Purpose During the past few decades, Lean Six Sigma (LSS) in the health-care sector has received increasing attention from both researchers and practitioners because it plays an imperative role in quality improvement and cost reduction initiatives. Although researchers have often focussed on evidence of model effectiveness through the study of performance indicators, too little attention has been given to the factors that lead to implementation failure and the causal relationships among them. This study aims to investigate the factors that may inhibit the successful implementation of the method by focussing on Italian public hospitals. Design/methodology/approach Through the use of the Delphi technique and fuzzy cognitive maps, this paper derives new and relevant results for researchers, hospital managers and policymakers. Findings The results show the factors with the greatest impact on LSS implementation and provide insight into the causal links and degrees of influence between critical failure factors and performance variables. Practical implications The findings could be considered useful, in particular, to hospital managers and policymakers, who could leverage the suggestions derived from the study to address LSS implementation. Originality/value This work overcomes a gap in the literature related to the absence of studies on the causal relationships between factors that determine the success or failure of LSS implementation.

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Purpose The purpose of this study is to investigate how the emotion expressed by a fictitious proposer influences the responder’s decision to accept or reject a severely unfair deal, represented by the splitting of a predetermined sum of money between the two players during an ultimatum game (UG). Rejection leads both parts to dissipate that sum. Critically the authors consider the situation in which both players have the best alternative to negotiation agreement (BATNA), which simulates a backup plan to rely on in case of no agreement. Design/methodology/approach The participants played a UG and, to foster the ecological validity of the paradigm, the parts could both rely on a more or less generous BATNA. The critical manipulation was the emotion expressed by the proposer while their BATNA was either hidden (Exp. 1) or communicated (Exp. 2). Findings The proposer’s emotions influenced participants’ own emotions, affected their social evaluations about the proposer, the desire for future interactions with the proposer and were used to infer the proposer’s BATNA when it was unknown. In this latter case, proposers’ emotions and in particular his/her happiness, decreased dramatically the participants’ tendency to reject even severely unfair offers. Originality/value Past research on UG has been predominantly aimed to investigate the effect of responders’ emotions or the effects of responders’ emotions on the proposer, devoting little attention to how the critical responder’s acceptance/rejection decision might be affected by the proposer’s emotion. Especially in the ecological situation where the parts have a BATNA in case of non-agreement.

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