From Classroom to Clinic: What Lean Six Sigma Looks Like in Practice

UH Reserach & Education Institute

When we talk about Lean Six Sigma, it's easy to focus on the tools, the phases, and the tollgates. What those conversations sometimes miss is what it actually feels like to use them in real workflows, with real people, real constraints, and real patient outcomes, when the data starts to tell the story you suspected was there all along.

Lean Six Sigma is a systematic approach for enhancing process by reducing waste, variation and errors. In healthcare, it helps teams improve quality, efficiency and patient outcomes by using data and frontline insight to guide change. The NEOMED Executive Education team recently followed up with two University Hospitals Green Belt cohorts to learn more about their projects, the impact they are seeing, and the lessons they learned along their quality improvement journeys. Their experiences are different in scope and setting, but the thread running through both is the same: structured problem solving, honest data, and a commitment to better patient outcomes.

Reducing Variation, Restoring Confidence: The Pre-Visit Chart Review

When Angel Velotta, CPC, CRC, CDEO, CPMA, set out to improve the pre-visit chart review process, the problem wasn't immediately obvious. She knew there was inconsistency in review times, variation in decision-making. Query quality was also varied, increasing the risk of defects and rework.

The DMAIC (Define, Measure, Analyze, Improve, Control—a structured problem-solving framework) roadmap gave Angel the foundation to do that. During the Define and Measure phases, she found that review times varied widely—by nearly 12 minutes between reviewers, a notable variation for a process that needs to be both efficient and accurate. Rather than making assumptions about why, Angel took the time to talk with reviewers about the pain points they faced and how they experienced the chart review flow day to day.

By integrating quantitative data with her department's experiences, the Analyze phase revealed root causes linked to the absence of standardized decision tools and quality audit process. That's where the real work began.

The Improve phase produced standardized operating procedures (SOPs), decision support tools, and a quality audit framework that supported the team in what they felt they needed most: a shared definition of what good looks like. Among SOP-aligned reviewers, standard deviation in chart review time dropped from 11.7 minutes to approximately 3 minutes. Quality audit performance improved by 17 percentage points, and the number of queries meeting the defined high-quality threshold more than doubled.

And those numbers, as impressive as they are, only describe one workflow. Here's how Angel described the broader impact:

"The impact of this project extends beyond one workflow. It created a more standardized, measurable, and sustainable process that supports documentation integrity, risk adjustment accuracy, team training, and compliance across the UH system."

That's the compounding effect of trusting the Lean Six Sigma process. A single well-executed DMAIC project doesn't just fix the problem it was aimed at — it builds the infrastructure for better work to happen consistently going forward.

What made that possible, she explained, was a willingness to slow down before speeding up.

"The experience changed the way I approach problems. Instead of jumping to solutions, I now know how to measure the current state, look for root causes, and use data to guide improvement. It helped me to see that effective change is not just about fixing a problem, it's about designing a process that is clear, sustainable, and meaningful for the people who use it."

For anyone wondering whether the Green Belt program is worth the commitment, here's what Angel said about what it takes and what it gives back:

"My advice would be to commit to the process, believe in yourself, and keep going. There were times when I doubted myself, felt frustrated, or faced challenges that seemed almost impossible to overcome. By trusting the LSS framework and continuing to move forward one step at a time, I was able to produce work I did not even know I was capable of. Quality improvement work can be challenging, but it is also deeply rewarding. The process helps you see problems differently, build confidence, and create solutions that can make a real impact."

A Ripple Effect in the ED: The Urine Collection Cycle Time Project

Shifting to the clinical side of improvement, Christine Giardino, Thomas Grano, Andria Paster, and Elizabeth Powers set out to reduce ED urine collection times. Urine tests are often the slowest step in diagnosing some of the most common emergency department presentations, including abdominal pain, fever, and suspected UTIs. When that step is slow, everything downstream slows with it.

Their problem statement was straightforward: patients in the emergency department were experiencing delays in urinalysis collection and processing, contributing to prolonged lead times and extended lengths of stay. In evaluating the current state, the team found that collection time averaged 179 minutes.

What they discovered during their Gemba visits, the place where the work actually happens, changed the direction of the project. In the triage area, incorrect urine specimen cups were often used due to easy access and excess supply, and in some cases, patients weren’t receiving them at all. These small process gaps were creating significant downstream effects. Christine described it this way: "The Gemba Walks were really the Aha moment for me. You cannot effectively understand the process without going to Gemba, the place where the work occurs."

Root cause analysis confirmed that inadequate supply management and a lack of standardization were driving both delays and variability in processing times. Once the team clearly identified the waste, they went after it directly. They implemented 6S (sort, set in order, shine, standardize, sustain, and safety) in triage supply carts to correct par levels and reduce unnecessary items, introduced visual management to guide staff to select the right collection kit, and delivered structured training to reinforce standard work, the team-built solutions that addressed the root causes rather than the symptoms.

Elizabeth Powers, BSN, MBA, RN, noted the importance of the multi-dimensional approach to solving their problem. While the team found multiple approaches to solving the problem, the improvements they selected were the ones they believed were the most important for improving quality.

As Christine put it, "Going through the Green Belt class, you begin to recognize inefficiencies, you can't unsee the waste in daily workflows." She added that standardization is the thing that makes improvement part of the culture rather than just a one-time fix.

Lessons Worth Sharing

Whether you work at the bedside, behind the scenes, or somewhere in between, these lessons apply to any role where processes, people and patients intersect. After sitting down with both teams, a few themes stood out that are worth passing along to anyone considering a quality improvement journey of their own.

1. The DMAIC framework isn't a shortcut — it's a compass. Both teams were clear that skipping phases, particularly jumping straight to Improve, is a path to solutions that don't stick. The discipline of measuring the current state and confirming root causes before designing improvements is what separates lasting change from a temporary fix.
2. Data changes how you see problems. Once you've built the habit of looking for where a process fails rather than who failed it, that lens doesn't turn off. When you first get started, it's easy to try to boil the ocean. As Christine shared, "Start small and learn how to successfully navigate a DMAIC cycle." The data will be your north star throughout.
3. The Control phase is not an afterthought. Standardization for sustainability came up in both projects as the thing that ensures improvements outlast the project itself. Building in the audit, the SOP, the visual management, and checking them regularly is what protects the work.

For anyone standing at the beginning of their first project or deciding whether to take the first step into quality improvement training at all, both teams landed on the same advice: start small, don't skip steps, and trust the framework enough to follow it all the way through. Both teams were also quick to add that you won't be doing it alone. As Angel shared, "I am especially grateful for the guidance and support from the NEOMED staff, who were with me every step of the way," and Christine echoed that sentiment: "The entire NEOMED team will guide you along the whole process and they are incredible!"

So, for those wondering what an approach that began in manufacturing has to do with healthcare, these projects show what happens when structured improvement methods are applied to real care environments, by people who know the work best.

Lean Six Sigma equips healthcare professionals with the tools and problem-solving mindset needed to analyze, improve, and lead in clinical, operational, and healthcare settings. By integrating traditional Lean and Six Sigma principles with healthcare-specific process science, the program builds capability to enhance workflows, improve care quality, and strengthen system performance.

If you or your team is interested in Lean Six Sigma certification, please visit the Digital Workplace: UH-NEOMED Education Programs: Lean Six Sigma. or contact UH Research and Education Institute team.