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

Utilizing the 3Ms of Process Improvement in Healthcare
A Roadmap to High Reliability Using Lean, Six Sigma, and Change Leadership

ISBN 9781439895351
Published May 18, 2012 by Productivity Press
320 Pages 60 B/W Illustrations

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Book Description

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.

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


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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.

Featured Author Profiles

Author - Richard  Morrow

Richard Morrow

Executive Director, Quality, Safety, Reliability, Patient Satisfaction, Healthcare Performance Partners
Nashville, TN, USA

Learn more about Richard Morrow »


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