{"id":589,"date":"2023-10-11T10:06:42","date_gmt":"2023-10-11T17:06:42","guid":{"rendered":"https:\/\/www.cdcr.ca.gov\/hcdom\/?post_type=dom&#038;p=589"},"modified":"2026-03-18T13:23:35","modified_gmt":"2026-03-18T20:23:35","slug":"5-9-2-statewide-lean-six-sigma-program","status":"publish","type":"dom","link":"https:\/\/www.cdcr.ca.gov\/hcdom\/dom\/chapter-5-administrative\/article-9-training\/5-9-2-statewide-lean-six-sigma-program\/","title":{"rendered":"5.9.2 Statewide Lean Six Sigma Program"},"content":{"rendered":"\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Procedure Overview<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>This procedure establishes a Statewide Lean Six Sigma (L6S) program and describes the major structures, processes, resources, and requirements that support the Program.\u00a0 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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Responsibility<\/strong><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><code>   <\/code>The Deputy Director, Quality Management, is the primary executive sponsor for this policy and procedure.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Procedure<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Statewide L6S Program<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>The Statewide L6S Program shall promote continuous process improvement throughout the organization by:<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Maintaining L6S certification programs for:<\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>White and Yellow Belt, facilitated by certified Green, Black or Master Black Belts.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Green and Black Belt, facilitated by certified Master Black Belts.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Promoting continuous improvement by integrating L6S strategies.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Providing program and institution leadership teams with guidance on how to utilize local L6S expertise for improvement work.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Providing technical assistance to staff as they apply L6S strategies.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Identifying statewide improvement opportunities that can be addressed using L6S strategies and proposing recommendations to the Statewide Quality Management Committee (QMC).<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>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.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Providing consultation to support the design and development of the statewide performance measurement system.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Identifying, adapting, and sharing best practices generated from L6S improvement projects.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Establishing forums and feedback systems for certified L6S staff to receive updates and provide input to the program.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Mentoring the impact of using L6S strategies for program development and improvement.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Utilizing L6S Expertise<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Headquarters&#8217; programs, regional offices, and institutions that have certified L6S staff shall leverage those resources and expertise for local improvement activities including, but not limited\u00a0to:<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Leading and facilitating improvement projects.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Consulting on improvement work and associated deliverables.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Conducting data and problem analysis.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Identifying and applying appropriate L6S strategies.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Educating local staff to L6S strategies.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p>Sharing best practices resulting from local L6S projects.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block\">\n\t\t\t\t\t<p><strong>Program Reporting<\/strong><\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>      The Statewide QM Lean Office shall report L6S Program activities to the Statewide QMC at least annually.<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>References<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>Institute for Healthcare Improvement (<a href=\"https:\/\/www.ihi.org\">www.ihi.org<\/a>)<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>James P. Womack, Lean Enterprise Institute (<a href=\"https:\/\/www.lean.org\/\">https:\/\/www.lean.org\/<\/a>)<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-bullet\">\n\t\t\t\t\t<p>The Joint Commission (<a href=\"https:\/\/www.jointcommission.org\">www.jointcommission.org<\/a>)<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p><strong>Revision History<\/strong><\/p>\n\t\t\t\t\n\t<ul class=\"cdcr-dom-group-block\">\n\t\t\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Effective: 08\/2019<\/p>\n\t\t\t\t\t<\/li>\n\t\n\n\t<li class=\"cdcr-dom-item-block is-style-no-marker\">\n\t\t\t\t\t<p>Revised: 3\/18\/2026<\/p>\n\t\t\t\t\t<\/li>\n\t\n\t<\/ul>\n\t\n\t<\/li>\n\t\n\t<\/ul>\n\t","protected":false},"parent":240,"template":"","class_list":["post-589","dom","type-dom","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.3 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>5.9.2 Statewide Lean Six Sigma Program - Health Care Department Operations Manual (HCDOM)<\/title>\n<meta name=\"robots\" content=\"noindex, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"5.9.2 Statewide Lean Six Sigma Program - Health Care Department Operations Manual (HCDOM)\" \/>\n<meta property=\"og:url\" content=\"https:\/\/www.cdcr.ca.gov\/hcdom\/dom\/chapter-5-administrative\/article-9-training\/5-9-2-statewide-lean-six-sigma-program\/\" \/>\n<meta property=\"og:site_name\" content=\"Health Care Department Operations Manual (HCDOM)\" \/>\n<meta property=\"article:modified_time\" content=\"2026-03-18T20:23:35+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-5-administrative\\\/article-9-training\\\/5-9-2-statewide-lean-six-sigma-program\\\/\",\"url\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-5-administrative\\\/article-9-training\\\/5-9-2-statewide-lean-six-sigma-program\\\/\",\"name\":\"5.9.2 Statewide Lean Six Sigma Program - Health Care Department Operations Manual (HCDOM)\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/#website\"},\"datePublished\":\"2023-10-11T17:06:42+00:00\",\"dateModified\":\"2026-03-18T20:23:35+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-5-administrative\\\/article-9-training\\\/5-9-2-statewide-lean-six-sigma-program\\\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-5-administrative\\\/article-9-training\\\/5-9-2-statewide-lean-six-sigma-program\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/chapter-5-administrative\\\/article-9-training\\\/5-9-2-statewide-lean-six-sigma-program\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"HCDOM\",\"item\":\"https:\\\/\\\/www.cdcr.ca.gov\\\/hcdom\\\/dom\\\/\"},{\"@type\":\"ListItem\",\"position\":3,\"name\":\"Chapter 5 &#8211; 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