How will this module help me?
Describes common Lean methods and how to select the right ones for your practice.
Identifies 6 steps to implementing Lean improvements in your practice.
Provides answers to common questions and concerns about Lean thinking and methods.
Presents success stories describing how practices are successfully using Lean techniques to organize workflows and provide better patient care.
Introduction: What Is Lean?
At its most fundamental level, Lean is about strengthening the problem-solving culture in your organization so everyone feels responsible and empowered to improve the practice. Lean is a quality improvement (QI) strategy and set of tools that provides techniques to help your practice or organization be more resilient and adaptable to future changes in health care.
The principles of Lean are closely linked with flow of production concepts implemented by Ford, and later Toyota.1 In the health care setting, Lean is both a mindset and a method to engage physicians and staff in improving their practices and organizations to run more smoothly. The focus of Lean is to minimize waste in every process, which improves effectiveness and efficiency, and adds value for the patient, provider, and full care team. The goal of lean thinking is to empower every care team member (provider, clinician, medical assistant, call center staff, etc) to take the initiative to find and fix the root cause of the most important problem daily. The role of the leader is to help.
Waste in health care causes physicians and the care team to spend time on activities that do not add value to the patient. Waste also causes physical and emotional fatigue and frustration for the team. Inefficiencies and duplications in care can lead to patient frustrations, time lost from work or family, additional expense, and may drive decisions to change health care providers.
Examples of waste include:
Lengthy patient wait-times
Patient and physician time spent waiting on the phone or walking down the hall to a printer
Delays from forgetting non-intuitive EHR steps
Moving in and out of the exam room to find information, other team members, or supplies
The core concept of Lean is to identify every step in a process, such as a patient visit, and determine which steps add value, which steps do not add value (ie, those that are a “waste”), and which steps could be improved. Those who do the work (physicians, nurses, medical assistants, front desk staff) are in the best position to redesign the process to make it easier to do the work and better for the patient.
Six STEPS to Implementing Lean Health Care:
Identify a High-Level Champion
Create an Interdisciplinary Improvement Team
Empower Front-Line Team Members
Get Started!
Celebrate and Spread
Sustain
STEP 1 Identify a High-Level Champion
Lean Health Care is fundamentally about process improvement through tapping into the creativity of front-line care team members and clinicians. It is usually easier to implement with the agreement and support of a high-level champion, such as the Chief Executive Officer, Chief Medical Officer, or lead physician from the practice.
Quiz Ref IDThe champion for Lean improvement should be dedicated to leading the effort and have sufficient authority or influence and access to organizational resources to ensure that initiatives make steady progress, and that the team can try out the desired changes (experiments) to improve the process.
STEP 2 Create an Interdisciplinary Improvement Team
For each Lean improvement initiative, bring together an interdisciplinary team from the different areas of your practice. These areas may include the reception team, medical assistants (MAs), nurses, physicians, and representatives from pharmacy, lab, radiology, administration, information technology, and/or the business office. If your practice or organization has operations specialists, they will also be a valuable resource, as their role is to maximize the effectiveness and efficiency of processes that impact patients and physicians.
It is important that everyone works together toward a common organizational goal. The role of the specialist or Lean coach is not to do the improvement work or make changes, but to foster an environment where the practice can succeed. They support the team in analyzing the work and identifying problems, root causes, and ideas to try. Team members, not the coach or improvement specialists, are the experts in the process.
STEP 3 Empower Front-Line Team Members
Successful Lean projects are usually chosen and designed by the people doing the work. Projects are more likely to fail when managers or coaches jump in and try to do it all without all team members involved in each process. Staff can be encouraged to view frustrations with systems as opportunities, and to use the following worksheet to submit improvement ideas.
Team Improvement Idea Worksheet (45 KB)You can use this document to identify process improvement opportunities in your practice.
Although it may seem daunting, the best way to learn Lean methods is to dive in. This process can be thought of as four smaller steps described below:
1: Choose a Starter Project
Work as an interdisciplinary team to identify an important process to improve. This first project should be small but meaningful. Limiting the scope to one narrow homogeneous problem or process is critical to early success.
2: Go See
Help the team visually map the process from beginning to end using a process map that identifies how the work is being done and where opportunities for improvement may exist. When possible, use direct observation. Process mapping is most frequently used to identify key steps, sources of waste, and changes that could result in creating the ideal workflow. The map should show work the way it actually occurs, not what should be happening or what the policy states.
Process Map Toolkit (151 KB)Use this toolkit to learn easy ways to create a process map for your practice.
3: Ask Why
Help the team decide the likely root causes of problems with the current process.
4: Show Respect
Help the team try out their ideas or experiments for improving the current process. Trusting the team's ideas is the most important form of respect and a critical element in building a culture of continuous improvement.
You may want to consider a 5S starter project. Quiz Ref IDThe 5S method stands for: Sort, Straighten, Shine, Standardize, and Sustain.
One example of a 5S project is outlined below, and focuses on having clean, organized workspaces to improve productivity and efficiency while minimizing stress. When tools and supplies are kept in a reliable location, fewer errors are made and less time is spent looking for misplaced supplies or missing information. You might be surprised by how much more work gets done when the workspace is uncluttered and reliably organized. Use 5S to reorganize a supply room, exam room, team documentation area, or workroom.
Table 1. The 5S Method
| Use the 5S method to increase productivity and eliminate waste within your practice. |
| Sort | For each item in the workspace ask:
Does this have a function in this area?
If we remove it, will it matter?
One tip is to tag each item with a colored sticker to indicate how often you use it. Green tags identify items that won't be used in the next 48 hours, but are used at least monthly. These items could be moved to a nearby storage area. Yellow tags are for items used occasionally, but less than once a month. These could be moved to more remote storage. Red tags are for unused, broken, or obsolete items that should be donated or discarded. |
| Straighten | Organize materials so that they are easy to find and close to where they will be used. The goal is to not waste time looking for supplies or performing unnecessary steps.
For example, it is helpful to keep all exam room supplies in the same place in each room. Strategically place printers in exam rooms and nearby hallways to eliminate time spent entering and exiting the exam room to pick up printouts. Small boxes, trays, and label makers are handy tools to assist with organizing. |
| Shine | Make sure all the materials in the workspace are clean and in optimal working condition. |
| Standardize | Make it easy to keep the workspace organized. Create a list for what's needed in each workplace. Modify the list whenever you discover something missing or no longer needed. Stock the room according to the list. Place all supplies in the same labeled location in each office.
For example, standardized procedure trays for common procedures can be created daily and brought into the room when needed. Post clear instructions where the trays are assembled so the standard set up is simple for anyone to follow. |
| Sustain | Identify team members who are responsible for ordering and stocking. Develop routines to make the 5S activities a habit for all team members. |
STEP 5 Celebrate and Spread
Share how you've tried to improve processes with others in your practice and organization. Spreading news of improvements helps build strong team culture and strengthen connectedness. Small celebrations of success will contribute to an atmosphere of camaraderie within the practice.
It's also important to note that not all solutions will work in every setting. It is okay to try an improvement and discover that it doesn't work or is not a good fit for your practice. This is not a failure. If a team does not succeed in an improvement, celebrate the problem-solving and learning process. The team can come to realize that they can learn more from a failed experiment than a success. Many practices have a bulletin board or other visual display to keep the team updated on successes and to acknowledge the work of team members.
The final step in Lean improvement is to maintain success. You can encourage lasting change by naming the new process. Use visual systems to reinforce the new process, such as a visibly posted checklist or flow diagram.
For example, if the intended improvement is to create an expanded rooming process for the nurses or MAs in the practice, name the new process “Advanced rooming.” Make sure that every clinical assistant's workstation has a list of the advanced rooming tasks to remind them how to properly perform each step.
Team meetings can also be used to reinforce new processes by providing opportunities for regular check-ins, discuss what's working and what's not, identify new problems and possible additional improvements, and celebrate continued success.
Lean approaches can bring about cultural change. Becoming a Lean organization has several advantages, including reducing or eliminating waste of time and/or resources, improving overall efficiency, tapping into the creativity of all your workers, and fostering team cohesion. The information in this module will help you identify opportunities for Lean improvements and teach you how to enact them in your practice or organization.
Box Section Ref IDGraphic Jump LocationAMA Pearls
Leaders as facilitators
Lean improvement requires that leaders shift their approach from being managers who design new processes to facilitators who support problem-solving and encourage staff to take action. Successful facilitators ask, listen, and support the team. Lean thinking shifts leaders from a stance of “command and control,” or “design and deploy,” to one of discovering and empowering.
Common vision
Develop a common vision for Lean improvement that rallies leaders and employees around a shared purpose. Examples of unifying statements include, “The needs of the patient come first” at Mayo Clinic3 and “Our promise to patients: We will know who you are and will be ready for you” at Borgess Health4. To set their common vision, ThedaCare™ in Appleton, WI, developed a guiding narrative around a fictional patient named “Lori,” a middle-aged woman caring for her aging mother, her husband, and her children.5 When making Lean changes, team members at ThedaCare™ consider how their decisions will impact Lori's patient experience.
Common language
The counterpart to a common vision is a common language. In crafting a common language, some organizations coin their own terms that suit their Lean improvement activities. For example, “flow-stopper” could be used to describe any activity that impedes patient flow. Many organizations adopt the nomenclature of Lean, including the tools that are outlined in this module, such as 5S, A3, Gemba, and Kaizen event. Pick the language that fits your organization.
Flow stations
Several clinics have developed “flow stations” as a result of their Lean analysis. In a flow station, the physician, nurse, and/or MA sit next to each other rather than in individual workspaces, in separate rooms, or down a hallway. The nurse or MA is the “flow master,” responsible for directing non-visit-based work to the physician in manageable batches. Forms, phone calls, and emails are broken down into small blocks that can be addressed in the short intervals between patients throughout the course of the day. This “in flow” Lean approach reduces the inherent waste in unused down time, and enables the physician to finish work earlier. Some organizations report that their physicians finish their work 30 minutes earlier when using the flow station configuration.
Workload balancing and cross-training: team- rather than task-orientation
Workload balancing means optimizing task distribution and maximally utilizing the people in a system to improve workflow. Cross-training of roles allows flexibility; therefore, when the demand varies, workers can “flex,” or adapt, to prevent breakdowns in the flow of work. For example, if three nurses on a team use the same standard work to room patients and do phone work (triage, advice calls, etc.), they can quickly shift work to meet the needs of the practice. When the need to room patients is high, all three could focus on rooming. If the phones are unusually busy, they can adjust from one nurse to two nurses answering phones.
Work conceptualized as team-oriented rather than task-oriented is easier to flex. In the team-oriented example above, all three nurses are able to support the work of the entire team. In a task-oriented approach, one of the nurses may see him/herself as the desk nurse who is only responsible for triage and advice, whereas the other two may see themselves as responsible for rooming patients. Team-oriented work allows practices to function more efficiently and with greater cohesion, so the team can focus on meeting patient needs.
Stop the line
Front-line team members see hazards in the system that may not be apparent to leadership. For example, in a Lean manufacturing environment, an assembly worker who sees a defect is empowered to “stop the line,” or to shut down the whole assembly line system unless the problem can be addressed in real-time. The line does not start again until the supervisor and the worker have addressed the issue.
This “stop the line” concept is crucial everywhere we deliver care, especially when procedures are being performed. The language of “stop the line” can be a transformative way for team members to communicate when a medical error is about to happen. Errors related to misidentified patients, unrecognized allergies, and incorrect medications can be prevented if every team member is empowered to use this common language and “stop the line.” Even if an error may not lead to a major safety concern, staff must feel comfortable highlighting the problem. If workers speak up when they see errors or abnormalities, they can identify problems early and revise the process to prevent a recurrence. If workers are afraid to raise problems, the problems remain hidden and continue to risk patients, frustrate workers, and waste resources.
Group recognition
Recognition and reward in a Lean culture is often at the group level, rather than at the individual level, to emphasize that improvement is a team sport that benefits from diverse perspectives. With Lean improvements, the focus changes from producing volume (eg, the number of patients seen), to producing value (eg, the number of patients who have all their needs met).
Situational awareness
Just as pilots need to see all the essential data on their control panel at a glance, health care professionals need to be able to view all crucial clinical information. Line-of-sight and visual controls are ways for practices to access crucial information to improve a clinic's efficiency. For example, when nurses or medical assistant can see the status of each exam room from their station, they will know when a room is free and can act on this information by rooming another patient.
Visual management system
A visual management system (VMS) is a tool to promote situational awareness. A VMS uses symbols, colors, and pictures instead of text to quickly and reliably create situational awareness. With this type of system, team members can unmistakably view visual cues so standards, activities, and defects are obvious, and a high level of performance can be maintained.
Example 1: A clinic call center
A VMS at a call center might include a yellow screen if an incoming call hasn't been answered in 30 seconds, and a red screen if the call hasn't been answered in 60 seconds. This alerts all team members, including managers, that someone should pick up the call.
Example 2: A clinic
In a clinic, a VMS might be a whiteboard listing physician schedules, staff schedules, and roles. The whiteboard can also include how many patients are on each physician's schedule, and any indications that a physician is falling behind and may need assistance with patient visits. Similarly, a patient's status can be flagged outside of an exam room door or within the electronic health record (EHR). Colored flags (or simple magnets) outside of the exam room door or colored dots in the EHR can represent where the patient is in the process of their visit, and which service they are waiting for.
Example 3: An office setting
In a clinic administration office, a VMS might be a list of key problems and the status of work on each item. In a storage room, a VMS would include labeling what supplies belong where and, when applicable, the label will have a corresponding picture of the item. Some clinics and organizations line their halls with data about every aspect of their work, including value stream maps, financial, quality, and satisfaction metrics. These data are regularly reviewed and used to drive further improvements. For example, leaders and their direct reports make weekly data rounds in these hallways to talk to front-line team members and strategize how to make processes better.