Unusual Lean Six Sigma Case Study And 4 Typical Mistakes In Your Organization

  • How to scope your improvement project using 80/20 rule (Pareto-law)?
  • Why cleaning up your data essential before you can solve any problems with Lean Six Sigma?
  • What are the common issues in companies, organization and institutions, etc. holding them back?


“First you have to learn walking before you can run.” This is even true for Lean Six Sigma – and other – improvement projects.

At one of my clients we have started a project to reduce the number of incident. Whether you are working in manufacturing, service industry, government or healthcare, etc. you always have occurrence of unpleasant event. Just think about injuries, mistakes, faults, scrap, incomplete information, etc.

In our specific situation it was about unwanted events that could cause injuries by patients.

Because there was a lot of data available about incidents, we thought we could quickly improve the situation.

But we had to do some homework first…


Too Many Incidents?

Just like with every Lean Six Sigma project we do, we try to describe the problem and scope the project as small as possible by answering questions like these:

– How many incidents were registered in the last period?

– What kind of incidents was registered?

The above graph show us that fall incidents (when a patient had injuries due to a fall) has contributed for 70% to the Total number of incidents last year.

So we were about to focus ONLY on fall incidents.

Furthermore, because the whole organization consisted of different units, we investigated the Pareto-distribution (like above) of the fall incidents per organizational unit (let’s call them locations).

Location 3 was chosen to focus our improvement efforts because it had the highest number of fall incidents reported last year.


Typical Mistake #1: Project Scope

If you want to achieve measurable improvement in short period of time, it is crucial to scope your project well.

You only need to apply the 80/20 principle (Pareto-law) just like I have done in above example.

Not scoping your project small will cost you time and motivation. This is the number 1 reason why improvement projects give up without delivering any tangible benefit.

In our current example our project is focusing on the reduction of fall incidents at Location 3.


What Are the Causes?

Using the data of the fall registration system we could analyze and split up the fall incidents per reason. See below graph on Location 3.

The distribution of fall incidents per reason shows that in 60% of the cases the reason is unknown. This led us to the 2nd common mistake.


Typical Mistake #2: Quality of Data

The high percentage of unknown incidents has surprised the team. Unfortunately the figures were the same for all the other locations.

We started investigating the individual fall incidents by studying the information registered by the employee.

Interestingly, in many situations we could find real reasons of the fall although the employee registered the incident as “Reason Unknown”.

It was obvious: the registration – thus the data quality itself – needs to be improved FIRST before we could do anything to reduce the number of fall incidents.

Data first, analyzes second.

Like someone said: “Good data is better than excellent analysis.”

This helped our team to scope or project even smaller:

“Reduce fall incidents with reason “unknown” at Location 3”


Typical Mistake #3: Register to register

Going through the individual incidents and re-classifying them based on the included information, we could reduce the number from 60% to 19% for the situation where reasons were unknown.

We realized: employees do not know exactly how to register and why to register. They just do the work their managers have asked them to do.

What is missing often? Explanation on…

– Why is it important to register the incident carefully including as many information as possible?

– How to complete the registration?

– What are we going to do with the data?

This later one brings us to the 4th typical mistake.


Typical Mistake #4: Registration Is Not Equal To ACTION

Many employees – I see it often in Healthcare – have many administrative tasks. In our example employees had to deal with 3 different kind of admin systems in connection with the incidents.

What was missing? Action. Doing actually something with the data to reduce / avoid incidents occurring again.

Due to many administrative tasks employees do not have time left to do something with the data, to improve the situation.

And this is exactly why we use Lean Six Sigma.

Do you want to finally change and improve your work?

>> You can learn how to do it yourself or

>> Get a helping hand by calling +31 55 737 00 02


Going back to our example, the employees of Location 3 got an extensive training on how to register and what we are going to do with the data. They clearly understood: without their commitment our improvement team is not able to find solutions.

Everybody got the message.

Everybody was happy to get a clear explanation.

Everybody understood the importance of change.


Result in 4 Months

We were able to dramatically reduce the number of unknown fall incidents from 60% down to 17% just in 4 Months time. Our goal is to stay under 10% and we can achieve that for sure.

Now we can start a new project that concentrates on the reduction of fall incidents.

First we had to learn walking but now we can start running.

Warm regards,


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