Using Lean Techniques to Improve Clinical Practice

Health care providers are increasingly using an organizing framework called lean to improve patient care and experience. Toyota uses the lean methodology to produce high-volume, high-quality, low-cost automobiles in an environment with reasonable staffing. Toyota’s goal is to continually increase its production volume and quality with no additional costs; this goal, implemented with lean techniques, has helped Toyota to become a dominant car company. What does automobile manufacturing have to do with health care, and specifically, what does it have to do with ophthalmology? As insurance reimbursements decrease and the volume of patients increases, ophthalmologists are tasked with delivering high-quality care to more patients at the same costs. The lean method may be a useful tool to help ophthalmology practices deliver this outcome.

Lean is a mind-set and a management toolbox to support the philosophy of delivering the right care at the right time every time. It focuses on value, in particular in determining, and then delivering, what is of value to the patient (of lesser priority, but still included, is what is of value to the physician and the institution). In other words, first ophthalmologists need to understand their patients’ wants and needs, especially what the patients perceive as “value” gained from their interaction with the ophthalmology clinic. Understanding value provides key information to the goals of: increasing quality, eliminating waste, managing staffing to volume, and reducing time to complete tasks.

An example of the implementation of lean techniques in an ophthalmology practice is a glaucoma clinic in an academic center whose patients consistently reported extended wait times. Although the clinicians were excellent, with high-quality surgical results and excellent patient reviews, several patients per month reported, both formally and informally, that they waited too long to see the ophthalmic technician and doctors. The clinic’s usual response to such patients included apologizing and explaining that the clinic had suffered unforeseen delays from complicated patients and/or unscheduled emergencies on the day in question. When the clinic realized that these delays were occurring too often, management decided to hire more staff members. Although the wait time improved slightly, it continued to be suboptimal; patient complaints continued, and the clinic suffered increased costs. Why did this not work? One reason that the quality of care did not improve was that the “evaluation and treatment procedures” at this clinic did not include a unifying organizing framework. In addition, management, rather than frontline workers, decided the action plans.

The following year, this clinic implemented a lean methodology to evaluate and improve their clinical practice. Their first step was to define and measure their outcome of interest. They used an electronic medical record to measure patients’ wait time and discovered that it ranged from 5 to 90 minutes. Their goal was less than 10 minutes! They canceled clinic for a day and called a meeting with all management, providers, and frontline staff to solicit answers to several key lean questions regarding waste, safety, delays, and quality.

Using these answers, the clinic created “areas of focus,” which had the highest-priority action plans. These action plans included structured daily huddles with staff at the beginning of clinic to discuss equipment problems, scheduling issues, missing charts, and recent quality or safety issues; at the end of the huddle, they allotted time for open discussion of any other issues. The clinic also created standardized work for each member of the team, eliminated paper printouts of schedules and patient face sheets, loaded rooms in the same order to create the same physician and patient movement, and removed any extra work that provided no value. Because lean represents “continual improvement,” each day the process is reevaluated, and yearly, the staff holds a kaizen evaluation meeting with different areas of focus. If improvements do not work, the clinic evaluates these failures. Over a 5-year period, with the same amount of staff, clinic visits increased 20%; revenues increased 50%; patient delays decreased 80%; staff satisfaction soared; and patients expressed their satisfaction to the clinic on a daily basis. Overall, this example suggests that lean may be a useful method for ophthalmology clinics to “work smarter, not harder” to improve value, give the highest quality of care, and provide exceptional service with the same or decreased resources.

• Simon RW, Canacari EG. A practical guide to applying lean tools and management principles to health care improvement projects. AORN J. 2012;95(1):85–100; quiz 101–103.

  Toussaint JS, Berry LL. The promise of Lean in health care. Mayo Clin Proc. 2013;88(1):74–82.

Excerpted from BCSC 2020-2021 series: Section 1 - Update on General Medicine. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.