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hence the term lean. Since then, lean methodology has been applied to many indus-
tries, including healthcare. For a lean approach to take hold within an organization,
management must yield the role of micromanaging problem-solving to the employ-
ees who are on the ground floor of daily operations. A lean system seeks to maxi-
mize steps that add value in the most logical sequence to deliver an unobstructed
workflow to deliver the services that the customer needs. This is often referred to
as a value stream, which is the entire series of steps necessary to produce a product
or service. A value stream approach attempts to improve the entire process, not just
to optimize the individual parts. Examples of waste in the healthcare system
include time spent in the waiting room, wasted inventory, inefficient work area
ergonomics, and time transporting patients between departments for multispecialty
care.
Six Sigma and lean methodology have been utilized within healthcare quality
improvement since 1998 [ 18 , 75 ]. They are complementary processes that can be
combined to create Lean Six Sigma, which is a five-step process referred to as the
DMAIC cycle – define, measure, analyze, improve, and control, which is summa-
rized in Table 11.2.
Educators at the University of Michigan (Ann Arbor, Michigan) reported on their
implementation of a QI curriculum for internal medicine residents [ 41 ]. A team of
residents, led by a faculty familiar with the lean thinking approach, piloted a project
to evaluate the response to an inhospital cardiopulmonary arrest. They participated
in interactive didactic sessions led by their faculty mentor. A hypothetical cardio-
pulmonary arrest case with patient safety and quality implications was then devel-
oped. The team used this example to identify areas of waste and then, using their
experiences, developed a current state value stream map of a cardiopulmonary arrest
response that was supplemented with data to better understand the process. Through
a literature review and reflection on previous experience, the team was able to
develop a plan of how an ideal cardiopulmonary arrest response could be performed.
This led to changes in the training modules and exercises used to train the cardio-
pulmonary arrest response teams.
Internal medicine residents at Columbia University (New York City, New York)
[ 83 ] applied the use of Lean Six Sigma methodology to standardize supply rooms
Table 11.2 Lean Six Sigma five-step process
Define The team should determine the following:
What is the goal of the project?
How will success be defined?
Who will be involved?
What is the timeline of the project?
Measure Data is collected from several sources to determine the depth of the errors in the
system
Analysis Deviations from the norm are identified to look for sources of process variation
Improve The team should brainstorm solutions and develop strategies for project
completion
Control Based on the previous steps, the team should develop policies, guidelines, and
safety checks to enforce the use of the new policyS. Helo and C. Welliver