There are many things in healthcare facilities that are frustrating, wasteful, or risky, but which we never seem to get around to fixing permanently. Many physicians and unit managers are reluctant to adopt quality improvement (QI) programs or implement Lean Six Sigma because they feel it is too complex, burdensome to use, and would have little practical value in daily operations.


In response to complaints, such as “If we only had more __________,” QI pundits often talk about the need to start small improvement projects, demonstrate value through small practical solutions, and address the “low hanging fruit” of improvement opportunities. These projects may look at how existing resources are being applied, and identify waste that can be eliminated, or process steps changed to produce a better result. QI projects often attempt to improve processes without additional expenditure.

However, in practice this advice is often experienced as impractical and unrealistic, and QI programs often never get started. When asked outright, medical staff can often not think of anything they would want to use QI methods to fix. The immediate problem is often an inability to identify meaningful candidate improvement opportunities, involve front line staff, and demonstrate the value of the methods by solving things that are visible risks or issues.

One approach that I have found effective in identifying opportunities and proving the value of QI methods involves what I have called, the “Novice’s Mirror”. It generates discussion, fosters learning, identifies opportunities, and gets staff involved in solving problems in a practical way.

Here is how it works.

Ask new staff to keep a diary in their first month of everything in the work or care environment that was

  • Surprising,
  • Frustrating, or
  • Confusing.

“New staff” can include people who were promoted or shifted into a new position, transfers from other units, or new hires.

To maximize recall, encourage them to make the diary note as soon as possible after the experience. People forget rapidly, and the experience tends to evaporate from memory pretty fast. The idea is to grab the memories while they are hot. Capturing it immediately is good, at end of day is ok, but a longer gap than that is going to be less than half as effective.

To keep the administrative burden down but capture enough information to make it actionable, we want three things: What was the issue, where and when was it encountered, what negative impact did it have.

The results generally fall into one of three buckets: risks and issues that need to go to security or HR pronto, misunderstandings that need to be clarified or updated in the onboarding training, and process improvement opportunities. Flick the HR stuff over to them, drop training suggestions on the people doing staff training and documentation, and grab the process improvement pile.

Each of your process improvement items will tell you what the issue was, and what effect it had on what they were trying to do. If you have many responses, ranking them in descending order of priority can enable you to start with the best value for the effort. One option is to rate each of these on a scale of 1-5 for the impact (or potential impact) versus likelihood of occurrence. An alternative ranking may be simply the degree to which it made a negative impression on the staff member – Reducing irritating obstacles is probably always a good thing. A more complex ranking system is using the STEEEPA model. In this approach, you rank each item on each of the seven care quality dimensions: safety, timeliness, effectiveness, efficiency, equitability, patient-centeredness, or care accessibility. An aggregated score across all seven dimensions gives you the ranking.

Once you have the list ranked, you can pick a small number off the top for action. Some may be “Just Do It” work, in which the problem and solution are obvious and do not require approval from any manager or use any budget to execute. In these cases, just go ahead and do it, but watch for potential unintended consequences.

Some may require unit manager or higher to approve – or take some money to solve. For these you may need documentation and justification, and the “Rapid Improvement Event” (RIE) or Rapid DMAIC approaches might help. Typically, RIEs are focused on a specific aspect of Lean (i.e. one of the 8 wastes). Value Stream Mapping exercises can identify areas of waste or other non-value-added steps, and could be a visual exercise to implement signage that helps to improve the process. For example, a 5S RIE could identify and solve work organization and environment.

For an RIE, we would sketch in the minimum details using the DMAIC and PDSA frameworks:

  • Define: Describe the problem and the desired future state.
    1. What is the problem you want to solve?
    2. Who are the stakeholders
    3. Describe in the voice of the primary stakeholder what the future ideal state looks like
    4. What are the critical to quality elements, the benefits. risks, and opportunities
  • Measure: Once we know what the ideal state is, who all the stakeholders are, and what elements represent success, we ask how these will be measured. In this step we describe how success will be measured, and how you will be able to tell that the problem has gone.
    1. How will the current as-is state be measured?
    2. How will we measure the to-be results?
    3. What are the upper and lower measurements between which we want the outcomes to be?
    4. Think: Outcomes, process, balancing
    5. Outcomes measures are the quantification of the things we want to achieve. E.g. fewer patient no shows, fewer pens going missing, fewer fall incidents, fewer last-minute shift changes, etc.
    6. Process measures are used to get an early warning of where the output measures are likely to land. Because output measures will be too late to avoid the problem, we want to measure unbiased predictors that help to forewarn us
    7. Balancing measures are tripwires we set to make sure that any adverse effects will be noticed for any solution we try. These warn us that we have adversely affected something else. Stay practical, but think safety, quality, cost
  • Analyze: Here we look at the processes and mechanisms of what is going wrong, and draw out any workflow diagrams, spaghetti charts, or time and motion sequences. Tools that help are the fishbone diagram, looking at the stakeholder movements, and workflow diagrams. Draw the process flow from the patient’s or staff member’s perspective.
    1. What are the root causes? Think: Policies, Equipment, Measurement, Environment, People, and Materials (Figure).
    2. Who was involved vs who should have been involved?
    3. What alternatives do you have for solutions?
    4. Which solution has the best cost, risk, benefit profile
  • Improve: This is where we plan and execute a solution and check to see if it worked. A key thing to remember is to scope the improvement so that it can be done within the available timeframe, resource, and enthusiasm. For low complexity solutions, we can do this with a simple Plan, Do, Study, Act/Adjust (PDSA) sequence.
    1. Plan how the fix will be implemented, conduct a dry run or two if possible, get all resources ready, make announcements, do training, Document who will do it, how will you see it worked, who will monitor and measure, and what you will do to adjust or adopt the solution. If you must abort and go back to the previous situation, how will you do it
    2. Do: implement the solution, start the monitoring, let everyone know who needs to know, and adjust if doing shows that small tweaks are needed, but abort if it looks unstable or uncovers a major flaw
    3. Study: examine results, and determine if it is working according to plan. Decide if we continue or abort. Check the metrics and poll stakeholders for input and document any discoveries that suggest a tweak or opportunity for more improvement is called for. Don’t get overconfident and start a new solution, stay watchful of the performance of this one
    4. Act/Adjust: if the solution didn’t need an abort, check the metrics, take the results of stakeholder polling. Make refinements to the solution if necessary, update SoPs, refresh training
  • Control: Here the focus is on making the solution or new process stick, address any resistance to adoption, initiate any remedial or adjustment PDSA cycles to refine the solution, and document any remaining gaps or opportunities.
    1. Document the plan for ongoing Monitoring & Evaluation, and who will do it.
    2. Document how you will do any organizational change management, and who will carry it out.
    3. Use control charts and other tools to identify any significant special causes, and watch for trends or outliers that are higher than the UCL or lower than the LCL
    4. Look for ways to make additional improvements, and trigger any required process improvement
    5. Poll stakeholders again for feedback
    6. Celebrate
    7. A final step is to review the improvement process itself, and to look for lessons to improve the QI process

Some questions that often come up around this process:

Q: Does it have to be new staff; can’t the existing staff do this?

A: New staff see things with fresh eyes, and often see things everyone else has already learned to ignore. They also tend not to have full schedules yet, so have more time to stop and write things down. However, if existing staff would like to participate, they should be welcomed.

Q: Is this just for junior staff?

A: No, although it’s good to start there to get the hang of the process. I have seen senior staff spot opportunities, and benefit from the experience. In one case, the head of surgery came away from a day of documenting surprises, frustrations, and confusions, and was amazed at how many things he suddenly noticed.

Q: Do I have to do the whole DMAIC/PDSA thing, it looks complicated?

A: No, although it’s a good structure even if you just have only one line in each section, if it’s something simple you can do without permission or money, just go ahead. If it needs permission or money, that’s a good sign that you will need to write up a plan to get approval. The DMAIC/PDSA structure will probably be a great help in getting approval, and being able to create a nice poster for the next time you want to brag about your unit.

Q: Can’t we just get someone else to do this stuff? – We are busy here!

A: Not really, no. You can get outside people to facilitate, document, and help with planning, measurement, and communication, but the selection of issues, creation of solutions, and implemention is on you.