White H, Harris AM and Bowling CB: Use of lean methodologies in outpatient urology clinic. Urol Pract 2021; 8: 649.

Lean methodologies, when applied correctly, have been shown to decrease waste, improve processes, and lower costs. Lean application continues to garner support secondary to improving patient satisfaction, easing workday frustrations, increasing patient-centered care, and improving health care value.¹ The latter is especially important given our nation spends nearly 17.7% of our gross domestic product, or $3.6 trillion, on health care and studies show up to 25% of this spending is wasteful.² Fortunately, the automotive, airline, farming, shoe, and technology hardware industries have given us examples of successful lean implementation and shown improvements in quality and value.^3,4

Using this information, we sought to study the outpatient urology clinic setting in order to ascertain if lean application would yield positive results. We chose this setting as we believed the work-to-reward ratio was favorable and because we had control over most of the clinic processes, thus making change attainable. We initially sought buy-in from both front line and top line stakeholders, and both groups became invested in the opportunity for improvement. After the communication was done and buy-in achieved, we studied the current state of the clinic by “going to the Gemba.” The first author on the work spent time with a stopwatch, pen, and paper tracking patient times as well as technician, provider, and patient movement for 85 patient visits. We found 5 different possible patient flows, with flows 2 and 3 being most efficient and flows 4 and 5 being the most inefficient and occurring in 33% of visits (fig. 1). The median wait time from appointment time to roomed was 15 minutes and this was secondary to lack of provider room availability.

Figure 1. Preintervention patient flows and times.

The time and patient flow tracking provided information concerning flow but did not provide information regarding reasons for inefficient flows. However, the spaghetti diagrams illustrated the needed information and showed excessive movement during the patient encounter (fig. 2). A median of 6 technician trips and 4 provider trips were seen per patient. Furthermore, the spaghetti diagrams showed up to 3 separate technicians could be involved in a single patient’s care. We found several examples of confusion over which technician was performing certain tasks, which led to duplication of work or wasting time asking one another if tasks had been completed.

Figure 2. Preintervention spaghetti diagram. Each color represents a different person.

Through studying the current state, we identified the following main issues:

1. The initial wait time was too long.
2. Technicians and providers were having to see the patient multiple times during a visit. An example of this would be the following: technician gets patient from lobby and rooms patient, provider decides a urinalysis is needed, patient goes with technician to get urinalysis and returns to provider, provider then decides a bladder scan is needed, technician takes patient to get bladder scan and returns patient to provider.
3. Lack of clear technician roles and responsibility.

After, and only after, thoroughly studying the current state, the following interventions were discussed with the frontline stakeholders:

1. Technicians would be assigned 1 technician to 1 provider instead of all technicians helping all providers.
2. Technicians would prepare the charts the day prior to anticipate patient technician needs, such as symptom questionaries, urinalysis etc.
3. The technician would “huddle” and review the list from #2 with their assigned provider the morning of clinic to confirm patient technician needs.

After reviewing this with the technicians, the technicians were tasked with implementing these workflows the most effective way possible from their perspective. Providers were then communicated the new workflow.

After implementation, the same mechanisms of study were used to assess if any changes occurred. Patient wait time decreased by 53% concerning all flows: the most efficient patient flows increased from 19% to 28% of patient visits, the most inefficient flows decreased from 33% to 17% of patient visits, and total appointment time decreased by 27% (see fig. 3 for other pertinent results). This saved the clinic 98 minutes per day. Furthermore, the spaghetti diagrams showed much improved movement with only 1 technician involved in the patient visit (fig. 4).

Figure 3. Postintervention patient flows and times.

Figure 4. Postintervention spaghetti diagram. Each color represents a different person.

The interventions in this study improved patient flows, increased efficiency, and improved the staff’s working conditions. The time saved allowed the staff to work in a less chaotic, or rushed, work environment. However, the key information from this work is not the results or the interventions; these interventions may not work in other clinics as they were designed specifically for this clinic. Seeing a problem and interjecting a solution prior to studying the problem is likely to yield poor results. The key in this work was the process by which the methodology was applied. The process was chosen and scoped appropriately, meaning we had influence to enact change in this area. The project was discussed in detail with front line and top line stakeholders to garner buy-in. The process was studied by going to the workplace to develop flow maps and spaghetti diagrams. By using the maps and diagrams, targeted interventions were developed and studied. Understanding and implementing this process will allow others the opportunity for replication in order to design appropriate interventions tailored to specific needs. This is considerably more important than the actual interventions deployed in this work.

For more information, please see the article “Use of Lean Methodologies in Outpatient Urology Clinic” in the November issue of Urology Practice^®.⁵