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The application of 6S in the care of COVID-19 patients: a Japanese perspective

Dear Sir:

Wei et al. introduced the original 5S and transformed 6S into 6S management mode for application in the nursing of coronavirus disease 2019 (COVID-19) patients [1]. As the authors described, the 5S concept is comprised of five Japanese words (Seiri, Seiton, Seiso, Seiketsu, and Shitsuke). 5S is among the Japanese customs that have been taught by parents since childhood in Japan and passed down the generations. Therefore, we are familiar with those words, and we would like to comment on the following three points.

First, the authors transformed five Japanese words into the 6S management strategy for convenience of application and understanding in the nursing of COVID-19 patients. However, there are two incorrect descriptions in Figure 1. The fourth S should not be Seiton but Seiketsu, and the fifth should not be Seiketsu but Shitsuke. “Seiketsu” means to continuously revise and maintain the results of Seiri, Seiton, and Seiso.

Second, the authors interpreted “Shitsuke” as “specialization and cooperation.” However, we believe “sustain rules and values” is a much closer translation of “shitsuke.” “Shitsuke” means to make someone not only follow the rules strictly, but also take over the good sense of value (originally, from parents to children) and cooperation with others with it. This sense of value is applied in the nursing management of COVID-19 patients as follows: In the high-stress COVID-19 work environment as the nurse, a good sense of value reduces further stress, sustains compassion for the patients, and facilitates cooperation within the nursing team.

Third, 5S, overall, means environmental (physical) cleanliness, which, indirectly, influences cleanliness in the mind. Cleanliness is similar to purity, which is discussed in Bushi-do, a traditional Japanese code of conduct [2]. This cleanliness in the mind is closely associated with good behavior, not only in the Japanese, but in all other peoples and situational contexts. As an example, the crime rate in New York declined predominantly when Mayor Giuliani eliminated graffiti in downtown New York [3].

Thus, the 5S or 6S concept is very valuable not only in the hospital setting but also in spiritual training as a person. We believe that this spiritual training would contribute to a positive impact on healthcare workers during the COVID-19 pandemic.

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Coronavirus disease 2019


  1. Wei W, Wang S, Wang H, Quan H. The application of 6S and PDCA management strategies in the nursing of COVID-19 patients. Crit Care. 2020;24(1):443.

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  2. Nishigori H, Harrison R, Busari J, Dornan T. Bushido and medical professionalism in Japan. Acad Med. 2014;89(4):560–3.

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  3. Kelling GL, Bratton WJ. Declining crime rates: insiders’ views of the New York City story. J Crim Law Criminol. 1998;88(4):1217–32.

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All authors had full access to all of the data in the study and take responsibility for the integrity of the data. Drafting of the manuscript: Mitsuhito Soh and Toru Hifumi. The author(s) read and approved the final manuscript.

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Correspondence to Toru Hifumi.

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Soh, M., Hifumi, T., Isokawa, S. et al. The application of 6S in the care of COVID-19 patients: a Japanese perspective. Crit Care 24, 542 (2020).

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