My first exposure to Lean as a quality improvement (QI) approach was at a well-known automotive producer, and it was alarming. The Master Black Belt Sensei flown in from Japan spoke in short, clipped, and heavily accented barks, the meaning of which were mostly quite opaque to us. He strode purposefully across the factory floor, repeatedly bellowing “Waste!” in a very intimidating way, and suddenly lunging and jabbing his finger here and there to the great alarm of those standing near him. He examined production sheets and stabbed a finger at one quality or operational target after another, shouting out changes. He sometimes doubled, sometimes halved, sometimes just roared.

Apparently, once one knew him better, understood the terminology, and grew accustomed to the process, this all made perfect sense. He wasn’t angry, just very enthusiastic.

On that day though, it was a deeply mysterious, somewhat alarming, and more than a little foreboding experience—which in truth is how most people in healthcare perceive Lean Six Sigma all the time. One area in which many have particular problems is in the selection of where to intervene and what targets to set. In this blog post, I cover three practical ways to pick targets for QI initiatives that won’t be intimidating or alarming, but instead should make perfect sense. We are going to look at dreams, outliers, tight shoes, and wrapping presents.


A very useful technique in QI is to picture the best a specific process could ever be, if there were no delays, no errors, and everything was running at top speed. Once that narrative is fully described, and story-boarded along with supporting sketches and images, we can do the same for what is happening now on the worst day.

Looking at the gaps between the two stories, we can usually identify obvious targets for improvement that can get us closer to the ideal.

The only drawback of this technique is that, while it often feels somewhat exhilarating to picture perfection, it sometimes generates cynicism. If you hear a lot of “yeah, right!” being muttered by staff thinking that perfection is so far off that they may as well not try, then look at the next option of playing with outliers.


A more mundane but very practical approach is to look at the best-ever historical performance of a specific metric that is part of our value chain. In this approach, we peg the target of our QI effort at making the best a process has ever performed and seeking ways to make that the average. This is a more practical approach (if a little boring) because we know that the target metric is possible from having been achieved before.

The exercise is to hunt down all the enablers that helped us achieve our best ever performance, and identify all the barriers that stop us from achieving it on an average day. Then we systematically look for ways to lock in the enablers and eliminate the barriers. While this method is far less fun than picturizing perfection, it is practical and systematic.

Tight Shoes

A third place to start is to look at tight shoes. Where is the current situation hurting most? What do staff curse about the most? Where do they find the biggest frustration in their day? By having a “curse bin” rather than a traditional “suggestion box,” we can collect instances of the biggest frustrations. We can then sit down with the staff to rank order the painful experiences and identify the things that will get the most support for a QI initiative. The approach makes the selection more democratic, gets the best buy-in, and can be used to cycle through the frustrations in order of agreed magnitude.

Wrapping the Gift

Putting these three approaches together, you can use the tight-shoe method to identify the biggest pain points, and then taking each of the top three in turn, picture perfection and select the largest gaps to look for ways to make the best ever experience to be the typical experience. This is your QI gift to staff: fixing what frustrates them the most and giving them hope that some degree of perfection is indeed reachable.