Urologists continue to experience burnout at an alarming rate. The more recent census data show 36% of urologists are experiencing burnout. Further, the gender gap has vastly widened, with women experiencing burnout growing from 35% to 49% from 2016 to 2021, compared to 36% to 35% in men.¹ Burnout is associated with substance abuse, depression, and physician suicide.^2,3 Expectedly, these conditions are associated with providing decreased quality of care, worse patient satisfaction, and increased adverse events.⁴ Interestingly, the 2020 AUA Census results show lack of time as a substantial barrier to professional success and the 2021 Census shows 75% of men and 95% of women experience conflict between work and personal responsibilities.^5,6 We can use the application of lean methodology to aid in efficient workflows to enhance timeliness.

The use of lean methodology has been shown to reduce waste and streamline processes.⁷ In the recent AUA webinar we discussed the correct environment for quality improvement (QI) and how the right culture fosters an attitude toward continuous improvement. We also discussed the proper QI process, which includes choosing the right process, communicating with key stakeholders, constructing a current state process map, constructing an ideal state process map, constructing a future state process map, implementing a Plan Do Study Act (PDSA) cycle, standardizing the process, and auditing the process. The webinar went into each of these in further detail. Afterward, we demonstrated the QI process in a urology clinic. The clinic was felt to be functioning inefficiently. Time studies were done to examine the clinic flow. These flows were found to be erratic and not standardized (Figures 1 and 2). Five different workflows existed, with the highly inefficient flows occurring 33% of the time. Patient wait times were 15 minutes, and total appointment time was 36 minutes. The current process did not have the charts prepped, so no one knew if the patients needed attention prior to the physician visit, such as a urinalysis or post-void residual. This created substantial rework, with the patients going in to see the provider and then out to see the medical assistant and then back in to see the provider. Multiple medical assistants were involved in 1 patient’s care, often with the medical assistants being unaware of what the other medical assistants might have already done for the patient. This, again, created substantial rework. These issues were identified through studying the process.

The next steps were to design interventions to ease these inefficient flows. The team decided to assign each provider to a medical assistant for the day. This way the provider knew exactly with whom to speak if a medical assistant was needed to participate in the patient’s care. The medical assistants also prepped the charts prior to the start of clinic so they had an idea of who would need their assistance. The medical assistant and the provider would then huddle prior to the start of clinic to validate which patients needed items such as a urinalysis or post-void residual. The team then studied the process again. After the PDSA cycle, substantial improvements were seen. A 48% decrease was seen in the most inefficient flows. The new process resulted in a 63% decrease in wait times in the more efficient flows. Overall, 6 minutes per appointment were saved, equating to 1.6 hours per day (Figure 3). This created a less chaotic clinic environment and allowed staff to have needed daily breaks, which greatly improved morale.

Utilization of QI methodology can help address some of the frustrations contributing to burnout, such as lack of time and work/personal conflict, by easing inefficiencies. Further, the QI tools will continue to be of importance as we focus on improving health care value. Those interested in learning how to develop improvement actions will benefit from learning how to utilize these tools. The full manuscript is referenced here.⁸