A Lean Six Sigma Case Study If you want to prosp

A Lean Six Sigma Case Study
If you want to prosper for a year, grow rice. If you want to
prosper for a decade, plant trees. If
you want to prosper for a century, grow people -- a wise old
farmer reflecting back on a life
of toil in the soil
PROJECT DESCRIPTION
The following Lean Six Sigma case study will reflect a real -life
healthcare problem with
Continuous Improvement and Lean Six Sigma Tools to show
how some of the tools are put into
place in the real world. The object of this project is your
appropriate use of Lean Six Sigma
tools and the data provided. Project completion is required to
pass the course. Project
assignments are assessed on a Complete/Incomplete basis. Each

Phase of the DMAIC process in
the Project has an assignment. Assignments must be submitted
to the instructor by the end of the
week corresponding to the DMAIC Phase. The exception is the
week 8 or Control phase
assignment which needs to be submitted early in the last week
of the course to allow grading.
The Instructor will determine if the student has submitted a
Project assignment that is Complete.
If the assignment is Incomplete, there will be interaction
between the Instructor and student until
the assignment is Complete. All project assignments must be
assessed as Complete for the
student to pass the course. An Incomplete project will result in
a Failing grade for the course.
Student Case Study
Case Study:
Process Improvement –
Reduction in Wait Time for
Patients in a Doctor Office

Executive Summary
Dr. Deasley is a popular Doctor in Tampa, Florida specializing
in primary care. He spends a great deal of
time with each of his patients, typically, 45 minutes to one (1)
hour. As a result, there are many other
patients waiting in the waiting room who become impatient at
the long wait time. The Doctor has hours
every day except Wednesdays. He has Hospital Clinic on
Wednesdays and does not have office hours.
Dr. Deasley’s office hours are 7:30 AM to 5:30 PM (patients
can be scheduled up until 5:30 PM) on
Tuesdays and Thursdays and 9:30 AM to 7:30 PM (patients can
be scheduled up until 7:30 PM) on
Mondays and Fridays. He does Hospital Rounds from 6:00 AM
to 8:00 AM. He conducts patient call
backs between patients, during his lunch hour and after office
hours. We triage the calls so he gets back
to more seriously sick patients first. However, sometimes he
doesn’t call back non-emergencies until the
next AM. Dr. Deasley is becomes overbooked because he likes
to have 10 patients scheduled per day.
However, due to time constraints he frequently needs to rebook
patients he is unable to see due to time
constraints.
Dr. Deasley’s patients and staff love him for his patience and
attention. But, several long term patients
have left his practice because of this issue. This has resulted in
a decrease in revenue for the office. In
addition, his office is experiencing a rather high rate of staff
turnover. Staff are responsible for booking

patients and managing the workflow in the office. When
backlogs occur and patients become annoyed
about wait times, the staff usually experience the brunt of the
patient dissatisfaction, which effects staff
morale. Each time the office hires replacement staff, it takes a
significant amount of time to train new
employees and it is costly to advertise and recruit competent
staff. Dr. Deasley is very concerned about
both his patients and staff.
His Office Manager, Ms. Smith, who recently was employed at
Memorial Hospital of Tampa, participated
in several Continuous Improvement Projects at the hospital. She
is a certified Lean Six Sigma Green Belt.
As a result, Ms. Smith has suggested a plan to the doctor to
conduct a Lean Six Sigma project with the
objective of Reducing Patient Wait Time and Improving Office
Workflow. Ms. Smith explained the
project improvements and objectives. Dr. Deasley has approved
the project. As an initial step, the Office
Manager has established her team. Each employee has a role in
the project. Based on patient
complaints and the doctor’s requirements, they have some
initial Voice of Customer (VOC). Patients
would like to see the Doctor within 10 minutes of arriving and
spend no more than 30 minutes in the
office total for routine visits. The Doctor would like to see 15
patients per day. These changes need to
be made within 3 months in order to minimize patient
dissatisfaction, stop patients leaving the practice
due to long wait times and rescheduling and improve employee
morale and retention.

Define
1. Complete a Project Charter with all of the required
Information
a. Please write the Problem Statement:
b. Please write the Goal Statement utilizing S.M.A.R.T.
objectives (Specific,
Measureable, Attainable, Relevant and Time Bound):
c. What is in Scope? What is out of Scope?
d. Who are Key Stakeholders?
e. What are key Milestones?
2. Please complete a High Level “As Is” Process Map.
3. Please create a SIPOC of the process based on the
information that you know. Feel free to
use your imagination for this.
a. Describe methods for collecting Voice of the Customer. (SEE
APPENDIX A for VOC)
4. Please create an Affinity Diagram or List based on VOC so
you can identify Customer
“NEEDS” for CTQ Tree
5. Please create a Critical to Quality Tree utilizing the Voice of
the Customer. Identify the
Needs, Drivers and Requirements or Metric to needed to meet
these needs
Conclusion of Define: The output of the DEFINE stage is a
PROJECT CHARTER (PC) and

STAKEHOLDER ANALYSIS (SA). The PC shall include a
Problem Statement with Goals
utilizing S.M.A.R.T. methodology to address the problems
identified. The Goal shall be
aligned with the customer CTQ Requirements. A clearly defines
SCOPE is included in
the PC. What is IN SCOPE and what is OUT OF SCOPE? Your
Team is identified and
Roles & Responsibilities are defined. A SIPOC Map is
completed. An “As Is” Process
Map is completed in order to better visualize the Work Flow in
the current process. The
DEFINE Phase provides for identification of the VOC and
CTQs, their needs, Drivers and
Requirements. The student will have evaluated and Affinitized
the VOC. CTQ trees
were created to identify key requirements for meeting the
customer’s needs. The
Project Team should have a list of external Key stake Holders,
if applicable, e.g.,
Hospital Radiology, who may be impacted by process changes
within the Doctor’s
medical practice. If the Doctor’s staff schedule testing
appointments for patients and
are required to make frequent changes, this has an impact on the
department or
entity conducting the testing. The Project Team will have met
with Dr. Deasley for his
approval to proceed and now has a baseline to begin the
Measure phase.

Measure
1. Based on Customer requirements the project team collected
initial data. Use Pareto Analysis
of # occurrences data to determine the 5 factors which are
causing over 95% of the problem
with wait time. You need to determine the 'biggest contributors
to the problem. One tool to
accomplish this is the Pareto Chart. You need to know if it is
reasonable to assume that
these five 'parameters' are normally distributed. (SEE
APPENDIX B)
a. Based on Pareto Analysis what are the focus areas?
b. Set up appropriate methods for tracking focus areas. You will
need to track # of
occurrences of each category and actual for measuring the
ability to meet the
requirements.
2. Define your Data Collection Plan. Include the types of data
you will be collecting (Discrete or
Continuous), Why? (In many instances you will have a mix of
both types of data depending
on the Data source.
3. Based on the data collected Construct FIVE (5) histograms
for the below data sets. (SEE
APPENDIX C) for data sets
a. Interpret each of the histograms to determine whether the
assumption of normality

is reasonable.
b. If the data are not approximately normally distributed, why
not?
4. The team also believed there was a Motorola shift during the
process. Please describe the
Motorola Shift and potential causes that they could have
experienced the shift.
a. Calculate the PPM/DPMO for this process and determine the
baseline sigma with
the Motorola shift.
5. Calculate the Process Performance, Pp and Ppk, based on the
current process. Student will
be able to compare current Process performance to Capability
Study performed for process
improvements. Tint: drawing a picture of the data based on a
Normal Curve may help
student visualize if data is skewed when evaluating population
distribution. Use UCL = 60
minutes and LCL = 0 Minutes. In Healthcare LCL will
frequently be “O”
Conclusion of Measure: A Data Collection Plan was created.
Data was taken of as many
parameters as possible before changing any variables. Key Data
has been provided for your
use as directed in the instructions above. Pareto harts have been
created and based on the
VOC. The 5 Largest Contributing Factors will have been
identified. These should have aligned
with the data provided. A method for tracking data to capture
for analysis should have been

identified even if the actual data is already provided. Then from
the categories and data
“collected”, 5 Histograms should have been created along with
the narrative for Analysis,
specifically related to determination if data was normally
distributed. An explanation of the
Motorola Shift is provided. PPM/DPMO is calculated. Pp/Ppk
are calculated and current
process Sigma Level is defined. It was found that Dr. Deasley
was spending more time with his
patients than necessary. The process needs to be analyzed
based on the data.
Analyze
1. Create a Stem and Leaf Plot for the downtimes that were
captured from the patient wait times
in the waiting rooms. (SEE APPENDIX D for data set)
2. Calculate Measures of central Tendenc y with Downtime data.
What can you interpret from
these measures? Please document a conclusion (SEE
APPENDIX D for data set)
3. Calculate Measures of Dispersion with Downtime data. What
can you interpret from these
measures? Please document a conclusion (SEE APPENDIX D
for data set)
4. Two individual staff members were being observed
performing identical activities in the
Doctor’s office. 25 random samples were taken for each staff
member. One of the Medical

Assistants is a new employee. Medical Assistant #1 has been
with Dr. Deasley for several years.
Medical Assistant #2 is a new employee and has been with this
medical practice for 9 months.
We want to determine how Assistant 2 performs when compared
to Medical Assistant #1. Since
she is a new employee. (SEE APENDIX E for data sets)
5. Please provide the following information based on your
analysis of the two Medical Assistants
a. Medical Assistant #2 Average
b. Medical Assistant #2 Standard Deviation
c. Null Hypothesis
d. Alternative Hypothesis
e. T-Test Statistic
f. Critical Value
g. Statistical Conclusion for the null and alternative hypothesis.
Conclusion of Analyze: Stem and Leaf Plots were created from
Downtime data provided, Measures of
Central Tendency were also determined using Downtime data
and an interpretation of the results
were made. Data was analyzed to review if different staff
members were performing similarly or not.
Students should have established a Null Hypothesis and
Alternative Hypothesis from the data for the 2
staff members. An appropriate test was performed and
conclusions made based on the outcome.

IMPROVE
1. A staff member has been stating for months that there is a
correlation between the Room
Availability and the Patient arrival time. Should the Office
Manager have listened to this staff
member’s observation? After completing items 2 through 5,
provided your thoughts on staff
observations and how they might have achieved Office Manager
Buy-In sooner.
2. Construct a scatter diagram and calculate the correlation
coefficient to see if she is correct. SEE
APPENDIX F for data set
a. Is there strong correlation between room availability and
patient arrival time?
b. IF there is strong correlation, is it positive or negative?
(Answer with positive, negative
or N/A)
c. What is the correlation coefficient between the two variables?
(Use 6 decimal places).
What does this mean?
3. Discuss the 8 Deadly Wastes (MUDA) of the process.
4. Create a Fishbone Diagram. List Potential Root Causes.
Narrow Potential Root Causes to Key
Root Causes. Explaining some of the key Root causes.
5. Discuss Improvements that you would suggest based on

findings from FISHBONE Analysis.
Conclusion of Improve: A Scatter Plot was constructed and a
Correlation completed. The
determination of whether the 2 factors Correlate based on a
Correlation Coefficient determination is
stated and comments on whether the correlation is Positive or
Negative are included. 8 Wastes were
evaluated and identified where applicable. A FISHBONE
DIAGRAM was created and many ideas were
brainstormed for Potential Root Cause. These were then
narrowed to the critical few Root Causes.
Many improvement suggestions were made.
CONTROL
An I-MR chart was plotted for the Doctor’s office to ensure the
specifications were performing as
planned and the patients and Doctors were satisfied.
1. Please indicate if the control chart is stable and if any
Shewhart Rules have occurred.

2. A normality test was conducted. Please advise if the data is
normal.
3. A capability study was completed. Please advise if the
process is stable and any analysis you
find is relevant.
4. Please complete a Control and Monitoring Plan for the
project.
5. Create a Dashboard which the office can utilize to monitor
the performance of the
improvements as well as supporting the sustainability of the
improvements
Conclusion of Control: Conclusion regarding the stability of the
Control Chart was made and any
violations of the Shewhart Rules were noted. Students then
observed the WET LAB TESTING and
discussed the Normality of the data. A Capacity Study was done
presumably using data from
improvements made and analysis of the Mini Tab output was
discussed. A Control and Monitoring
Plan was created to ensure monitoring of improvements for
Sustainability. Final a Dashboard was

developed to be used for staff to visually track their
performance and for discussion with Dr. Deasley.
We have collected data after making many improvements to see
if the process is now stable. We will
continue to monitor our progress and follow the control plan.
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>
APPENDIX A: VOICE OF THE CUSTOMER
Feedback from Patients:
I wait too long. I only have an hour for Lunch. I make my
appointments specifically at Lunch
time because I can’t come after work.
I like to come very early and be one of Dr. D’s first pati ents. If
I am not his 1st, I end up waiting
and am late for work. My company is very strict about being on
time.
I wouldn’t mind if the doctor spent less time with me. I only
usually come for an Annual
Checkup and a Flu shot. If I feel really sick, I call the office.
When I broke my arm last year, the
doctor sent me right to the hospital. You guys made the
arrangements for my X-Ray so I didn’t
need to wait.
I can’t be late when I come in the afternoon. I need to pick my
daughter up from school. If I
come in the afternoon, can you make it a short visit?

The doctor spends so much time asking me questions, can’t he
look at my chart before I get
into the exam room?
The last time I was here, you put me in a room with someone
else’s clothes. The woman had
gone to the Ladies’ room and came back to get dressed. I had to
wait in the hallway.
Feedback from Staff
We need to organize the exam rooms. Dr. Deasley is always
looking for something and I need to
go find it.
We can’t have multiple people at the Front desk assigning
patients to rooms. They don’t always
assign patients to the right room and equipment is not available
Dr. D keeps taking equipment with him from room to room,
The patients are not getting here early enough to get them ready
for the doctor. He like to have
their Blood Pressure, Weight and Temperature done before he
comes in.
Patients keep arriving the last minute, then they get angry
because they miss their appointment
and need to wait.
I hope I never have to reschedule Mrs. Smyth for a new
appointment because the doctor
couldn’t see her. She was practically screaming at me.

We had 2 patients, Mrs. Jones and Mr. Thomas ask for their
records to be sent to a new
doctor’s office. That is the 4th time that has happened this year
and we are only ½ way through
the year.
The new Medical Assistant was complaining because she said
there is too much chaos here. I
think she might be sorry she came her. I hope she doesn’t go
back to the hospital. It takes so
much time to find good people and train them.
Feedback from Doctor
I don’t always have the instruments I need in the Exam Room. I
need to have my Assistant go
find what I need. I’ve started taking Instruments with me to my
next patient only to find 3 of
the same instrument I am carrying in the next Exam Room.
I have seen several patients waiting in the hall outside the Exam
Room. I don’t like that
situation. We need to stop this practice.
I see some staff running around like crazy and others sitting
around appearing to have nothing
to do.
I am not one of these “hands off’ doctors, I like to spend time
with my patients. But sometimes
a patient will sit there with nothing to say and another patient
will have a long list of issues.

If this improvement project is successful, I would like to see 15
Patients a day. We need to keep
operating costs in mind. We need to keep our equipment up to
date and I need to ensure we
plan for salaries and bonuses at year end.
I notice we have had 3 people leave within the past 18 months. I
would like to understand why.
It is very expensive to recruit staff and it takes time before they
are proficient in their jobs. The
team we have now is very good. I would like to keep all of
them. We do monitor salaries and
compare with market standards so I know our salaries and
benefits are competitive.
Feedback from Other Sources
Radiology Department is complaining because they state we
make too many changes to the
patient appointments.
The Laboratory department is complaining because our patients
are coming for testing outside
their assigned appointment time and too late in the day.
APPENDIX B: Based on VOC data to be used to construct
CTQ’s. Project Team will
identify key focus areas in Doctor’s Office using Pareto
Diagram. These focus
areas will then be monitored as defined in Data Collection Plan.

Time the Doctor was spending with Patients – 79
Number of times Dr arrives late - 4
Proper Medical Devices not Available - 30
Number of times patient is left in the hallway - 17
Rooms Available at Doctor’s Office -22
Number of times staff arrive late - 3
Staffing of Doctor’s Office -41
Number of times scheduling changes were made for patient
testing - 15
Number of times patient had to be rescheduled for Dr visit - 10
Arrival Time of Patients - 52
APPENDIX C: Data set to be used to construct 5 Histograms

Proper
Medical
Devices
N/A
Rooms
Available
at Dr.
Office
Staffing at
Dr. Office
Arrival
Time of
Patients
Time Dr.
Spends
with
Patients
10.82 7.45 0.5502 172 48
10.82 7.55 0.5522 169 34
10.86 7.67 0.546 177 23
10.87 7.65 0.5462 170 32
10.84 7.62 0.5491 174 19

10.85 7.59 0.5486 175 37
10.86 7.6 0.5428 167 20
10.87 7.52 0.5532 171 47
10.89 7.49 0.5472 168 27
10.8 7.54 0.5522 172 31
10.81 7.52 0.5494 168 44
10.89 7.61 0.5519 163 27
10.81 7.52 0.5509 174 61
10.9 7.61 0.5412 169 17
10.87 7.53 0.5518 171 26
10.86 7.57 0.5523 172 50
10.85 7.59 0.5415 172 11
10.85 7.55 0.5477 168 53
10.86 7.61 0.553 169 18
10.86 7.54 0.55 166 75
10.83 7.57 0.5437 172 27
10.89 7.51 0.5463 168 36
10.76 7.63 0.5566 174 40

10.78 7.5 0.541 175 30
10.86 7.58 0.5542 164 23
10.9 7.55 0.5569 173 15
10.83 7.51 0.5432 168 15
10.82 7.5 0.5487 170 35
10.87 7.59 0.5537 173 45
10.88 7.58 0.541 170 25
10.67 7.64 0.5554 173 42
10.72 7.48 0.5521 167 64
10.65 7.57 0.5532 169 23
10.7 7.46 0.5563 172 53
10.67 7.53 0.5508 165 50
10.65 7.6 0.5527 170 16
10.6 7.49 0.5546 169 41
10.66 7.65 0.5478 170 7
10.61 7.55 0.5468 165 31
10.69 7.55 0.5566 172 18

10.71 7.51 0.5531 168 53
10.66 7.49 0.5482 173 34
10.64 7.49 0.5473 172 37
10.62 7.49 0.5442 170 80
10.63 7.56 0.5491 176 19
10.67 7.59 0.5596 175 26
10.62 7.47 0.5491 170 13
10.62 7.58 0.5507 169 18
10.63 7.55 0.556 177 36
10.65 7.47 0.5428 178 7
10.68 7.63 0.5488 172 34
10.68 7.47 0.5531 171 28
10.63 7.68 0.5483 171 44
10.68 7.55 0.5431 171 18
10.58 7.47 0.545 177 23
10.59 7.59 0.5392 172 17
10.64 7.57 0.5512 170 25
10.64 7.53 0.5465 169 15

10.68 7.58 0.5479 164 23
10.6 7.6 0.5452 174 21
Upper Spec 11 7.66 0.56 180 60
Lower Spec 10.5 7.45 0.54 165 0
Target 10.75 7.55 0.55 170 20
APPENDIX D: Data represents Wait Time in minutes beyond
their scheduled
Appointment Time for the last 70 patients. Use to create Stem
and Leaf Plots.
PATIENT
WAITING
TIME
PATIENT
WAITING
TIME
PATIENT
WAITING

TIME
PATIENT
WAITING
TIME
PATIENT
WAITING
TIME
PATIENT
WAITING
TIME
PATIENT
WAITING
TIME
16 15 19 48 14 47 21
16 17 16 45 80 20 46
17 13 26 50 6 71 48
37 47 17 49 49 47 20
47 11 65 63 48 50 64
32 47 15 17 47 95 16
48 38 17 22 48 47 44
21 17 48 10 52 20 82
18 20 16 18 46 50 51
75 49 44 51 48 35 58

APPENDIX E: Data set for determining performance for
Medical Assistant #2. The
historical mean for Medical Assistant #1 was .0126.
MEDICAL ASSISTANT #2
Data
MEDICAL ASSISTANT #2
Data
0.009
0.015
0.010
0.011
0.011
0.011
0.011
0.012
0.010

0.008
0.011
0.011
0.013
0.008
0.012
0.010
0.013
0.014
0.012
0.009
0.014
0.011
0.015
0.011
0.012
APPENDIX F: This is the data set for evaluating Correlation
between Room

Availability and Patient Arrival
Room # Availability Patient Arrival Time
154 0.554
153 0.553
152 0.552
152 0.551
151 0.549
151 0.549
151 0.548
151 0.548
151 0.548
151 0.547
151 0.547
151 0.547
151 0.547
151 0.547
151 0.547
151 0.546
150 0.546
150 0.546
150 0.546
150 0.546
150 0.546
150 0.545
150 0.545
150 0.545
149 0.545
DMAIC_RoadmapLean Six Sigma DMAIC RoadmapPurposeKey
ToolsKey OutputsDefineTo establish a quantified problem

statement, objective and business case that will become the
foundation to your Six Sigma project. Conduct stakeholder
analysis, select team members and kick-off your project.Primary
MetricProcess MapProject CharterProject Plan* Process Map
* Gather VOC
* Translate VOC to CTQ's
* QFD/HOQ
* COPQ
* Primary & Secondary Metrics
* Establish Project Charter
* Stakeholder Analysis
* Team Selection
* Project PlanMeasureRefine your understanding of the process.
Assess process capability relative to customer specificati ons.
Validate measurement systems. Brainstorm potential
x's.C&ESIPOCFMEACpk* Early Y=f(x) Hypothesis
* Detailed Process Map
* SIPOC
* Cause & Effect Diagram
* Cause & Effect Matrix
* FMEA
* Basic Statistics
* Normality Test
* Capability Analysis
* Gage R&RAnalyzeConduct data collection and planned
studies in order to eliminate non-critical x's and validate critical
x's. Establish a stronger and quantified Y=f(x)
equation.Normality TestANOVA2 Sample t-testEqual
Variances* Narrowed Y=f(x)
* 1 & 2 Sample t-tests
* 1 & 2 Proportions tests
* Equal variance tests
* Normality tests
* ANOVA
* Moods Median
* Mann Whitney

* Paired t-test
* Chi-Squared testImproveDesign, test and implement your new
process or product under live operating conditions. Pilot
solutions if feasible before broadly deploying expensive
improvements or products. Pugh MatrixLinear RegressionBinary
Logistic RegressionDOE* Refined Y=f(x)
* Pugh Matrix
* Correlation
* Simple Linear Regression
* Multiple Linear Regression
* Binary Logistic Regression
* Full Factorial DOE
* Fractional Factorial DOEControlPlan, communicate, train and
implement your product or process solutions. Ensure control
mechanisms are established. Use Poke Yoke, visual controls,
SOP's and SPC wherever possible.Control
PlanSOP'sCommunication PlanSPC* Control Plan
* Training Plan
* Refined FMEA
* Communication Plan
* Standard Operating Procedures
* Five-S Audit
* Poke Yoke
* Visual Controls
* Statistical Process Control
DMAIC_Project_ChecklistD.M.A.I.C Project
ChecklistDEFINEIMPROVE2Projecct Charter2Potential
Solution
s Developed2Business Case (why is this project
important)2Potential

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