Lean Six Sigma Green Belt Process Improvement Project. Industrial Hygiene Surveys were delinquent in meeting the 45 day policy requirement. Baseline process had a mean of 42 days with a standard deviation of 30 Days. Improved process has a mean of 25 days with a standard deviation of 8 days. Reduced DPMO by 375,813. Out of Specification was reduced by 98% from 38.51% to .93%.

1. Lean Six Sigma
NHTP FY17: Reduce Incidence of Delinquent IH Survey
Reports
Naval Hospital Twentynine Palms
Project Belt: Mrs. Amanda Cervantes
Champion: CDR Wendy Stone
Command Black Belt: Mrs. Mary Ellen Hogan
Black Belt Mentor: Michael Teegardin
23 February 2017

2. Pre-Event Tollgate
4/24/2017 DON024502 2
Task Start Complete
Project Charter 10/17/2016 10/19/16
Communication Plan 10/24/2016 11/1/16
SIPOC 10/19/2016 10/26/16
Voice of the Customer 10/21/2016 11/2/16
Data Collection Plan 10/26/2016 11/10/16
Preliminary Analysis 10/28/2016 11/17/16

3. Project Team
4/24/2017 DON024502 3
Core Team
Project Lead
Project Sponsor /
Champion
Command Black Belt Financial SME
Amanda Cervantes CDR Wendy Stone Mary Ellen Hogan NA
Team Members
Steven Augustine
Peter Sharpe
Tejpal Basra

4. Project Charter
4/24/2017 DON024502 4
Problem Statement: Project Goal:
During a recent review of the Industrial Hygiene Program Metrics at NH
Twentynine Palms, it was identified that 17of 48 Periodic Industrial Hygiene
Survey Reports (PIHS) did not meet compliance of the 45 day requirement
within the established process. This results in delays for MCAGCC Tenant
Commands .
Eliminate delinquent PIHS reports by FEB 2017 to improve program metrics
and reduce internal stress.
Expected Benefits: Metric Baseline Improvement Goal
Operational improvement to internal process to decrease the mean-time
between the walk-through, and survey serialization. Personnel-related
improvement to new employee development process and increase quality of
work.
Compliance to survey
requirement
64% 100%
Tollgate Planned End Date Actual End Date Primary Metric:
Pre-Event 11/17/16 11/17/16 Survey Serialization – Walk through completion = Compliance Time
(process cycle time)
Event 12/16/16 12/16/16
Post Event 2/17/17 2/17/17 Secondary Metric:
Validate 2/23/17 2/23/17 Total items correct/total items (Survey Checklist Validation
Measurement)

5. Communication Plan
4/24/2017 DON024502 5
Purpose Audience Media Discussion Topics Responsible Person
Frequency of
Communication
Location Notes / Status
MEETING AGENDA
Project Team Share Drive
Database
E-mail
Project Status
Next Team Meeting
Action Item Status
Other Project Information
Project Belt Weekly / As Needed Office
Telephone
E-Mail
TOLLGATES
Green Belt
Project Team
Discussion Tollgate Development
Pre-Event
Event
Post Event, Validate
Project Belt
Team
Weekly / As Needed Office
Telephone
E-Mail
CHAMPION MEETING
Champion
Green Belt
Sponsor
Process Owner
Meeting Project Charter Brief
Tollgate Briefs
Project Status
Project Belt As Needed Office
Telephone
E-Mail
TEAM MEETING
Staff Meeting Charter
SIPOC, Current State Map
Ishikawa, VOC, VSM
Project Team Weekly / As Needed Office
Telephone
EVALUATION MEETING
Staff Meeting Review BUMED Regulations
Review MTF Data
Review VOC, Develop VSA
Project Team Weekly / As Needed Office
Telephone
E-Mail
REPORTING MEETING
Staff Meeting
PowerPoint
Team Reviews
Project Status Reviews
Project Team Monthly / As Needed Office
Telephone
E-Mail
DECISION MAKING MEETING
Staff Meeting Team Reviews
Project Status Reviews
Ishikawa
VOC
Project Team Weekly / As Needed Office
Telephone
E-Mail
PROBLEM SOLVING MEETING
Staff Meeting Brainstorming
Ishikawa
VSA, VOC
Project Team Weekly / As Needed Office
Telephone
E-Mail
PLANNING MEETING
Staff Meeting Brainstorming Project Team Weekly / As Needed Office
E-Mail

6. SIPOC
4/24/2017 DON024502 6
Suppliers
Activity Program Managers
IH Tech
Admin. QA
IH Reviewer
Assigned IH
Higher Authority (BUMED,
DoD, OMB)
Director, Public Health
Inputs
Schedule Walk-through
Provide Samples
Administrative Review
Technical Review
Workplace information &
field observations
Regulations and Policy
Serialized Survey
Process Outputs
Productivity Metrics
Employee exposure results
Health Information and
recommendations
Timely Activity Survey
Customers
Higher Authority (BUMED,
DoD, OMB)
Occupational Medicine
Activity Program Managers
Start Stop
Last day of walk-
through
Write PIHS report Review report
Signed/Serialized
report
CTP CTC

7. Voice of the Customer (VOC)
Voice of the Customer Why it is Important Critical Customer Requirement
Timely Report Metric Compliance <45 day completion from last day of
walk-thru to serialization
4/24/2017 DON024502 7

8. Data Collection Plan
Metric Data Type Operational Definition Sampling Notes Source & Location Collection Method
Who will Collect
the Data
Cycle Time Continuous
Total time to conduct onsite
evaluation of Activity
All PIHS FY15/16 PIHS Reports Dates onsite IH/Data QA
Process Cycle
Time
Continuous
Time from last walk-thru
date until report
serialization
All PIHS FY15/16
PIHS Report
Database
PIHS dates Data QA
Defects Discrete
Attribute identification of all
causes of delays
3 current PIHS
reports in process
Industrial
Hygienists
Pareto Chart Data QA/IHs
4/24/2017 DON024502 8
How will the Data be Used? To evaluate time constraints in each process
How will the Data be displayed? Charts
What is the plan for starting Data Collection? Data collection currently exists – FY15/16
1 How long does it take until survey is serialized?
2 What are the causes of defects?
3 How long does it take to complete a Command Walk through?

9. Baseline Data Sample
4/24/2017 DON024502 9
Command On Site Off Site Complete Date Complete Days Days on Site PCT
G-8: Comptroller 18-Dec-13 18-Dec-13 9-Jan-14 22 1 23
1st Tank BN 5-Sep-14 5-Sep-14 15-Sep-14 10 1 11
3rd BN/7th Marines 11-Sep-14 11-Sep-14 20-Oct-14 39 1 40
MCTOG 24-Sep-14 24-Sep-14 24-Nov-14 61 1 62
DeCA Commissary 9-Oct-14 21-Oct-14 24-Nov-14 34 13 47
Tactical Training Exercise Control Group 9-Oct-14 9-Oct-14 31-Oct-14 22 1 23
Marine Corps Communications & Electronics School 17-Nov-14 30-Jan-15 13-Mar-15 42 75 117
G-7: Provost Marshal Office 18-Nov-14 25-Nov-14 30-Dec-14 35 8 43
Naval Hospital 24-Nov-14 8-Dec-14 13-Apr-15 126 15 141
Vet Service 1-Jan-15 20-Jan-15 11-Mar-15 50 20 70
G-7: Combat Center Fire Department 6-Jan-15 12-Jan-15 27-Apr-15 105 7 112
VMU-1 10-Feb-15 11-Feb-15 23-Jun-15 132 2 134
G-4: SW Region Fleet Transportation 11-Mar-15 11-Mar-15 8-Jun-15 89 1 90
MACS-1 DET A 11-Mar-15 6-May-15 23-Jun-15 48 57 105
Marine Wing Support Squadron -374 5-May-15 6-May-15 30-Jul-15 85 2 87
G-3: Exercise Support Division 15-Jun-15 13-Aug-15 2-Sep-15 20 60 80
G-4: Natural Resources & Environmental Affairs 15-Jun-15 15-Jun-15 14-Aug-15 60 1 61
23rd Dental Co. 21-Jun-15 14-Jul-15 19-Aug-15 36 24 60
Marine Corps Community Services 31-Jul-15 28-Aug-15 18-Sep-15 21 29 50
G-4: Center Magazine Area 11-Aug-15 14-Aug-15 10-Sep-15 27 4 31
1st BN / 7th Marines 18-Aug-15 18-Aug-15 2-Sep-15 15 1 16
G-4: Center Logistics Division 24-Aug-15 8-Sep-15 18-Sep-15 10 16 26
3rd BN/11th Marines 1-Sep-15 1-Sep-15 10-Sep-15 9 1 10
7th Marine Regiment 2-Sep-15 9-Sep-15 25-Sep-15 16 8 24
4th Tank/RSU 10-Sep-15 10-Sep-15 25-Sep-15 15 1 16
G-6: Communications & Info Systems 5-Oct-15 9-Oct-15 30-Oct-15 21 5 26
Vet Service 13-Oct-15 13-Oct-15 10-Dec-15 58 1 59
Base Safety (G- 7) 29-Oct-15 29-Oct-15 10-Dec-15 42 1 43
Combat Logistics Company -13 16-Nov-15 18-Nov-15 22-Jan-16 65 3 68
3rd Amphibious Assault BN / Delta Company 23-Nov-15 25-Nov-15 28-Jan-16 64 3 67
Naval Hospital 23-Nov-15 31-Mar-16 4-Apr-16 4 130 134
1st Tank BN 1-Dec-15 17-Dec-15 29-Jan-16 43 17 60
G-4: FMD & PWD 15-Dec-15 1-Mar-16 21-Apr-16 51 78 129
Naval Criminal Investigative Service 16-Dec-15 16-Dec-15 22-Jan-16 37 1 38
3rd Light Armored Recon BN 20-Jan-16 27-Jan-16 21-Apr-16 85 8 93
Base Safety (G- 7) 8-Mar-16 9-Mar-16 11-Mar-16 2 2 4
2nd BN/7th Marines 21-Mar-16 24-Mar-16 9-May-16 46 4 50
NEX West Coast 4-Apr-16 5-Apr-16 27-Apr-16 22 2 24
Marine Wing Support Squadron -374 PRI 1 ARFF 4-May-16 11-May-16 14-Jun-16 34 8 42

10. Baseline Data Analysis
4/24/2017 DON024502 10
0
20
40
60
80
100
120
140
Sample 1Sample 2Sample 3Sample 4Sample 5Sample 6
Days to
Complete PIHS
Baseline
Process Data - Completion of PIHS
0
2
4
6
8
10
12
14
16
18
20
2-23 24-45 46-67 68-89 90-111 112-133
Frequency
Completed Days Categories
Completed PIH Surveys - HISTOGRAM
Completed Frequency Relative Frequency Percent Frequency
2-23 18 0.38 38%
24-45 13 0.27 27%
46-67 11 0.23 23%
68-89 3 0.06 6%
90-111 1 0.02 2%
112-133 2 0.04 4%
Grand Total 48 1.00 100%
Completed PIHS - Descriptive Statistics
Mean 41.5625
Standard Error 4.2879414
Median 36
Mode 22
Standard Deviation 29.70773
Sample Variance 882.5492
Kurtosis 1.7189848
Skewness 1.3035082
Range 130
Minimum 2
Maximum 132
Count 48
Defects Opportunities DPU DPMO Sigma ST Sigma LT
17 48 0.354167 354166.7 1.87 0.37

11. Investigate Existing Solution
4/24/2017 DON024502 11
No Results found in CPIMS (10/26/2016)
Pertaining to Compliance Rate of Completed
PIH Surveys

12. Event Tollgate
4/24/2017 DON024502 12
Task Start Complete
Define Current State 11/18/16 11/30/16
Root Cause Analysis 11/21/16 12/5/16
Define Future State 12/5/16 12/16/16

13. Process Value Stream Map
4/24/2017 DON024502 13
Requirements
DOD
BUMED
OSHA
Review PIHS
Previously
Completed
Surveys
Interaction with
Customer
DPH IH Office
Plan PIHS
Periodicity
Schedule
Perform PIHS
Periodicity
Schedule
Write PIHS
Multiple Rework
Handoffs
Delays
DOEHRS
Data Entry
Send PIHS
Serilization
MCAGCC Tenant
Commands
Capture Data For Metrics
Defined
Requirements
On Site
.354167 DPU
1.87 Sigma ST
Plan Exposure Monitoring
Reproductive Hazards
Carcinogens
Environmental
Perform Exposure
Monitoring
Reproductive Hazards
Carcinogens
Environmental
Assess Esposure
Monitoring Results
Reproductive Hazards
Carcinogens
Environmental
PIHS Histoical Record
PIHS Results
Previous PIHS Data
Monitor Results
IH Data
PIHS Results
RIE PROJECT
Multiple Reviews
Handoffs
Resource Scheduling
Sigma LT is .37
Does Not Meet Requirements

14. Current State Process Map
4/24/2017 DON024502 14
IndustrialHygenistQualityAssuranceDepartmentHeadDirector
Start
Complete Tenant
Command
Walthrough
Complete Draft
Survey
x bar - 13 Days
stdev - 24 Days
x bar - 30 Days
stdev - 62 Days
Rework/Route To
IH for Review
Rework?
QA Review
No
Yes
Current State Consists of Baseline Data for 48 Surveys
2 day Turn with a Range of 11 Days
20%
80%
Rework?
DH Review
Rework?
DIR Review
Rework?
No
Yes
Yes
DIR Signs DIR Routes to QA
QA Serializes
Serialization
Complete
Stop
NoYes
DH Signs
No
80%
20%
10%
90%
17 of 48 Surveys were not compliant
with 45 Day Requirement
35.4% Defect Rate
64.6% Success Rate
-Failure to proofread surveys
-Administrative Errors
-Survey Errors
-Resource SchedulingFPY=.144
6
1
4
1 day Turn with a Range of 15 Days
1 day Turn with a Range of 2 Days
1 day Turn with a Range of 3 Days

15. GEMBA
# Observation Area/Activity Observed
Findings / Data Collected or
Reviewed /Concerns for
Further Analysis
1 Administrative Errors IH Review, QA Review, DH Review
Rework (185 errors in 48
surveys)
2 IH Survey Errors IH Review, QA Review, DH Review
Rework (124 errors in 48
surveys)
3 Hand-off Delays IH Review, QA Review, DH Review
Average 2 day wait for
signatures at each stage of
approval
4 IH Absenteeism(Leave, Liberty, Sick, etc.) During Draft and review of Survey
Waiting for IH return. 45 day
requirement clock continues
4/24/2017 DON024502 15

16. Root Cause Analysis- Affinity Diagram
4/24/2017 DON024502 16
People
Absent
Unaware of
Requirements
De-conflict
Schedules
Process
Multiple Hand-
offs
Defects Passed
Down Stream
Build Quality
into the process
Happy to Glad
Changes
Lack of Survey
Tracking
Policy
Validate
Requirement
Lack of Standard
Templates
Unclear SOP
Scheduling
Tenant
Command
Schedule
Personnel
Availability
Schedule
Alignment to DH
and DIR
shedules
What are the barriers to complying with 45 day requirement?

17. 7 Forms of Waste (MUDA)
Observed Type Location Team Voting
Transport
Inventory
Motion
X Waiting Survey Signatures 2
Over-Production
X Over-Processing Routing / Review Process 5
X Defects Requiring Rework or Scrap Review Process 5
4/24/2017 DON024502 17

18. Defects - Categorical
4/24/2017 DON024502 18
Count 185 124
Percent 59.9 40.1
IH SurveyAdministration
200
150
100
50
0
Frequency
Frequency of Errors (Defects per Category)

19. Defects - Cumulative
4/24/2017 DON024502 19

20. Future State Process Map / Value Stream Map
4/24/2017 DON024502 20
IndustrialHygenistQualityAssuranceDepartmentHeadDirector
Start
Complete Tenant
Command
Walthrough
Complete Draft
Survey
x bar - 10 Days
stdev - 3 Days
x bar - 18 Days
stdev - 4 Days
QA Review
3%
Rework?
No
DIR Signs DIR Routes to QA
QA Serializes
Serialization
Complete
Stop
DH Signs
97%
-Created SOP for Survey Completion
-Created Sampling Results (Standardized) Sheet
-Created Survey Checklist
-Created IH Survey Template
7
0
1
Yes

21. Ideal State Process Map / Value Stream Map
4/24/2017 DON024502 21
IHSURVEY
PROCESS
VAData
Start
Complete Tenant
Command
Walthrough
Complete Draft
Survey
x bar - 13 Days x bar - 20 Days
QA Review DIR Signs
Serialization
Complete
Stop
5 00
x bar - 25 Days

22. Post Event Tollgate
4/24/2017 DON024502 22
Task Start Complete
Implementation Plan 12/16/16 1/20/17
Control Plan 1/16/17 2/17/17
CPIMS Documentation 2/23/17 2/23/17
Benefits Workbook 2/20/17 2/20/17

23. Implementation Plan
Problem
Identified
Action Needed
Created
Date
Completed
Date
Improvement
Metrics
Person
Responsible
What is the waste?
How is the waste
Eliminated?
Administration
Errors (Process)
Create Survey Checklist 12/16/16 1/20/17
Items Accurate/Total
Items
QA Rework (Defects)
Sampling Errors
(Process)
Create Sampling Results
Sheet
12/19/16 1/3/17
Eliminate defects in
documenting sample
information
QA Rework (Defects)
Lack of Training
(Policy)
Create Instruction (SOP) for
completion of Surveys
1/4/17 1/18/17
Improve awareness of
administrative and
documentation
procedures
QA Over Processing
Administration
Errors (Policy) Create IH Survey Template 1/5/17 1/16/17
Mistake proof common
errors by having pre-
filled data and drop
down selection
QA Over Processing
Scheduling
(People)
Align schedules with
requirement
12/17/16 1/4/17
Ensure availability of
resources
DIR, QA Waiting
4/24/2017 DON024502 23

24. Mistake Proofing Documents
4/24/2017 DON024502 24
IH Survey Template.dotx
Created to reduce the number
of opportunities where defects
are found.
IH Survey Review Checklist
Created to standardize requirements
from multiple reviewers of the Survey.

25. Control Plan
Name of
Measure
Measure
Definition
Measure
Calculation
Data
Source
Goal
Measure
Frequency
Sample
Size
When to
Act
Who
Decides to
Act
Who
Acts
Reaction
to Out of
Control
Display
Method
Cycle Time
Last day of
walkthrough-
serialization
Delta between
dates
Survey
Tacker
<45 Days Weekly 1 At Day 25 QA IA
Prioritize at
day 25 for
projected
completion.
Control Chart
FPY
Survey
completed
without rework
During Review IH Survey 50%
Daily once in
review
pipeline
1
When
rework is
required
ALL QA
Correct and
forward
Control Chart
Checklist
Validation
Update Checklist
for new defects
At completion
of Survey
Survey
Tracker
100% As required 1
As new
defects
occur
QA QA
Update and
share new
checklist as
needed
SOP
4/24/2017 DON024502 25

26. Post Intervention Data Sample
COMMAND SCHED. DATE
START WALK
THROUGH
COMPLETE WALK
THROUGH
DRAFT
START
DRAFT
COMPLETE
IH REVIEW
START
IH REVIEW
COMPLETE
QA REVIEW
START
QA REVIEW
COMPLETE
ROUTE TO
DH DH SIGNS
ROUTE TO
DIR DIR SIGNS
ROUTE TO QA
FOR SERIAL.
SERIALIZATION
COMPLETE
Provost Marshal 10/3/2016
10/5/16 11/10/16
10/6/16 11/22/16 11/22/16 11/29/16 12/7/16 12/8/16 12/7/16 12/7/16 12/8/16 12/9/16 12/9/16
12/9/16
29
Veterinary Service unk
10/3/16 10/10/16
10/11/16 10/25/16 10/25/16 10/26/16 10/31/16 11/1/16 10/27/16 10/31/16 11/2/16 11/2/16 11/2/16
11/2/16
23
DeCA 10/14/2016
10/18/16 10/19/16
10/20/16 10/24/16 10/24/16 10/28/16 10/27/16 11/1/16 11/1/16 11/1/16 11/1/16 11/1/16 11/1/16
11/1/16
13
MCTOG unk
9/13/16 9/13/16
9/14/16 9/29/16 9/29/16 9/29/16 9/29/16 9/29/16 9/29/16 9/29/16 9/29/16 9/29/16 9/30/16
9/30/16
17
TTECG unk
9/13/16 9/13/16
9/14/16 9/29/16 9/29/16 10/5/16 9/29/16 9/29/16 10/5/16 10/5/16 10/6/16 10/6/16 10/6/16
10/13/16
30
23rd Dental Co unk
8/3/16 8/4/16
8/8/16 8/31/16 9/1/16 9/6/16 8/31/16 8/31/16 9/7/16 9/8/16 9/8/16 9/9/16 9/9/16
9/9/16
36
4/24/2017 DON024502 26
Created Data Collection Format to collect all data within and between process
steps IOT ensure process between ‘Walk-through Complete’ – ‘Serialization
Complete’ is completed within 45 day requirement
Standardized ‘Review Process’ to align upstream deliverables. Removes the
reliance on inspections to identify defects.

27. Post Intervention Data Analysis
4/24/2017 DON024502 27

28. Post Intervention Data Analysis
4/24/2017 DON024502 28

29. Post Intervention Data Analysis
4/24/2017 DON024502 29

30. Post Intervention Data Analysis
4/24/2017 DON024502 30
0
20
40
60
80
100
120
140
Sample 1Sample 2Sample 3Sample 4Sample 5Sample 6
Days to
Complete PIHS
Baseline Post Event
Process Data - Completion of PIHS
45 day requirement to complete ‘Walk-through Complete’ –
‘Serialization Complete’ process.
Reduced median by 10 days.

31. Project Benefits
• Tangible
– Process mean reduced by 17
days
– Standard Deviation was
reduced by 77.6%
– 90% Confident that the mean
will be between 17 and 31 days.
• Intangible
– Improved morale
– Improved scheduling
4/24/2017 DON024502 31