Health Care Department Operations Manual

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Chapter 5 – Administrative

Article 9 – Training

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5.9.2 Statewide Lean Six Sigma Program

  • Procedure Overview

    • This procedure establishes a Statewide Lean Six Sigma (L6S) program and describes the major structures, processes, resources, and requirements that support the Program.  The Statewide Quality Management (QM) Program shall maintain a QM Lean Office to provide oversight of the Statewide L6S Program. L6S merges two powerful improvement methodologies in an approach that combines Lean principles of identifying and removing waste with Six Sigma data-driven strategies to support continuous quality improvement to sustain a high-performing health care delivery system.

  • Responsibility

  • The Deputy Director, Quality Management, is the primary executive sponsor for this policy and procedure.

  • Procedure

    • Statewide L6S Program

      • The Statewide L6S Program shall promote continuous process improvement throughout the organization by:

      • Maintaining L6S certification programs for:

        • White and Yellow Belt, facilitated by certified Green, Black or Master Black Belts.

        • Green and Black Belt, facilitated by certified Master Black Belts.

      • Maintaining training and staff development programs to orient staff to the L6S approach, augmenting existing orientation and training programs with the L6S approach, and establishing a continuing education program for certified L6S staff.

      • Promoting continuous improvement by integrating L6S strategies.

      • Providing program and institution leadership teams with guidance on how to utilize local L6S expertise for improvement work.

      • Providing technical assistance to staff as they apply L6S strategies.

      • Identifying statewide improvement opportunities that can be addressed using L6S strategies and proposing recommendations to the Statewide Quality Management Committee (QMC).

      • Facilitating L6S improvement initiatives in alignment with the Statewide Performance Improvement Plan and in coordination with relevant committees and program areas at headquarters, regional, and institution levels.

      • Providing consultation to support the design and development of the statewide performance measurement system.

      • Identifying, adapting, and sharing best practices generated from L6S improvement projects.

      • Establishing forums and feedback systems for certified L6S staff to receive updates and provide input to the program.

      • Mentoring the impact of using L6S strategies for program development and improvement.

    • Utilizing L6S Expertise

      • Headquarters’ programs, regional offices, and institutions that have certified L6S staff shall leverage those resources and expertise for local improvement activities including, but not limited to:

      • Leading and facilitating improvement projects.

      • Consulting on improvement work and associated deliverables.

      • Conducting data and problem analysis.

      • Identifying and applying appropriate L6S strategies.

      • Educating local staff to L6S strategies.

      • Sharing best practices resulting from local L6S projects.

    • Program Reporting

    • The Statewide QM Lean Office shall report L6S Program activities to the Statewide QMC at least annually.

  • References

  • Revision History

    • Effective: 08/2019

    • Revised: 3/18/2026