At least one important input is typically missing from healthcare quality improvement:  the voice of the patient.  In Lean & Six Sigma, we typically use the VOC (Voice Of the Customer) to serve as the measure against which defects are determined.  For instance, if the customer is only willing to wait in line 25 minutes at most, that becomes the Upper Specification Limit for a project to decrease wait time.

In healthcare, there's rarely (if ever) such a use of the Voice Of the Patient (VOP).  Why?  Typical reasons given include "patients can't know what quality looks like" or "patients lack the specialized expertise to know what good is".  Interesting idea, but flawed.  Patients know, and ultimately can determine, what they will and won't accept in many healthcare endpoints.  The claim that they don't (or can't) know what they want is as incorrect as stating people don't know what they want in other facets of their lives either.  My claim is that there are other issues, unique to healthcare, that sometimes prevent a clear use of the voice of the patient.

When Lean, Six Sigma & similar toolboxes are applied to healthcare, there are several subtle (and key) differences to make sure those systems work.  First, "customer" (the group that determines the yardstick against which data are measured) is not always the patient.  (Related work on that here.) Patients may receive the output of a given system, yet, in fact, third party payers are often the "customer" whose specifications matter.  (More here.) So, whether we are looking to improve a system that gets patients the colonoscopies they need when they need them, or one that appropriately creates progress notes that capture the patient's current state and treatments, it's important to remember how "customer" and "Voice Of Customer" come from the group that directly receives the output of system we are looking to improve...and this may be the patient, the third party payer, neither, or both!