Figure 4.21 shows the swim lane process map for a patient undergoing a lumpectomy (the surgical removal of a small tumor from the breast). Nine parties, including the patient, were involved in the process. For many of the steps in Figure 4.21, a box has been drawn around multiple parties, indicating that two or more parties were involved in the step. For example, the
"surgery" step involved three parties: the patient, the surgeon, and the hospital.
During the treatment process, the patient (who was a registered nurse) detected two errors. Error 1 occurred when the surgeon intended to employ a needle locator to identify the location of the tumor, but failed to forward an order to that effect to the hospital. The patient identified the omission prior to surgery. No harm occurred. Error 2 was a typographic error on the pathology report indicating that the tumor was 1.6 millimeters diameter when in fact it was 1.6 centimeters.
This could have been a more serious mistake, but a phone call to confirm the correction avoided any harm.
1. Who or what organization is responsible for this process from start to finish? What are the implications for managing and improving the treatment process?
2. Which process steps should be standardized? Which process steps should be more artistic? Explain.
3. Consider the errors that occurred during the treatment process. How might you use the Six Sigma methodology and continuous improvement tools to keep these errors from reoccurring? Looking ahead, what kinds of solutions might you see coming out of such an analysis?

  • CreatedApril 10, 2015
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