Table 1

Lean Six Sigma practitioners and other quality improvement experts can better incorporate the principles of diversity, equity and inclusion into their work through these six practical suggestions

Suggestion to advance DEI	Guiding question(s) for LSS practitioners	Application/modification of existing LSS tools
(1) Promote inclusivity within QI teams (LSS specific).	How inclusive is the team conducting QI work? How are stakeholders empowered within QI teams to prevent tokenism?	Project charter: Articulation of DEI as core principles of the quality improvement.
	How are stakeholders represented in defining the problem?	Voice of the customer: Identify customer needs of diverse populations through steps like patient panels. Critical to Quality Tree: Determine critical needs, drivers and performance requirements within stakeholder groups and modify QI teams accordingly.
	What stakeholder groups are vulnerable to potential changes? How are the interests of these vulnerable groups accounted for?	Stakeholder analysis: Map stakeholders and how groups will be affected by potential change.
(2) Incorporate measurements that reflect diversity within populations (LSS specific).	Are the selected measures equitable for the affected populations?	Data collection plan: Selection of measures that are tailored towards the population and subpopulations.
	Do the selected measures account for diversity of human experiences and backgrounds?	Operational definitions: Ensure that operations and measures are comprehensively defined in equitable ways.
	Do baseline data account for the affected population’s diversity?	Stratification factors: Stratify selected measures by subpopulation to have more appropriate baseline data.
(3) Identify stakeholders that share socioeconomic or demographic affinities (not LSS specific).	What groups of stakeholders exist within this larger population?	Scatter plot: Scatter plots of data can identify potential groups of stakeholders and relationships within data.
	How does variability within stakeholders impact variability within the larger population?	Rational subgrouping: Organisation of statistical process charts by groups of stakeholders.
(4) Adopt a holistic view of socioeconomic determinants of health as inputs of unwarranted variation (not LSS specific).	How are implicit biases addressed as drivers of disparities?	Root cause analysis: Incorporation of Socioeconomic Determinants of Health within root cause analyses.
	How do socioeconomic determinants of health impact the execution of the project?	PESTLE and SWOT analysis: Analyse and monitor macroenvironmental factors that constitute threats and weaknesses.
(5) Maintain equity among vulnerable stakeholders on project completion (LSS specific).	Can the project be sustained among vulnerable populations?	Pilot interventions: Interventions can be piloted among vulnerable subpopulations first to assess suitability and sustainability for the larger population.
	Are metrics sensitive enough to detect loss of control in vulnerable populations?	Statistical process charts: Use of statistics like cumulative sum for early identification, or g-chart or t-chart for rare events.
	What steps can be taken to sustain changes among vulnerable populations?	Control plan: Incorporate plans for sustaining improvements, with specific focus on more frequent assessment of control among vulnerable populations.
(6) Create a culture of DEI within the larger QI community (not LSS specific).	Has DEI been addressed within the results of quality improvement projects?	Documentation of DEI efforts: Inclusion of how LSS practitioners addressed DEI within manuscripts and other scholarly materials.
	What opportunities exist for incorporating DEI concepts within LSS?	Dissemination and synthesis of knowledge: Mapping the literature through systematic reviews.

DEI, diversity, equality and inclusion; LSS, Lean Six Sigma; PESTLE, Political, Economic, Sociological, Technological, Legal and Environmental; QI, quality improvement; SWOT, Strength, Weakness, Opportunities, Threats.