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1<br />
Ricardo Leaño, MD, MBA, CSSBB<br />2<br /><ul><li>Physician. Board Certified Anesthesiologist
Master of Business Administration. Specialization in Health Administration and Policy. University Of Miami.
Leading Teams and Organizations, Effective Leadership, Executive Leadership Strategies. University of Notre Dame. Mendoza ...
American Society for Quality (ASQ) Certified Six Sigma Black Belt.
Co-Chair Educational Committee ASQ-HCD
American College of Healthcare Executives-ACHE</li></li></ul><li>Ricardo Leaño, MD, MBA, CSSBB<br />3<br /><ul><li>Clinical
Managerial
Leadership
Quality</li></li></ul><li>4<br />“It is not the strongest that survive,<br />nor the most intelligent,<br />but the one <b...
Why you are here<br />5<br />"Change happens by listening and then starting a dialogue with the people who are doing somet...
HealthcareorganizationsSix SigmaEmpowerment.   H.O.R.S.E. LEAN<br />Ricardo Leaño, MD, MBA, CSSBB<br />6<br />
7<br /><ul><li>Healthcare
ORganizations
Six sigma
Empowerment</li></ul>H.O.R.S.E. Lean<br />horse [v. to haul or hoist energetically]<br />                                 ...
H.O.R.S.E. Concept<br />8<br />The H.O.R.S.E. principles greatly emphasize leadership and strategic management together wi...
H.O.R.S.E. Concept<br />9<br /><ul><li>Every internal organization must understand how and why other individuals/organizat...
11<br />
Lean, Six Sigma and Lean Six Sigma<br />12<br />Jing, G.G. “A Lean Six Sigma Breakthrough”<br />Quality Progress. May 2009...
primum non attero [first do no waste]<br />primum non nocere<br />First do no harm<br />secundus non attero<br />Second do...
ISO 26000 Defines Social Responsibility<br />14<br />“responsibility of an organization for the impacts of its decisions a...
…in healthcare…<br />15<br />wasted<br />
Margin<br />16<br />Revenue     =      Outputs      x        Prices<br />     Expenses    =        Inputs       x         ...
Margin<br />Margin Compression  <br />↑<br />Revenue     =      Outputs      x        Prices<br />      Expenses    =     ...
Budget<br />18<br /><ul><li>Profit is determined by revenue and expenditures
Financial position is determined by profit and capital expenditure
These are determined by
Market share
Price
Customer satisfaction
Quality
Worker satisfaction </li></ul>Griffith J, White K “The Well-Managed Healthcare Organization”. 6th Edition<br />
DRA (Deficit Reduction Act of 2005)<br />19<br />Beginning October 1, 2008, Medicare will no longer pay the higher MS-DRG ...
falls and trauma;
surgical site infection after bariatric surgery for obesity, certain orthopedic procedures, and bypass surgery
vascular-catheter associated infection;
catheter-associated urinary tract infection;
administration of incompatible blood;
air embolism; and
foreign object unintentionally retained after surgery. </li></li></ul><li>To err is human<br />20<br />“medical errors do ...
Institute of Medicine<br />21<br />Six Aims for Improvement<br />Safety – Avoiding injuries<br />Effectiveness – Services ...
Healthy People 2010 goals…<br />22<br />“…safe, effective, patient-centered, timely, efficient, and equitable care that ex...
Concepts<br />23<br /><ul><li>Sigma (). Standard deviation. Provides an estimate of the variation in a set of measured data
Sigma level. Describe the performance of a process relative to the specification limits.
Process: Sequence of activities that transform inputs into Outputs
Quality: “Is a predictable degree of uniformity and dependability, at low cost and suited to the market”</li></ul>Deming, ...
Sigma Level<br />25<br />Performance of a process relative to the specification limits<br />
International Survey Supported by the Commonwealth Fund 2007<br />26<br /><ul><li>One in three of U.S. respondents reporte...
Highest rate of any of the six countries in the survey.
U.S.			32%
Canada			28%
Australia			26%
New Zealand	 	22%
Germany			16%
U.K. 			24%
Most patients (61% - 83%) in each country said health care providers did not tell them about the errors.</li></ul>(Schoen,...
Process. Y = f(x) <br />27<br />Everything is a Process<br />“A systematic series of actions directed to the achievement o...
Lean Six Sigma<br />28<br />Blame the process<br />not the individual<br />
To err is human<br />29<br />“medical errors do not result from … a ‘bad apple’ problem. More commonly, errors are caused ...
Quality Definitions<br />30<br /><ul><li>“…a predictable degree of uniformity and dependability, at a low cost and suited ...
“…any characteristic that improves the product or service in the eyes of the buyer.” J. Griffith, K. White
Hard to define, but you recognize it when you see it        ACHE Congress 2008
“The least cost to Society”       Genichi Taguchi</li></li></ul><li>Lean Six Sigma Definitions<br />31<br /><ul><li>“A com...
Lean Six Sigma<br />32<br /><ul><li>Structured methodologies for sustained process improvement
Both are complementary processes, not competitive approaches
Both represent a cautious compilation of previously developed quality tools and a framework for action with the particular...
Identify and reducevariation
Understand and optimize processes by focusing on inputs</li></li></ul><li>DMAIC<br />34<br /><ul><li>Define
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LEAN SIX SIGMA HEALTHCARE

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LEAN SIX SIGMA HEALTHCARE

  1. 1. 1<br />
  2. 2. Ricardo Leaño, MD, MBA, CSSBB<br />2<br /><ul><li>Physician. Board Certified Anesthesiologist
  3. 3. Master of Business Administration. Specialization in Health Administration and Policy. University Of Miami.
  4. 4. Leading Teams and Organizations, Effective Leadership, Executive Leadership Strategies. University of Notre Dame. Mendoza College of Business
  5. 5. American Society for Quality (ASQ) Certified Six Sigma Black Belt.
  6. 6. Co-Chair Educational Committee ASQ-HCD
  7. 7. American College of Healthcare Executives-ACHE</li></li></ul><li>Ricardo Leaño, MD, MBA, CSSBB<br />3<br /><ul><li>Clinical
  8. 8. Managerial
  9. 9. Leadership
  10. 10. Quality</li></li></ul><li>4<br />“It is not the strongest that survive,<br />nor the most intelligent,<br />but the one <br />most responsive to change”<br /> Charles Darwin (1809-82)<br />
  11. 11. Why you are here<br />5<br />"Change happens by listening and then starting a dialogue with the people who are doing something [you don't believe] is right.“<br />Jane Goodall<br />InformationWeek Daily Newsletter www.informationweek.comWeekend Edition: Saturday, March 28, 2009<br />
  12. 12. HealthcareorganizationsSix SigmaEmpowerment. H.O.R.S.E. LEAN<br />Ricardo Leaño, MD, MBA, CSSBB<br />6<br />
  13. 13. 7<br /><ul><li>Healthcare
  14. 14. ORganizations
  15. 15. Six sigma
  16. 16. Empowerment</li></ul>H.O.R.S.E. Lean<br />horse [v. to haul or hoist energetically]<br /> Webster’s II New Riverside University Dictionary<br />
  17. 17. H.O.R.S.E. Concept<br />8<br />The H.O.R.S.E. principles greatly emphasize leadership and strategic management together with Lean Six Sigma methodologies so as to hoist energetically our healthcare system in the right direction. <br />
  18. 18. H.O.R.S.E. Concept<br />9<br /><ul><li>Every internal organization must understand how and why other individuals/organizations work, how and why they make decisions and unite them to keep the mission, vision and goals of their institution as part of their own missions, visions and goals. </li></li></ul><li>10<br />
  19. 19. 11<br />
  20. 20. Lean, Six Sigma and Lean Six Sigma<br />12<br />Jing, G.G. “A Lean Six Sigma Breakthrough”<br />Quality Progress. May 2009<br />Lean:<br />Improvement approach aimed at improving efficiency by removing wastes<br />Six Sigma:<br />Improvement approach aimed at improving process capability by reducing variation<br />Lean Six Sigma:<br />Improvement approach aimed at combining both Lean and Six Sigma to improve efficiency and capability primarily by removing wastes and variation<br />
  21. 21. primum non attero [first do no waste]<br />primum non nocere<br />First do no harm<br />secundus non attero<br />Second do no waste<br />13<br />
  22. 22. ISO 26000 Defines Social Responsibility<br />14<br />“responsibility of an organization for the impacts of its decisions and activities on society and the environment, through transparent and ethical behavior that contributes to sustainable development, health and the welfare of society; takes into account the expectations of stakeholders; is in compliance with applicable law and consistent with international norms of behavior; and is integrated throughout the organization and practiced in its relationships”<br />Vincent, C. “Back in Circulation”<br />Quality Progress. May 2009<br />
  23. 23. …in healthcare…<br />15<br />wasted<br />
  24. 24. Margin<br />16<br />Revenue = Outputs x Prices<br /> Expenses = Inputs x Costs<br /> Profitability=ProductivityxPrice Recovery<br />
  25. 25. Margin<br />Margin Compression <br />↑<br />Revenue = Outputs x Prices<br /> Expenses = Inputs x Costs<br /> ↑ ↑<br />Margin Looseness<br />↑↑ ↔ ↑<br />Revenue = Outputs x Prices<br /> Expenses = Inputs x Costs<br /> ↓ ↓ ↓<br />Profitability=ProductivityxPrice Recovery<br />↑ ↑ ↑<br />17<br />
  26. 26. Budget<br />18<br /><ul><li>Profit is determined by revenue and expenditures
  27. 27. Financial position is determined by profit and capital expenditure
  28. 28. These are determined by
  29. 29. Market share
  30. 30. Price
  31. 31. Customer satisfaction
  32. 32. Quality
  33. 33. Worker satisfaction </li></ul>Griffith J, White K “The Well-Managed Healthcare Organization”. 6th Edition<br />
  34. 34. DRA (Deficit Reduction Act of 2005)<br />19<br />Beginning October 1, 2008, Medicare will no longer pay the higher MS-DRG for these HACs (Hospital Acquired Conditions) <br /><ul><li>pressure ulcer stages III and IV;
  35. 35. falls and trauma;
  36. 36. surgical site infection after bariatric surgery for obesity, certain orthopedic procedures, and bypass surgery
  37. 37. vascular-catheter associated infection;
  38. 38. catheter-associated urinary tract infection;
  39. 39. administration of incompatible blood;
  40. 40. air embolism; and
  41. 41. foreign object unintentionally retained after surgery. </li></li></ul><li>To err is human<br />20<br />“medical errors do not result from … a ‘bad apple’ problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. “<br />I N S T I T U T E OF M E D I C I N E November 1999<br />
  42. 42. Institute of Medicine<br />21<br />Six Aims for Improvement<br />Safety – Avoiding injuries<br />Effectiveness – Services based on scientific knowledge<br />Efficiency – Avoiding waste<br />Patient-centered care – Care that is respectful of and responsive to individual patient preferences, needs and values<br />Timeliness – Reducing waits and harmful delays<br />Equitable care – Equal care to all regardless of gender, ethnicity, location and socioeconomic status <br />Institute of Medicine<br />Crossing the Quality Chasm:<br />A New Health System for the 21st Century<br />
  43. 43. Healthy People 2010 goals…<br />22<br />“…safe, effective, patient-centered, timely, efficient, and equitable care that extends the quality [and length] of life and reduce health disparities”<br />Griffith, J.R., White, K.R.<br />“The Well-Managed Healthcare Organization”<br /> 6th ed. Health Administration Press<br />
  44. 44. Concepts<br />23<br /><ul><li>Sigma (). Standard deviation. Provides an estimate of the variation in a set of measured data
  45. 45. Sigma level. Describe the performance of a process relative to the specification limits.
  46. 46. Process: Sequence of activities that transform inputs into Outputs
  47. 47. Quality: “Is a predictable degree of uniformity and dependability, at low cost and suited to the market”</li></ul>Deming, W.E.<br /><ul><li>Defect: Failure to meet customer requirements</li></li></ul><li>Sigma<br />24<br />Wide Variation<br />Narrow Variation<br />
  48. 48. Sigma Level<br />25<br />Performance of a process relative to the specification limits<br />
  49. 49. International Survey Supported by the Commonwealth Fund 2007<br />26<br /><ul><li>One in three of U.S. respondents reported experiencing medical mistakes, medical errors, inaccurate or delayed lab results.
  50. 50. Highest rate of any of the six countries in the survey.
  51. 51. U.S. 32%
  52. 52. Canada 28%
  53. 53. Australia 26%
  54. 54. New Zealand 22%
  55. 55. Germany 16%
  56. 56. U.K. 24%
  57. 57. Most patients (61% - 83%) in each country said health care providers did not tell them about the errors.</li></ul>(Schoen, et. al. Health Affairs, Web Exclusive; W5-509-W5-525)<br />
  58. 58. Process. Y = f(x) <br />27<br />Everything is a Process<br />“A systematic series of actions directed to the achievement of a goal” J.M. Juran<br />Method<br />(x)<br />Man<br />(x)<br />Material<br />(x)<br />PROCESSING<br />(f)<br />Output<br />(Y)<br />Machine<br />(x)<br />Environment<br />(x)<br />
  59. 59. Lean Six Sigma<br />28<br />Blame the process<br />not the individual<br />
  60. 60. To err is human<br />29<br />“medical errors do not result from … a ‘bad apple’ problem. More commonly, errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them. “<br />I N S T I T U T E OF M E D I C I N E November 1999<br />
  61. 61. Quality Definitions<br />30<br /><ul><li>“…a predictable degree of uniformity and dependability, at a low cost and suited to the market” W.E. Deming
  62. 62. “…any characteristic that improves the product or service in the eyes of the buyer.” J. Griffith, K. White
  63. 63. Hard to define, but you recognize it when you see it ACHE Congress 2008
  64. 64. “The least cost to Society” Genichi Taguchi</li></li></ul><li>Lean Six Sigma Definitions<br />31<br /><ul><li>“A comprehensive and flexible system for achieving, sustaining and maximizing business success”</li></ul>MoreSteam University<br /><ul><li>“…relentless and rigorous pursuit of the reduction of variation in all critical process … that impact the bottom line … and increase customer satisfaction”</li></ul>H. Gitlow. University of Miami<br /><ul><li>“a disciplined, data-driven approach and methodology for eliminating defects (driving towards six standard deviations between the mean and the nearest specification limit) in any process”</li></ul>iSixSigma.com<br /><ul><li>An objective journey toward process improvement</li></ul>Ricardo Leaño<br />
  65. 65. Lean Six Sigma<br />32<br /><ul><li>Structured methodologies for sustained process improvement
  66. 66. Both are complementary processes, not competitive approaches
  67. 67. Both represent a cautious compilation of previously developed quality tools and a framework for action with the particular and common objective of improving quality by performing relative to customer requirements and eliminating waste.</li></li></ul><li>How they work<br />33<br /><ul><li>Identify and eliminatenon value-added activities
  68. 68. Identify and reducevariation
  69. 69. Understand and optimize processes by focusing on inputs</li></li></ul><li>DMAIC<br />34<br /><ul><li>Define
  70. 70. Measure
  71. 71. Analyze
  72. 72. Improve
  73. 73. Control</li></li></ul><li>Define (DMAIC)<br />35<br /><ul><li>Dashboard - Scorecard
  74. 74. Project charter (Business Plan)
  75. 75. SMART project (specific, measurable, achievable, relevant, time bound)
  76. 76. SIPOC analysis
  77. 77. Process Flow Chart
  78. 78. Voice of the Customer (VoC) analysis</li></ul>Affinity Diagram<br />Operational Definitions<br />
  79. 79. 36<br />
  80. 80.
  81. 81. 38<br />Charge RN sends for next patient (Surgery)<br />Pt leaves the OR<br />MSA leaves OR to pick up the patient (Surgery)<br />OR tech removes instruments<br />MSAs clean the room<br />Pgt arrives to holding area (Floor or Same day Surgery)<br />Bring new instruments to the room<br />Holding RN verify check list (Green Check List)<br />Anesthesiologist OKs patient (Consent)<br />X-Ray tech needed<br />Get X-Ray tech<br />Surgeon sign consents and mark site<br />OR RN goes to Holding to verify if next pt is ready<br />Patient in to the OR<br />
  82. 82. Voice of the Customer – Affinity Test<br />Surgeons (12)<br />Anesthesia (4) <br />MSAs (10)<br />Lack of paper work readiness/Site not Marked. <br />They are responsible for two different task (cleaning room and transportation)<br />Lack of Pre-op evaluation on time<br />Lack of adherence to original schedule.<br />Short staff (3 MSA for 6 ORs)<br />CTQ TAT (Door to Door)<br />Delay in the tech availability <br />Supply not stocked properly <br />Lack of communication among OR RNs with floor<br /> RNs and Residents<br />Insufficient C-arms <br />Washer machine broken frequently <br />Shortage of RNs<br />Radiology (6)<br />Instruments (8)<br />Nurses (8)<br />
  83. 83. Measure (DMAIC)<br />40<br />“If you can’t measure it, <br />you can’t improve it”<br />“Not everything that can be counted counts and not everything that counts can be counted”<br />Albert Einstein<br />
  84. 84. Measurement System Analysis<br />41<br /><ul><li>Identify what to measure
  85. 85. Determine how to measure
  86. 86. Develop sampling plan and reaction plan
  87. 87. Validate measurement system (Gage R & R)
  88. 88. Add to overall control plan</li></li></ul><li>SPC charts<br />42<br />
  89. 89. Analyze (DMAIC)<br />43<br />Identify and understand causal relationships<br /><ul><li>Characterize the process (current state)
  90. 90. Fishbone, Box plots, Regression Analysis,
  91. 91. Validate the suspects and compare treatments (which action is more effective)
  92. 92. Hypothesis testing. Z-test, t-test, ANOVA, chi squared
  93. 93. Model the process (understand relationships, how X impact Y)
  94. 94. DOE (Design Of Experiments)</li></li></ul><li>Pareto Chart<br />44<br />
  95. 95.
  96. 96. Improve (DMAIC)<br />46<br /><ul><li>Benchmarking
  97. 97. Brainstorming
  98. 98. FMEA (Failure, Mode, Effect, Analysis)
  99. 99. Poka-yoke (Error-Proofing)
  100. 100. Continuous flow
  101. 101. Quick changeovers
  102. 102. Theory of constrains
  103. 103. Pull scheduling/JIT (Just In Time)
  104. 104. Correction action matrix
  105. 105. Pilot a solution</li></li></ul><li>47<br />
  106. 106. Improve - Benchmarking<br />48<br />Process of developing higher performance standards for your process based on a comparison to other processes, internal within your organization or external from competitors with better performance (most common)<br /><ul><li>Industry publications & trade journals
  107. 107. Industry related meetings
  108. 108. Public financial reports
  109. 109. Third party studies
  110. 110. Company publications/ facility visits</li></li></ul><li>Improve - Brainstorming<br />49<br /><ul><li>Brainstorming is a technique used to elicit a large number of ideas from a team using its collective thinking power”</li></ul>Gitlow, HS “Six Sigma for Green Belts and Champions”<br /><ul><li>The foundation of brainstorming is an atmosphere of suspended judgment (no criticism) so that a large number of ideas freely flow from the participants.
  111. 111. Brainstorming is intended to encourage fresh thinking and ‘crazy’ ideas</li></ul>Moresteam.com/university<br />
  112. 112. Improve - FMEA<br />50<br /><ul><li>Failure Mode Effect Analysis is a tool used to prioritize potential defects based on their severity, expected frequency, and likelihood of detection
  113. 113. Scores are assigned to each potential defect mode of a process in 3 categories: Severity, Occurrence, Detection
  114. 114. Scores will lead to a Risk Priority Number (RPN)
  115. 115. The highest RPN would be the highest priority for improvement</li></li></ul><li>Improve – F.M.E.A.<br />51<br />
  116. 116. Improve – Poka-yoke<br />52<br /><ul><li>Error-proofing or mistake proofing refers to the implementation of fail-safe mechanisms to prevent a process from producing defects
  117. 117. The philosophy: It is not acceptable to make even a very small number of defects, and the only way to achieve this goal is to prevent them from happening in the first place
  118. 118. FMEA, fishbone and brainstorming are used to organize efforts</li></li></ul><li>Improve – Quick Changeovers (SMORE) <br />53<br /><ul><li>Single Minute Operating Room Exchange. From Shigeo Shingo’s SMED (Single Minute Exchange of Die)
  119. 119. The foundation is the distinction between Internal Setup (work that occurs when the system is idle) and External Setup (work that occurs while the system is running)</li></ul>moresteam.com/university<br />
  120. 120. Improve – Quick Changeovers (SMORE)<br />54<br /><ul><li>Staged equipment (preference cards)
  121. 121. Operations conducted in parallel (emergence–bags out)
  122. 122. Standardization (same tools, stretchers, 5S)
  123. 123. Quick attachments (laparoscopic equipment)
  124. 124. No-Adjust equipment and tooling
  125. 125. Duplicate equipment and tooling (double instruments)
  126. 126. Assisted tool movement (for cleaning, equipment, patient, etc)</li></ul>moresteam.com/university<br />
  127. 127. Improve – Continuous Flow<br />55<br /><ul><li>In many ways, the term Continuous Flow defines Lean Methods by improving the movement of material or information through a process
  128. 128. It means a service progresses through a series of value-added steps without delays (inventory), rework (defects) or non-value added operations
  129. 129. Reducing cycle time requires achieving a more continuous flow to match the pace of demand with the pace of production</li></li></ul><li>Flow in a Healthcare Environment<br /><ul><li>Flow of patients
  130. 130. Flow of clinicians
  131. 131. Flow of medication
  132. 132. Flow of supplies
  133. 133. Flow of information
  134. 134. Flow of equipment
  135. 135. Flow of process engineering
  136. 136. [Flow of housekeeping]</li></ul>Black, J with Miller D<br />The Toyota Way to Healthcare Excellence<br />ACHE Management Series. 2008<br />56<br />
  137. 137. Control (DMAIC)<br />57<br /><ul><li>The goals of the Control phase are
  138. 138. 1. Sustain the improvement
  139. 139. SPC
  140. 140. 5S [Sort, Set in order, Shine, Standardize, Sustain]
  141. 141. Total Productive Maintenance (TPM). Goal: Drive waste to zero
  142. 142. 2. Sharing the knowledge
  143. 143. Best practices & Lessons learned
  144. 144. Project Close-Out
  145. 145. Maintain LEAN education and LEAN ambiance </li></li></ul><li>Waste (Muda) - TaiichiOhno<br />58<br /><ul><li>Overproduction
  146. 146. Defects
  147. 147. Inventory
  148. 148. Motion primum non attero
  149. 149. Overprocessing
  150. 150. Transport
  151. 151. Waiting
  152. 152. [Underuse of talent]</li></ul>Black, J with Miller D<br />The Toyota Way to Healthcare Excellence<br />ACHE Management Series. 2008<br />
  153. 153. primum non attero [first do no waste]<br />primum non nocere<br />First do no harm<br />secundus non attero<br />Second do no waste<br />59<br />
  154. 154. 5 S<br />60<br /><ul><li>Sort (seiri): Sort out necessary from unnecessary items
  155. 155. Set in Order (seiton): Necessary items should be easily accessible
  156. 156. Shine (seiso): Dispose of unnecessary item
  157. 157. Standardize (seiketsu)
  158. 158. Sustain (shitsuke)</li></li></ul><li>The most essential tool<br />61<br />The least common of the senses..<br />the Common Sense<br />
  159. 159. 62<br />
  160. 160. Barriers to Lean 6<br />63<br /><ul><li>Lack of knowledge
  161. 161. Fearfulness of statistics
  162. 162. Lack of unification of information . ASQ
  163. 163. Stubborn
  164. 164. Fear of physicians desertion</li></li></ul><li>Change<br />64<br /><ul><li>Three types of Knowledge
  165. 165. Awareness knowledge. Information that innovation exist
  166. 166. How-to knowledge. Information to use it properly
  167. 167. Principles knowledge. Information dealing with the principles underlying how the innovation works
  168. 168. Equilibrium
  169. 169. Stable equilibrium. Status Quo
  170. 170. Dynamic Equilibrium. The rate of change occurs at a rate that is equal with the system’s ability to cope with it
  171. 171. Disequilibrium. The rate of change is too rapid to permit the system to adjust</li></ul>Rogers, E. M. Diffusion of Innovations. 5th Edition<br />
  172. 172. To Remember<br />65<br /><ul><li>Everything is a process
  173. 173. If you can’t measure it, you can’t improve it
  174. 174. Use data instead of ‘paper, scissors, rock’
  175. 175. Software will help with statistics
  176. 176. Maintain Lean ambience and education
  177. 177. primum non attero - First do no Waste
  178. 178. Be Socially Responsible
  179. 179. Start a dialogue</li></li></ul><li>Why you are here<br />66<br />"Change happens by listening and then starting a dialogue with the people who are doing something [you don't believe] is right.“<br />Jane Goodall<br />InformationWeek Daily Newsletter www.informationweek.comWeekend Edition: Saturday, March 28, 2009<br />
  180. 180. Be clear<br />67<br /><ul><li>TEACHER: Maria, go to the map and find America MARIA: Here it is. TEACHER: Correct. Class, who discovered America? CLASS: Maria. </li></ul>&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&<br /><ul><li>TEACHER: What is the chemical formula for water? DONALD:     H I J K L M N O. TEACHER:  What are you talking about? DONALD:     Yesterday you said it's H to O. </li></li></ul><li>68<br />ralmdmba@yahoo.com<br /> Thank You!<br />
  181. 181. 69<br />

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