Utilizing the 3Ms of Process Improvement in Healthcare: A Roadmap to High Reliability Using Lean, Six Sigma, and Change Leadership, 1st Edition (Paperback) book cover

Utilizing the 3Ms of Process Improvement in Healthcare

A Roadmap to High Reliability Using Lean, Six Sigma, and Change Leadership, 1st Edition

By Richard Morrow

Productivity Press

320 pages | 60 B/W Illus.

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Utilizing the 3Ms of Process Improvement in Healthcare supplies step-by-step guidance on how to use the 3Ms of change leadership to improve healthcare processes. Complete with forms, templates, and healthcare case studies, it illustrates the proper application of the 3Ms. It weaves stories throughout the book of role models who have succeeded, as well as some who have failed. It identifies the specific elements that were missing or defective in the failed attempts to teach readers about how the three elements work together.

Arming you with a culture change method that is based on changing behaviors, it provides a leadership and management guide to achieving your objectives. The 3Ms have worked for Ben Franklin, Abraham Lincoln, and the author’s teams across the globe. Now, with this book, you can put the power of the 3Ms to work for you in your quest towards improving processes, providing better care, and reducing costly errors.

The author encourages reader interaction and feedback on his website: www.rpmexec.com. He also provides you with access to the forms and templates described in the book.


In this book, Rick Morrow provides a clear, structured, and disciplined approach to improving processes and systems in healthcare, an industry in great need of improvement. He gives readers great insight into how all the tools of improvement can indeed be used in an integrated approach to improve reliability of care, clinical utilization, quality, patient safety, and efficiency. He wraps this around straightforward steps and the management systems required to sustain improvements. A must read for all looking to improve a complex organization and delivery system.

—Charles Hagood, President & Founder, Healthcare Performance Partners, Inc & Co-Author of Lean Led Hospital Design

With Rick Morrow’s help, we were able to reduce hospital acquired infections by over 50% using the tenets described in this book. Those improvements have been sustained. Rick provides a simple and elegant description of improvement methods and how to apply them. Those serious about performance could benefit from this book.

—David Munch, MD, Senior VP, Chief Consulting and Clinical Officer, Healthcare Performance Partners, Inc. (HPP), A MedAssets Company

As an international expert in quality and safety, Utilizing the 3Ms of Process Improvement for Healthcare is my go-to-guide for practical applications in process improvement. This is a must read for all healthcare professionals looking to create sustainable processes and improve outcomes.

—David Jaimovich, MD, President of Quality Resources International

The stories that Rick shares in this book, I think, everyone can relate to. His ability to translate difficult lessons into easy, memorable stories will engage even the most skeptical readers. … This book includes a step-by-step approach to change that begins with proven techniques. … includes templates that guide teams in driving change and utilization of the 3Ms for process improvement. This book is a great place to start your journey in process improvement. The key to longevity and success in process improvement is the utilization of the 3Ms. I can’t imagine succeeding without the concepts shared in this book.

—Erin DuPree, MD, Deputy Chief Medical Officer, Vice President Patient Safety, Mount Sinai Medical Center, New York

I have made it a habit to listen more carefully to those who have actually been successful doing what they teach. Rick Morrow has the track record to back up the methodology suggested in his book. To the degree that it is theory, it is theory tested and proven on the front lines. He is a veteran in the ongoing ware to improve the patient experience, reduce waste and enhance quality of the care we provide. As such, he is worth listening to. Take the time to read his book. It will be time well invested.

—Terry Howell, Ed.D., Chief Quality Officer, Hennepin County Medical Center

Table of Contents

Overview of Process Improvement and the 3Ms

Outcomes Are the Result of Processes

Performance Excellence

3Ms for Process Improvement


Manage to the Measure

Make It Easier

We Need All Three Ms to Sustain the Improvements

The Science of Process Improvement

Quality Foundational Process Improvement Tools

Productivity Process Improvement Tools

Change Leadership

Case Study in Process Improvement

Utilizing the 3Ms for Process Improvement

3Ms, Scientific Methodology, Change Leadership

Key Points


Change Leadership

What Is Change Leadership? Change Management? How Do They Differ?

The Need for Leadership in Change: A Case Study in Healthcare

Too Many Examples of Not Leading Change Well

Management and Leadership: "Scientific Management

Perfect Example of Scientific Management"

Definition of Manager and Leader

What Happens When There Is No Leader?

Leadership Principles

Abraham Lincoln on Leading Change

Abraham Lincoln’s Principles of Leadership

Leading Change to a Slave-Free America

Healthcare’s Change Leaders

Walking the Talk

Definition of Common Terms across Methodologies

Key Points


Resistance to Change and Process Improvement

Forces against Change: Resistance, Time, Natural Laws

A Quick Win against Resistance

Role of the Change Leader

A Policy of Change and Continuous Improvement

Piloting Changes

What Can Happen if Change Is Not Piloted First

Balancing Change and Continuity

The Emancipation Proclamation

What Happens When One or More of the Ms Is Missing?

Dr. Semmelweis and Washing Hands: The Right Change, but …

Why Is Change Needed in Healthcare?

Semmelweis Dies and So Did His Improvement

Forcing Does Not Always Work

The Force of Resistance

Ben Franklin, Electricity, and Change Leadership

Principles of Electricity Explain Resistance to Change

What You Cannot See Can Hurt You

Using Resistance to Help Lead Change

Electricity and Forcing Change Can Be Dangerous

Getting Change to Flow

The Resistance to Change Can Vary within the Same Person

Resistance between Two Bodies

Resistance at Home

Key Points

Process Improvement Methodologies

Overview of the Most Popular Methodologies

You Need at Least One Recipe and Do Not Forget a "Heaping Tablespoon" of Change Leadership

Which Recipe Delivers the Culture and Change Leadership Skills?

Work with Toyota and for Motorola

Motorola and Toyota Use Lean and Six Sigma Tools and Concepts

PDSA and PDCA Compared to Six Sigma

All Good Methods Analyze for Root Causes before Solutions

Case Study of Sterilized Instrument Processing

A "Milk Run"

Cross Reference of PDSA, Six Sigma, Lean, Change Leadership

Human Factors and Ergonomics in Process Improvement

Case Study: Human Factors Added to Lean Six Sigma?

Hand Hygiene Change Leadership Issue

Failure to Engage Others with the Measure

Baseball and Managing to the Measure

Measures for Research Purposes

Measures for Process Improvement Purposes

Cedars-Sinai Using Measure and Manage to the Measure

Key Points


Roadmap for Process Improvement


Start the Journey on Main Street

Let Us Start on Our Journey

Possible Shortcut

Prepare for Change



Articulating a Vision

Elements in a Vision Statement

Try Out Your Vision Statement

How Does One Communicate the Vision?Abraham Lincoln’s Vision

Advocate a Vision and Continually Reaffirm It

For Whom the Bell Tolls



Quality Circles

Enabling during the Recession of the Early 1980s

Assumptions and Decisions


Key Points


Chartering the Process Improvement Work

The Charter

No Charter? Big Problem

Sharing Findings before Departing

Clear Definition of the Issue and What Was to Be Measured Are Key

The Final Report and Surprise

The Charter Template

The Issue Statement

The Measures or Metrics

Outcome and Process Measures


Progressive Goals and Successive Successful Approximations

Measures and Goals to Build a Safer Culture

Hold Off on Financial Metrics Until

Scope the Work

Charter "Signatories"


Chartering Is Iterative

Sign the Charter

Key Points

Practicing Skills: Chartering


Stakeholder Analysis

Purpose of Stakeholder Analysis

Case Study in Stakeholder Analysis

Mission and Values of the Organization


Overview of the SHA

Measuring the Gap: The Level of Resistance

Three Stakeholder Analysis Scenarios to Know Up Front for Your Strategy

Designing the "Circuit" to Achieve Flow and Manage Resistance

Difficult to Be Perfect

Them Is Us Eventually

Starting a New Clinic

Time to Assess Each Stakeholder’s Buy-in

Key Points


Finding the Root Causes, Improving, and Controlling

Explore Together

Doctor Livingstone, I Presume?

Explore Together with Empathy and Patience

Building the Team

Case Study: Patient Feeds Go Missing

Work-Arounds in the "Factory of Hidden Defects"

Exploring Using the "Five Whys"




Brainstorming for Solutions

Building Consensus


Additional Benefits from the Process Improvement

Train, Enable, Empower, Hold Accountable

Training in the Improvements

Case Study: Enabling and Engaging the Customer in the Process

There Are Good Times, and There Are Bad Times



Hold Accountable

Times Not to Speak Up?

Key Points


Utilizing the 3Ms: Measure, Manage to the Measure, and Make It Easier



Practicing Measure

Manage to the Measure

Make It Easier

Visual Management

Measuring Example

Managing to the Measure Example

Make It Easier Example

Takt Time: A Measure of the Pace Needed to Meet Customer Demand

Measuring: The Most Important M

Applying the First of the Three Ms and Seeing the Value

Setting Up Your Experiment

Measuring the Baseline

Statistical Process Control Charting: Turning Data into Information

Sample Size

Hand Hygiene and the 3Ms

Ready to Observe

Alternative Experiment

The Hawthorne Effect

Desire to Increase Productivity

Utilizing the 3Ms by Changing the Measure

Incentive Piecework as a Measure

More on the Perverse Incentive Measure

French Restaurant Dining

The Hawthorne Effect Revisited

Case Study in Timeliness in Sharing the Measure

Key Points


What to Measure


Hidden Factory of Rework and Swiss Cheese

Getting Started: Preparing for Change, Chartering, and Stakeholder Analysis

Case Study: 3Ms Improving Surgical Safety

The Measure Is Invented

Measuring the Errors to Reduce the Risk of Wrong-Site Surgery

Measuring the Quality of a Decision

Practicing Measuring


A Change in One Area May Affect Other Areas

Inventory Management

Balancing Metrics, Be Careful What You Measure!

Measure What the Customer Measures

Base the Measure on Correlation with the Outcome

High-Reliability Organizations: What Do They Measure?

A Safety Culture and How to Measure

Measuring the Inputs versus Just the Outcomes

Measuring the Culture

Key Points


Measure Risk to Achieve High Reliability


The FMEA Form

The Process Step or Design Function

Input, Failure Modes, Effects, Causes, and Scoring of Risk

Existing Controls

Risk Priority Number

One FMEA Every Eighteen Months Sends the Wrong Message

FMEA for Information Technology

Data Can Be a Component in Today’s High-Tech Equipment

But There Never Has Been an FMEA on Data Components

FMEAs Do Not Always Prevent Catastrophic Failure

Lesson of 3Ms: Must Manage to the Measure, Not Just Measure

Facilitating an FMEA

Key Points


Measurement as a System


Measurement as a System

Measuring the Quality of a Measurement System (Measurement System Analysis)

Qualities of an Acceptable Measurement System

Measuring the Quality of a Measurement System: A Measurement System Analysis

Accuracy and Precision





Designing a Measurement System

Performing a Measurement System Analysis

MSA Can Be Really Easy

MSAs Are Critical in Utilizing the 3Ms

Inaccurate Measurement Systems Can Lose You Customers

A Measurement System Using Actual Data by Surgeon and by Procedure


Measurement Systems that Add No Value to the Client

Calibrating a Measurement System

Categories and Types of Data

Checklists as Measurement Systems



Overview of Performing a Gauge R&R Study

MSA for Blood Pressure Reading

MSA for Attribute Data

Attribute Agreement Analysis

The Soft Drink Challenge with AAA



Overview of MSA for Continuous Data and High Granularity

Gauge Repeatability and Reproducibility

Example of a MSA and Steps

Precision to Tolerance (%P/T)

Knowing Good from Bad

Percentage Precision to Total Variation (%P/TV)

Percentage Contribution


Should I Measure 100% or Sample?

Sampling Quality

Key Points


How to Share and Communicate Measurements


Pareto Charts

Pareto Analysis to Reduce Resistance

Ask Why Five Times

Statistical Process Control (SPC) Charts

May 1924

High-Reliability Organizations and SPC

The "Swiss Army Knife" for Process Improvement

Components of the Control Chart

Control and Out of Control

Case Study: Ambulatory Surgical Center Wait Times

Interpreting SPC Charts

Reliability and SPC

SPC Is Often Preferred in Managing to the Measure

Prove Change Really Occurred

Change Management without SPC?

Frontline Workers Have Been Using SPC Since the 1920s

Run Charts

Measuring Common Healthcare Measures

Key Points


3Ms: Manage to the Measure

The Scoreboard

Visual Management

What to Expect Short and Long Term from Measuring

Instructing and Coaching

Training within Industry

Job Instructions

Job Methods

Job Relations

Program Development

Standard Work to Manage to the Measure

Coaching Is Key in Managing to the Measure

Coach’s Playbook

Key Points


3Ms: Make It Easier

Performance Improvement Makes It Easier to Change

The "Laws" in Change Leadership

Case Study: Nurses Spending Time with Patients

Job Satisfaction

Making Change Easier Is What We Need to Do

Satisfaction and Loyalty Measurement


Experiment, Explore, Build Consensus

Choosing the Best Countermeasures

Piloting and Choosing the Best Countermeasures

Piloting to See if the Measure Moves

Train, Enable, Empower, and Hold Accountable

Mindfulness and Control


Commitment to Resilience

Case Study: Penn Medicine Utilizing the 3Ms

SPC Making It Easier

Key Points


High Reliability


Case Study: SKF

High-Reliability Program Number 1

High-Reliability Program Number 2

The Products Surrounding the Variation

Scrapping versus Inspecting

Utilizing the 3Ms in Zero Defects and SWOC

Program 3: Building a Safety Culture2

A Story of a Seal and Its Grease

Change Is Not Always Easy, Except

Stakeholder Analysis Revisited for Making It Easier

Designing an Experiment Should Start with the People Doing the Work

Key Points



Utilizing the 3Ms Is the Answer


Mistake-Proofing Promotes Defect Prevention versus Detection

Types and Levels of Mistake-Proofing Devices

Start with Failure Modes and Effects Analysis, Then Mistake-Proof the High Risks

Errors Cause Defects

Human Error Drives the Need for Mistake-Proofing

Mistake-Proof Approaches

Train, Engage, Enable, and Empower the People Doing the Work

Control Plans

Last and Definitely Not Least: Reinforcing Continuous Process Improvement

Key Points



Roadmap for Performance Excellence

Process Improvement Foundational Tools

The Emancipation Proclamation

Charter Template

Stakeholder Analysis Template

Hand Hygiene Data Collection Sheet

Hand Hygiene Compliance Chart for Posting

Measure Data Collection Tool

FMEA Severity, Occurrence, Detection Tables

The Soda Drink Challenge to Learn Attribute Agreement Analysis


About the Author

Rick Morrow is a consultant with more than 25 years of senior leadership experience in healthcare, aviation, construction, automotive and high tech. Morrow leads Healthcare Performance Partners’ Quality, Safety, and High Reliability unit, a MedAssets company. He has authored Lean Six Sigma performance excellence courses and taught and deployed programs internationally for Eaton Corporation, SKF, Motorola, United Airlines, The Joint Commission, and Healthcare Performance Partners.

Morrow is the author and leader of HPP’s Six Sigma consulting and wrote and leads the Belmont University Lean Healthcare Certification Program for Supply Chain Professionals, which is a blend of The Toyota Production System, Six Sigma, and Change Leadership. Morrow also wrote and taught The University of Penn’s Penn Medicine Leadership and Performance Improvement courses. He authored the Lean Six Sigma Program at The Joint Commission and led its Center for Transforming Healthcare, where he and his team led collaborations improving patient care and safety with major academic medical centers including Cedars-Sinai, Johns Hopkins, Mayo Clinic, Intermountain Healthcare, North Shore Long Island Jewish, and Stanford University.

Morrow earned his MBA from the University of Illinois’ Executive Program and has a B.S. in Business from Illinois State University. Certifications include Motorola Master Black Belt and Lean Enterprise from the University of Tennessee. He is an international speaker on Lean Six Sigma, Quality, and Safety at conferences including NPSF, ASC and ASQ. Morrow is also the author of the companion book, Utilizing the 3Ms in Process Improvement, and is a contributing editor on performance improvement, quality and safety publications. He is as proud in his work coaching his son and daughter in baseball and soccer and leading as President of Holy Family Commission of Education.

Subject Categories

BISAC Subject Codes/Headings:
BUSINESS & ECONOMICS / Management Science
BUSINESS & ECONOMICS / Quality Control
MEDICAL / Administration