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Lean Health CareEliminate Waste and Spend More Time with Patients

Learning Objectives:
1. Describe Lean methods of improvement
2. Identify how to create an interdisciplinary improvement team
3. Explain how to use Lean tactics to identify sources of waste in clinic workflows
4. Outline steps to help you get started with Lean Health Care
0.5 Credit CME
How will this module help me?

  1. Describes common Lean methods and how to select the right ones for your practice.

  2. Identifies 6 steps to implementing Lean improvements in your practice.

  3. Provides answers to common questions and concerns about Lean thinking and methods.

  4. 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.

Box Section Ref ID

Q&A

  • Are Lean and Six Sigma different?

    Both can be used in the health care setting, yet these methods have different goals. Lean emphasizes waste reduction while Six Sigma is about reducing waste and simultaneously trying to reduce variation in processes, leveraging methodologies such as Data-Driven Improvement Cycle (DMAIC) or Define, Measure, Analyze, Design and Verify (DMADV).

  • I am already way too busy. Why should I consider Lean?

    Are you too busy to improve? Maybe you are too busy because of all these problems. Lean improvements are small investments of time and resources which emphasize better workflows, eliminate waste, and pay big dividends. You can focus your efforts on problems that waste time and invest the time saved to make even more improvements.

  • How can Lean improve the way my practice operates?

    Lean thinking leads to a shift in culture by empowering all team members to identify inefficiencies and offer innovative countermeasures to address these problems. Lean works best with the agreement and involvement of everyone on the team.

Six STEPS to Implementing Lean Health Care:

  1. Identify a High-Level Champion

  2. Create an Interdisciplinary Improvement Team

  3. Empower Front-Line Team Members

  4. Get Started!

  5. Celebrate and Spread

  6. 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.

Box Section Ref ID

Q&A

  • Should we include patients on the improvement team?

    As part of the Lean improvement approach, it is important to understand the voice of the patient. Some organizations create a patient advisory panel to help identify processes that need modification from the patient perspective. Other organizations invite patients to be part of internal improvement committees or teams. Seeing the care your practice provides through a patient's eyes can be incredibly valuable.

  • As a practice manager, I think this sounds great. How can I get my busy physicians to engage?

    Ask one high-functioning team to identify an inefficient or frustrating process and commit to trying a project. At the end, it would be unusual if other physicians and staff weren't intrigued and ready to engage after seeing positive results.

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.

STEP 4: Get Started!

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.

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.
SortFor 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.
StraightenOrganize 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.
ShineMake sure all the materials in the workspace are clean and in optimal working condition.
StandardizeMake 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.
SustainIdentify team members who are responsible for ordering and stocking. Develop routines to make the 5S activities a habit for all team members.
Box Section Ref ID

Q&A

  • We are spinning our wheels in our clinic. What sort of workflow processes might we tackle?

    Ask your team where they would like to start. Examples of small but meaningful starter projects include: decreasing the number of steps in the patient registration process, decreasing wait times for appointments, reducing faxes between different offices or departments, and improving inbox management.

  • Do we need to hire a Lean consultant?

    Many organizations hire a Lean practitioner to assist with organizational transformation and large-scale improvements. The consultant can work with leaders to help all employees learn the language and the methodology of scientific problem solving, but only the practice leaders can ensure the employees are engaged and prepared to participate in change events.

    It is not necessary for every practice to hire a consultant or facilitator to begin to develop a culture of Lean thinking. This module was intentionally created for practices and organizations wanting to move to Lean thinking while using their existing resources.

  • How can we find time to do a 5S project?

    You can start small or start big. Some groups identify and ask one interested staff member to work on one space over a few hours. Many groups will close their office for a half day or bring their staff in on a Saturday morning to rigorously organize and clean their workspaces. This is often accompanied by some fun team-building activities. Others will conduct Lean improvement on a weekday morning or evening. Usually the time investment will be worthwhile because your team will be able to work more efficiently.

  • How many changes should be made at a time?

    It is usually best to start small and implement one change at a time. This is the only way determine if the change has had the desired effect. Each change is an experiment. It helps you learn more about your work. Checking and reflecting after each experiment helps team members appreciate their empowerment. The care team and leaders learn and adjust when changes don't work out as expected.

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.

STEP 6: Sustain

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.

Box Section Ref ID

Q&A

  • How much baseline and post-intervention data should we collect to assess the impact of change?

    One principle of Lean thinking is to collect just enough facts and data to run a first experiment and no more. Don't develop analysis paralysis!

    For some problems, tests of change should have multiple measurements from a variety of times, such as multiple days of the week or a.m. and p.m. shifts, to understand normal variations in your processes. That may help you decide to focus on more than one morning or one day of the week for your first experiment. For example, exam room supplies might be depleted by Friday, and only measuring the supplies on Mondays might not identify this.

    Post-intervention measurements also ideally sample multiple points over time. More specific projects (eg, moving printers) may not require these data measurements.

  • We are a small organization without a budget for data analysts. How can we do all of this measurement and still take care of patients?

    Small and informal measurements are often sufficient. Having patients take a simple survey can give you a lot of information. For example, if you want yes or no feedback from patients about a new process, give each patient a poker chip and have them place it in a “Yes” or a “No” basket on their way out of the office. You can quickly survey staff the same way. Staff can make a check mark on a sheet posted in the hallway to note the specific cause of common problems. A white board in a breakroom can be an easy way to track data while involving staff in visualizing their successes.

Conclusion

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 ID
Graphic Jump Location
AMA Pearls

AMA 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.

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Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

0.5 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;

0.5 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;

0.5 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and

0.5 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

Article Information

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of 0.50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

Renewal Dates: February 22, 2016; May 23, 2019; May 22, 2020

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