Measuring performance and defining good quality is a relatively recent phenomenon in healthcare. Starting in the 1980s, when the publi- cation of report cards and information about outcomes of practice, healthcare has steadily improved its skill with using data to understand perfor- mance with the intention of making improvements in clinical care as well as in financial performance. Throughout the last 30 years, there have been sever- al methodologies that have been introduced to assist organizations in improv- ing quality, including Total Quality Management (TQM), Clinical Quality Improvement (CQI), and Value Stream Management (VSM). While the rest of this article will concentrate on Lean Six Sigma and how it was used to execute a hospital design project, it is vital to understand that these methodologies and their associated tools are all part of a larger toolbox, and can be integrated with other tools or methodologies based on the needs of a particular improve- ment project.In order for improvement to take root and flourish in an organization, an intense commitment on the part of senior management is required to support improve- ment activities through training, monitoring, and continued improvement activities after initial implementation. In addition to the need for management support for improvement projects, all employees must embrace some basic prin- ciples of quality and performance improvement. Good quality and productive work can't be accomplished without well-defined processes and metrics that are monitored over time. It is also impossible to have good quality without under- standing the needs of customers, both internal and external. Finally, it is vital for everyone to remember that the main source of quality defects is within the pro- cess itself or the system that is being used, not with the people who are involved in the process. It is far too easy to blame particular people or departments for poor quality, when it is often the system that is fundamentally flawed.Increasing performance can only be achieved in two ways: increase capacity or reduce variation. If the concentration is (and should be) on making the system better, the concept of variation becomes paramount. Understanding variability is the key to improving a process or a system so that goods or services produced meet the needs of customers. Variation can be described as deviation from a stan- dard process. Variation is ubiquitous, additive, and in most systems that involve humans, can't be completely eliminated. Traditional approaches seek to mitigate the effects of variation in process, sometimes putting a quick-fix into place that ends up not only not fixing the problem at hand, but often also making the entire system work less effectively and efficiently.But in discussing the best way to approach quality improvement, there are some other basic principles to consider. Poor quality leads to incremental cost to the business, for example, in terms of rework, dealing with customer complaints, loss of market share, among others. In some processes, up to half of the work done is non-value-added, that is, work that does not contribute to either the bot- tom line or to satisfying customers. An organization can't improve everything at once, so it should concentrate on the processes or systems that are most vital to core business objectives. Decisions should be made based on data that have been analyzed using sound scientific and statistical thinking. Improvement needs to be embraced at every level of the organization, or it will not be sustained.What Is Lean Six Sigma?In very broad terms, Six Sigma is a statistically based approach to process improvement. Lean is a methodology that focuses on eliminating waste-doing more with less-and has its origins in the Toyota Production System that was introduced in Japan. Lean Six Sigma combines the toolboxes of the separate methodologies of Lean and Six Sigma to provide a hybrid approach to process improvement. …