. Each category has a group of CEs, which can be seen in Table I. Each group
has several expectations, as can be seen in Table I. We start building the first room of the
HOQ (Table I) by adding the CEs from the main level, and analyzing additional information
that is computed as columns. In the original survey, the customer was asked to rate the
level of importance for each CE (importance of the WHATs to the customer, column 2).
The following three columns have the benchmarking of the different CEs comparing the MC
under study with its two main competitors. Column 6 shows the desired target number that
our MC wants to achieve in each area. The improvement factor (column 7) represents the
amount of work required to go from our current state to the desired future product. Column
8 shows the market leverage, also known as sales factor. Sometimes, there are CEs that are
underestimated by customers, but internally, the company knows its hidden benefit, and
would like to assign an additional importance. The additional importance is assigned by the
market leverage/sales factor in column 8. A combination of the importance of the WHATs
(column 2), the improvement factor (column 7) and the market leverage factor (column 8)
shows the overall importance (column 9) (Mazur et al., 1995; Hauser and Clausing, 1988;
Einspruch, 2006; Gonzalez et al., 2005). Overall importance helps us prioritize the CEs. When
we analyze the overall importance rating, two categories are significantly higher than the
rest: patient confidence and financial issues (19.83 and 20.53, respectively). This means that
MC can benefit from working toward improving these two categories first, as a way to
prioritize their continuous improvement projects.
In QFD, there is a measure called “sales point”. Higher sales point, compared to
competitors, mean that the organization under study has a competitive advantage and
should use the attribute as a “bragging point,” without maintaining continuous
improvement. Figure 4 shows that the MC has one “sales point”: convenient to use,
which indicates that the MC has a stronghold in the following customer attributes E1, E2,
E3, E4, E5, E6 and E7. As the customer evaluates these expectations as strong points in MC,
the marketing strategy for attraction of new customers must be based on these expectations.
On the other hand, MUSC and Doctors Care have a better position in the other customer
attributes. Analyzing these main expectations, the MC has a gap in four of them to improve
and satisfy in a better way the CEs. They could use a lean process in order to state a
procedure to identify and improve in these areas so that these CEs can be satisfied.
When we analyzed in detail all the variables that are part of the main expectations level,
we found interesting conclusions that could help in the development of the strategic plan to
capture more customers. Using the information from Table I, we developed another spider
graph (see Figure 5) that shows in detail all the variables that we summarized from the
entire set of CEs.
As can be seen in Figure 5, the MC presents a sales point (they are better than the other
medical facilities) in E6 ( free parking access). But can be seen the weaknesses of the center are:
 Our Market
Importance of medical Doctors Our future Improvement leverage Overall
the WHAT’s center MUSC Care product factor factor importance

Convenient to use 3.70 3.61 3.16 3.11 4.09 1.09 3.89 15.77
Nearby (E1) 3.10 3.50 2.80 3.00 4.00 1.10 3.50 11.90
Easy to access (E2) 3.40 3.50 3.50 2.50 4.00 1.10 3.50 13.10
Public transportation to the center (E3) 3.50 3.40 3.00 2.50 4.00 1.10 3.40 13.30
Appointment flexibility (E4) 4.10 3.00 4.00 3.00 5.00 1.40 4.00 23.00
Appointments availability (E5) 4.50 2.90 3.80 3.80 4.00 1.20 3.80 20.90
Parking access free (E6) 3.80 4.80 2.00 3.50 4.00 0.80 4.80 15.30
Speedy service at my appointment time (E7) 3.50 4.20 3.00 3.50 3.60 0.90 4.20 12.90
Patient communication 4.60 3.05 3.00 3.00 3.50 1.08 3.08 15.35
Clear information provided (E8) 4.20 3.30 3.00 3.00 4.00 1.10 3.30 15.80
Doctor’s shows expertise (E9) 4.80 3.00 3.00 3.00 3.00 1.00 3.00 14.40
Adequate time spend with the nurse (E10) 4.50 3.00 3.00 3.00 4.00 1.20 3.00 16.20
Doctors explaining the problem and treatment (E11) 4.90 2.90 3.00 3.00 3.00 1.00 3.00 15.00
Patient confidence 4.25 3.78 4.00 3.75 4.25 1.08 4.25 19.83
Provide the best diagnosis possible (E12) 4.50 3.30 4.00 3.00 4.00 1.10 4.00 20.50
Feels an adequate solution to your medical condition (E13) 4.50 4.00 3.00 3.00 4.00 1.00 4.00 18.00
Give me the correct prescription (E14) 4.00 4.00 4.00 4.00 4.00 1.00 4.00 16.00
Do not rush me through the tests (E15) 4.00 3.80 5.00 5.00 5.00 1.20 5.00 24.80
Financial 4.77 3.50 3.67 2.83 4.17 1.13 3.83 20.53
Abuse on the costs (E16) 4.50 3.00 3.50 3.50 4.50 1.30 3.50 20.50
Reasonable costs (E17) 4.80 3.50 4.00 2.00 4.00 1.10 4.00 21.10
Be covered by my insurance (E18) 5.00 4.00 3.50 3.00 4.00 1.00 4.00 20.00
Environment 4.18 3.30 3.30 3.60 3.70 1.08 3.60 16.50
Friendly and helpful staff (E19) 4.50 4.00 4.00 4.00 4.00 1.00 4.00 18.00
Give me my privacy (E20) 4.40 3.00 3.00 3.00 3.00 1.00 3.00 13.20
Comfortable waiting area (E21) 3.50 3.00 3.00 3.00 3.00 1.00 3.00 10.50
Clean and professional facility (E22) 4.00 3.50 3.50 4.00 4.50 1.20 4.00 19.20
Comfortable testing rooms (E23) 4.50 3.00 3.00 4.00 4.00 1.20 4.00 21.60
customer

861
Improving

satisfaction

expectations (room 1)
Table I.
Customer’s
BIJ Convenient To Use
4.00
26,3 3.50
3.00
2.50
2.00
1.50
Environment Patient Communication
862 1.00
0.50
Our Medical Center
0.00
MUSC
Doctors Care

Figure 4.
Main customer
expectations’
overall evaluation
Financial Patient Confidence

(E1)
(E23) 5.00 (E2)

(E22) 4.50 (E3)

4.00
(E21) 3.50 (E4)

3.00
SALES POINT
(E20) 2.50 (E5)
2.00
1.50
(E19) 1.00 (E6)
Our Medical Center
0.50
MUSC
0.00
Doctors Care
(E18) (E7)
Market Leverage Factor

(E17) (E8)

(E16) (E9)

Figure 5. (E15) (E10)

Customer
expectations analysis (E14) (E11)
(E13) (E12)

E16 (abuse on the costs), E13 ( feels an adequate solution to your medical condition), E11
(doctors explaining the problem and treatment) and E10 (adequate time spent with the nurse).
MC should act quickly in making sure that they improve these CE to improve their overall
customer satisfaction. This again is a great tool to prioritize those continuous improvement
and lean projects. Results in Figure 5 confirm our previous conclusion given by Figure 4.

Responding to the customer needs (building the HOQ)

The second stage in QFD implementation is the definition of the HOWS (room 2), known in
the QFD language as technical requirements (Mazur et al., 1995; Hauser and Clausing, 1988;
Einspruch, 2006; Gonzalez et al., 2005). This step is the translation of the CEs identified in
the VOC into technical requirements within the organization. The “HOWS” are the design
requirements of the service, it is necessary to define how the service provider will satisfy
each CE. These measurable features could be evaluated at the end of the development Improving
process. This stage comes (second room of the HOQ), when we develop potential solutions to customer
implement the possible processes created in the design stage. satisfaction
In order to satisfy the HOWS, the QFD team split the solution in three areas: the center’s
logistics, the customer satisfaction care and the level of professional care. The center’s
logistics includes activities that are related with the facility and the easiness to receive a good
service. Customer satisfaction care is related with the professional service provided by the 863
hospital or medical unit. Finally, the level of professional care is concerned with the medical
service provided by doctors and nurses. The detail of these HOWS can be found in the room 2
of the HOQ (Figure 6). The relationship between WHAT’s and HOW’s is developed by an
interdisciplinary team and summarized in room 3. As any other part of the process, there
needs to be an interdisciplinary team that helps building the HOQ. Once the HOQ is
developed, it is very easy for the MC to identify weaknesses and strengths, and compare with
their competitors, as well to prioritize on real actions to take for continuous improvements.
Some of the improvements/solutions that the team came up with after building this HOQ are:
• MC can use a card marking service and software to produce identification cards for
each patient. The downside of this option is the increased risk of identity theft and
the need to keep information confidential.
• MC is already participating in a program that allows them to share electronically
patients’ medical records with other hospitals in the area.
• MC can offer their own financing to patients who do not have insurance and accept
more insurance plans.
• MC can also advertise to make the surrounding community more aware of their
achievements and to try to improve their reputation.

Competitive analysis, the benchmarking (room 4)

The benchmarking analysis in this research is based on the results that room 4 provided. As
can be seen in Figure 5, the light dashed line represent the ideal future center, these
objectives where predetermined in room 5 (Figure 2) by the interdisciplinary team.

Patient Communication Patient Confidence Environment Items

Items Items
2
Convenient to use
Financial Items
Items

Figure 6.
0 Competitive analysis
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 per section (room 4)
MC MUSC Doctors Care Future Product
BIJ As is explained by several authors such as Parast and Adams (2012), Hokey et al. (1997),
26,3 Milosevic et al. (2013), Andersen and Camp (1995), Rogers (1993), Whymark (1998),
Woodburn (1999), benchmarking is powerful tool that help to observe the weakness and
strength factors in our companies, allowing to identify gaps of improvement. Said that, and
using the information provided by room 1 and Figure 5 we can conclude that in the items
related to convenient to use, MC is the best evaluated by the customers, and as we said
864 previously this strength constitute a sales point for the MC. As can be seen in Figure 5 MC
have room for improvement because the final objective of an ideal center. According to the
results, a lot of improvement must be done in the patient communication items because the
MC is behind the other competitors. Important improvements must be conducted in
the patient confidence items, in all the items the MC is weak, aspect that must call the top
management attention. It is not part of this study but the variable trust is critical in the
service field and therefore top management must take corrective action in this area. In the
other two sections, the MC need to improve because is behind of the competitors and
financial and environment are two critical factors in the heath area.
As can be see the benchmark analysis allow the company identify the strong points
and weakness areas where the company need to improve if they want to satisfy the
customer requirements.

Deployment
The final stage proposed in this paper for lean applications in healthcare industry is the
development of HKPP as the deployment stage. This process answers the following questions:
How will we better serve the patients? How can we make administrative procedures more
efficient? How can we be more competitive in the healthcare field? The answer to these
questions started with the HOQ (Figure 5) and is translated into real actions in the Hoshin
Kanri X-matrix (Figure 6). The purpose of the Hoshin Kanri X-matrix is to develop and
implement plans that are both strategic, tactical and coordinated among key people across the
organization. The X Matrix also ensures that there is ownership and accountability at all levels
for each of the actions presented. This approach to strategic planning also encourages
organizational learning, faster process corrections and cross-departmental coordination. Hoshin
means, “shining metal pointing direction” – in other words, it is a compass that points to
True North. We follow six steps that we describe below to analyze HKPP X-matrix in Figure 7.

Key objectives
Lean is fundamentally long-term thinking. The idea is to develop many lean projects that
will have an aggregate benefit in the overall performance of the organization, but these
benefits are usually better measured in the long term. HKPP enforces this by first looking at
objectives that are three to five years out. There can only be a few of them. In our study for
MC (Figure 6), we show the most representative that represent direct solutions to problems
presented in the QFD matrix (Figure 5). The key objectives identified by the team are:
improve center logistics, increase staff training in service quality, increase social media
presence and increase/improve medical center services (Figure 8).

Main initiatives
Main initiatives are those that the team identifies as shorter term solutions to operationalize
the key objectives. The research identified a few short-term (within one year) objectives that
align or nest under each of the longer-term breakthrough objectives. The X-matrix shows
the main initiatives on the left, and it allows us to create a relationship matrix that aligns the
key objectives with the main initiatives. Main initiatives are: improve corporate image;
re-engineering of activities (lean analysis); reorganization of the MC (customer service
 Improving
customer

Hours of physician availability to patients

System availability for appointments
Direction of Improvement

Logistics at the end of the process

satisfaction

Scheduler speed and knowledge

Maximize

Waiting time for see the doctor

1.0
Target 0.0

Comfortable waiting rooms

Minimize –1.0

Customer Satisfaction Care

Level of Professional Care

Importance of the WHATs

Our Medical Center

Our Future Product

Market Leverage Factor
Rooms environment

Improvement Factor
Our Medical Center

Our Future Product

Scheduler flexibility

Competitive Analysis
Professional Care
Website updated

Doctors flexibility

Percent Importance
Staff capabilities

Overall Importance

Doctors Care
Customer Care

Care available

Doctors Care
Center’s logistic

Accessibility

MUSC
MUSC

Max= 5.0

Min = 2.0
865

10

11

12

13

14

15

16

17

18
1

9
Direction of Improvement 1

Convenient To Use 1 1

Nearby 2 3.1 3.5 2.8 3.0 4.0 1.1 3.5 11.9 3.0 2

East to access 3 3.4 3.5 3.5 2.5 4.0 1.1 3.5 13.1 3.3 3

Public transportation to the center 4 3.5 3.4 3.0 2.5 4.0 1.1 3.4 13.3 3.4 4

Appointment flexibility 5 4.1 3.0 4.0 3.0 5.0 1.4 4.0 23.0 5.8 5

Appointments availability 6 4.5 2.9 3.8 3.8 4.0 1.2 3.8 20.9 5.3 6

Parking access free 7 3.8 4.8 2.0 3.5 4.0 0.8 4.8 15.3 3.9 7

Speedy service at my appointment time 8 3.5 4.2 3.0 3.5 3.6 0.9 4.2 12.9 3.3 8

Patient Communication 9 9

Clear information provided 10 4.2 3.3 3.0 3.0 4.0 1.1 3.3 15.8 4.0 10

Doctor’s shows expertise 11 4.8 3.0 3.0 3.0 3.0 1.0 3.0 14.4 3.6 11

Adequate time spend with the nurse 12 4.5 3.0 3.0 3.0 4.0 1.2 3.0 16.2 4.1 12

Doctors explaining the problem and treatment 13 4.9 2.9 3.0 3.0 3.0 1.0 3.0 15.0 3.8 13

Patient Confidence 14 14

Provide the best diagnosis possible 15 4.5 3.3 4.0 3.0 4.0 1.1 4.0 20.5 5.2 15

Feels an adequate solution to your medical condition 16 4.5 4.0 3.0 3.0 4.0 1.0 4.0 18.0 4.6 16

Give me the correct prescription 17 4.0 4.0 4.0 4.0 4.0 1.0 4.0 16.0 4.0 17

Do not rush me through the tests 18 4.0 3.8 5.0 5.0 5.0 1.2 5.0 24.8 6.3 18

Financial 19 19

Abuse on the costs 20 4.5 3.0 3.5 3.5 4.5 1.3 3.5 20.5 5.2 20

Reasonable costs 21 4.8 3.5 4.0 2.0 4.0 1.1 4.0 21.1 5.3 21

Be covered by my insurance 22 5.0 4.0 3.5 3.0 4.0 1.0 4.0 20.0 5.1 22

Environment 23 23

Friendly and helpful staff 24 4.5 4.0 4.0 4.0 4.0 1.0 4.0 18.0 4.6 24

Give me my privacy 25 4.4 3.0 3.0 3.0 3.0 1.0 3.0 13.2 3.3 25

Comfortable waiting area 26 3.5 3.0 3.0 3.0 3.0 1.0 3.0 10.5 2.7 26

Clean and professional facility 27 4.0 3.5 3.5 4.0 4.5 1.2 4.0 19.2 4.9 27

Comfortable testing rooms 28 4.5 3.0 3.0 4.0 4.0 1.2 4.0 21.6 5.5 28
Max= 5.0
The Medical Center
MUSC Standard 9 – 3 –1

Doctors Care Strong 9.0

Targets for Our Future Product Moderate 3.0
Weak 1.0
Min = 2.0
3.0
4.0

3.0

4.0

4.2

4.0

5.0

4.0

3.0

3.0

3.0

4.0

3.0

3.6

4.0

Competitive Benchmarking Results 2

2.0 3.0
3.0 4.0

3.0 3.0

4.0 4.0

3.8 4.0

4.0 3.0

4.0 5.0

3.0 4.0

3.0 3.0

3.0 3.0

3.0 3.0

4.0 4.0

3.0 3.0

3.6 3.2

4.0 4.0

The Medical Center 3

MUSC 4
Figure 7.
4.5 3.0
4.0 3.0

4.0 3.0

4.5 2.0

4.5 4.2

4.5 3.0

5.0 4.0

4.3 3.0

4.2 3.0

4.2 3.0

4.0 3.0

4.3 4.0

4.2 3.0

4.1 3.0

4.2 4.0

Doctors Care 5
House of
Targets for Our Future Product 6
quality (HOQ)
10

11

12

13

14

15

16

17

18
1

layout); redefine service quality and create vision; create teams in each area for continuous
improvement projects; define staff responsibilities; connect marketing efforts with current
customer database and increase customer database for social media. The relationship
matrix shows, for example, that the initiative to define staff responsibilities is aligned with
three of the four key objectives (not strong, but important relationships). We also can
analyze each of the initiatives in a single matrix and their impact on key objectives. What
are the specific initiatives that we are pursuing in the achievement of our key objectives?
This is answered with our main initiatives step of the HKPP X-matrix.

Tactical actions
Key objectives are strategic, whereas the actions listed on the top of the HKPP X-matrix are
tactical in nature. Strategic objectives are long-term objectives (they define what we will try
BIJ
Ownership Progress Date
26,3 Create a customer improvement team (multidisciplinary team) 0%
Implement a corporate training strategy 0%
More involvement between staff and doctors care professionals 0%
Center layout re-design 0%
New customer contact strategy 0%

5.00 per year/p

Tactical Actions

Unit
866
Redefine service quality and create a vision based on it

Connect marketing function with customer database

Re-organize the center (customer services’ layout)

1%

5%
Goal

1
Increase customers database (social media)
Re-engineering activities (lean process)

Create work team per operational area

Corporate image improvement

Incorporate Continuous improvement process

Define staff responsibilities

Main Initiatives

Hoshin Kanri X Matrix

Key Metrics

Reduce physical waste (space)

Create a Facebook website

Create Twitter account

Thematic Goal:

Lean trainig sessions

Operational Excellence

Item

Finance tactical team leader

Quality tactical team leader

General Lean team leader

IT tactical team leader

BSI
Key Objectives

L
I

I
Improve Center Logistics
Increase staff training in Service Quality
Increase and Improve Medical Center Services
Increase Social Media presence

Figure 8. Correlation BSC

Hoshin Kanri Strong
Improtant
F Financial
C Customer
planning process Weak I Internal Processes
L Learning and Growth

to achieve), main initiatives convert into shorter term but still, within a year range. On the
other hand, tactical actions are more flexible, they are how we choose to convert main
initiatives into practical actions at this specific moment in time (right now), and they can
change as the teams find better and more efficient ways to improve the processes. Some
researchers call these tactical actions as short-term improvement opportunities and
priorities. The tactical actions identified by the MC lean team are: create a customer
improvement team (multidisciplinary in nature), define specific topics for the training
strategy to empower employees, promote more interaction between staff and doctors,
redesign the MC physical layout and deploy a new customer contact strategy. Each of the
improvement opportunities (tactical actions) should align with an annual main initiative and
each annual main initiative should align with a three to five-year breakthrough key
objective. For example, we can see in the HKPP X-matrix, that by deploying a new customer
contact strategy, we are directly increasing the customer database for social media, which in
turn supports our long-term key objective of increasing social media presence.

Key metrics: measure, metrics, targets to improve in Hoshin Kanri X-matrix

We cannot say that we have improved if we do not measure! This is true and it is a key
element of any lean process. Before improvement, there needs to be defined key performance
indicators (key metrics) that will be measured at the beginning of any lean project, and at
the end, to measure improvement (pre- and post-assessments). Figure 6 shows some of the
key metrics defined by the lean team at MC, but more were created in their complete matrix.
Examples could include: reduce space waste by 5 percent, which is associated with the
tactical action of redesigning the center physical layout, which affects the main initiatives of
re-engineering activities and reorganizing the center layout; and at the end, improves our
long-term key objective of improving the center logistics.
Ownership: teams and ownership and X-matrix Hoshin accountability Improving
The HKPP X-matrix is a great planning tool, if combined with QFD, the HOQ, it is perfect to customer
translate the VOC into specific tactical actions in the organizations. However, none of the satisfaction
action plans in the matrix is of worth if there is not ownership and accountability associated
with each of those initiatives. Therefore, the HKPP X-matrix has room to assign actual
responsibilities that are also related with each of the tactical actions. In the last section, we
are able to complete the X-matrix by filling in the names of the accountable and responsible 867
people for each project, metric and objective. For the purpose of Figure 6, we did not include
names but we indicated them as positions in the teams, but it is meant to show real names.

Conclusions
Healthcare organizations need to line up the customer requirements and characteristics that
provide a maximum impact on their competitive performance. It is critical for providers of
medical services to identify the customer needs and expectations in order to produce the
best services to increase customer satisfaction. The HOQ shows that the best strategy for
the MC is to employ specialized workers that help to improve efficiency. The MC’s main
local competitors are MUSC after hour care and Doctors Care. Each of these MCs has their
own area of specialty that draws their patients in from wide distances. MUSC has a well-
known and respected reputation for research and their children’s healthcare services.
Doctors Care strives to provide the friendliest care and to be a good workplace. By
employing specialized doctors and improving their systems, the MC can fill the need for a
quick and efficient MC in the area.
The results of the CEs survey can direct the MC on which areas to improve. Many
patients dislike a long waiting time and like friendly customer service, but do not expect to
receive it at a hospital. Patients would also like the check-in process to be hassle free. All of
these expectations correlate to the needs we determined in our VOC evaluation.
By employing only, the best doctors and staff, accepting more insurance plans, using the
space in an efficient way and taking advantage of the human resources expertise, will
improve all the administrative procedures. The MC can better serve their patients. They can
make their administrative procedures more efficient by decreasing the amount of
paperwork required of patients (lean process), therefore decreasing the potential for errors.
Finally, The MC can be more competitive in the healthcare field by providing specialized
services or increasing their allotment to research and development.
The HKPP matrix (Figure 7) gives us a perspective of the future MC, with specific goals
and objectives. With a correct interpretation and following of the matrix, the process could
be more effective, efficient and a pleasure to use for the customers.

Implications for research

Based on the discoveries reported above, future research evidently should consider increase
the number of facilities under study, also increase the number of lean tools in order to
improve the facilities capacity and efficiency. In addition, future research could also
incorporate wider elements of Lean practices, which are still applicable in both
manufacturing and pure service operations like is the case presented in this research.

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Corresponding author
Marvin E. Gonzalez can be contacted at: GonzalezM@cofc.edu

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