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Utilization of lean management principles in the ambulatory clinic setting

Nature Reviews Urology volume 6, pages 146–153 (2009)Cite this article

Abstract

The principles of 'lean management' have permeated many sectors of today's business world, secondary to the success of the Toyota Production System. This management method enables workers to eliminate mistakes, reduce delays, lower costs, and improve the overall quality of the product or service they deliver. These lean management principles can be applied to health care. Their implementation within the ambulatory care setting is predicated on the continuous identification and elimination of waste within the process. The key concepts of flow time, inventory and throughput are utilized to improve the flow of patients through the clinic, and to identify points that slow this process—so-called bottlenecks. Nonessential activities are shifted away from bottlenecks (i.e. the physician), and extra work capacity is generated from existing resources, rather than being added. The additional work capacity facilitates a more efficient response to variability, which in turn results in cost savings, more time for the physician to interact with patients, and faster completion of patient visits. Finally, application of the lean management principle of 'just-in-time' management can eliminate excess clinic inventory, better synchronize office supply with patient demand, and reduce costs.

Key Points

  • 'Lean management' principles, encapsulated by the Toyota Production System of automobile manufacture, can be employed in ambulatory health-care clinics to optimize patient throughput without compromising patient safety or satisfaction

  • The central tenet of lean management is continuous and systematic identification and elimination of waste by workers (as opposed to higher management)

  • Limiting variability and removing noncritical activities from the process 'bottleneck' (often the physician in an ambulatory clinic) are essential to successful implementation of lean management concepts

  • Strategic scheduling of patients with differing needs (i.e. new, return, procedure-related) can minimize variability

  • Work capacity can be increased by improving the efficiency of existing resources, rather than investing in additional resources

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Figure 1: Flow of patients through the Northwestern Department of Urology ambulatory clinic.

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References

  1. McClellan MB (21 July 2005). Testimony of Mark B. McClellan, MD, PhD, Administrator, Before the House Ways and Means Subcommittee on Health on Value-Based Purchasing for Physicians Under Medicare. Washington, DC: Centers for Medicare & Medicaid Services

    Google Scholar 

  2. Kohn LT et al. (Eds; 2000) To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press

    Google Scholar 

  3. Committee on Quality Health Care in America, Institute of Medicine (2001) Crossing the Quality Chasm: a New Health System for the 21st Century. Washington, DC: National Academy Press

  4. Eitel DR et al. (2008) Improving service quality by understanding emergency department flow: a white paper and position statement prepared for the American Academy of Emergency Medicine. J Emerg Med [doi:10.1016/j.jemermed.2008.03.038]

    Article  Google Scholar 

  5. Spear S and Bowen HK (1999) Decoding the DNA of the Toyota Production System. Harv Bus Rev 77: 96–106

    Google Scholar 

  6. Prentice JC and Pizer SD (2007) Delayed access to health care and mortality. Health Serv Res 42: 644–662

    Article  Google Scholar 

  7. Green LV et al. (2007) Providing timely access to care: what is the right patient panel size? Jt Comm J Qual Patient Saf 33: 211–218

    Article  Google Scholar 

  8. Murray M and Berwick DM (2003) Advanced access: reducing waiting and delays in primary care. JAMA 289: 1035–1040

    Article  Google Scholar 

  9. Schall MW et al. (2004) Improving patient access to the Veterans Health Administration's primary care and specialty clinics. Jt Comm J Qual Saf 30: 415–423

    Article  Google Scholar 

  10. Hankinson MT et al. (2006) Sustained improvement for specialty clinic access. Jt Comm J Qual Patient Saf 32: 142–151

    Article  Google Scholar 

  11. Pomerantz A et al. (2008) Improving efficiency and access to mental health care: combining integrated care and advanced access. Gen Hosp Psychiatry 30: 546–551

    Article  Google Scholar 

  12. Murray M et al. (2003) Improving timely access to primary care: case studies of the advanced access model. JAMA 289: 1042–1046

    Article  Google Scholar 

  13. Mehrotra AM et al. (2008) Implementing open-access scheduling of visits in primary care practices: a cautionary tale. Ann Intern Med 148: 915–922

    Article  Google Scholar 

  14. Ben-Tovim DI et al. (2007) Lean thinking across a hospital: redesigning care at the Flinders Medical Centre. Aust Health Rev 31: 10–15

    Article  Google Scholar 

  15. Dickson EW et al. (2008) Application of lean manufacturing techniques in the emergency department. J Emerg Med [doi:10.1016/j.jemermed.2007.11.108]

    Article  Google Scholar 

  16. Serrano L and Slunecka FW (2006) Lean processes improve patient care. Observing processes through patients' eyes can lead to improvements. Healthc Exec 21: 36–38

    PubMed  Google Scholar 

  17. Spear SJ (2005) Fixing health care from the inside, today. Harv Bus Rev 83: 78–91

    PubMed  Google Scholar 

  18. Thompson DN et al. (2003) Driving improvement in patient care: lessons from Toyota. J Nurs Adm 33: 585–595

    Article  Google Scholar 

  19. Nelson-Peterson DL and Leppa CJ (2007) Creating an environment for caring using lean principles of the Virginia Mason Production System. Jt Comm J Qual Patient Saf 37: 287–294

    Google Scholar 

  20. Jimmerson C et al. (2005) Reducing waste and errors: piloting lean principles at Intermountain Healthcare. Jt Comm J Qual Patient Saf 31: 249–257

    Article  Google Scholar 

  21. Sunyog M (2004) Lean management and six-sigma yield big gains in hospital's immediate response laboratory. Clin Leadersh Manag Rev 18: 255–258

    PubMed  Google Scholar 

  22. Furman C and Caplan R (2007) Applying the Toyota Production System: using a patient safety alert system to reduce error. Jt Comm J Qual Patient Saf 33: 376–386

    Article  Google Scholar 

  23. Page L (2005) Getting the skinny on lean management. Mater Manag Health Care 14: 26–29

    PubMed  Google Scholar 

  24. Kim CS et al. (2009) Lean health care: what can hospitals learn from a world-class automaker? J Hosp Med 1: 191–199

    Article  Google Scholar 

  25. Endsley S et al. (2006) Creating a lean practice. Fam Pract Manag 13: 34–38

    PubMed  Google Scholar 

  26. Schultz K et al. (2007) Care transitions in the outpatient surgery preoperative process: facilitators and obstacles to information flow and their consequences. Cogn Technol Work 9: 219–231

    Article  Google Scholar 

  27. Anupindi R et al. (2006) Managing Business Process Flows: Principles of Operations Management. Upper Saddle River: Pearson Prentice Hall

    Google Scholar 

  28. Mulvehill MJ III (2001) Operations management: a tool to increase profitability. J Calif Dent Assoc 29: 227–230

    PubMed  Google Scholar 

  29. Stewart M (1993) Pick and pack: a just-in-time forms order and delivery system. J Healthc Mater Manag 11: 36–41

    CAS  Google Scholar 

  30. Gonzalez CM et al. (2006) Significant clinical practice cost savings through downsizing office supply inventory and just in time ordering. J Urol 176: 267–269

    Article  Google Scholar 

  31. Friedman BB (1994) Controlling inventory in a small specialty hospital. HospMater Manag Q 15: 8–13

    CAS  Google Scholar 

  32. Scanlin T (1997) A case for “just in time:” could it be right for your hospital, too? J Healthc Resour Manag 15: 10–14

    CAS  PubMed  Google Scholar 

  33. Liker JK (Ed.; 1998) Becoming Lean: Inside Stories of US Manufacturers. Portland: Productivity Press

    Google Scholar 

  34. Ruffa SA (2008) Going Lean: How the Best Companies Apply Lean Manufacturing Principles to Shatter Uncertainty, Drive Innovation, and Maximize Profits. New York: AMACOM

    Google Scholar 

  35. Spear SJ (2006) Fixing healthcare from the inside: teaching residents to heal broken delivery processes as they heal sick patients. Acad Med 81: S144–S149

    Article  Google Scholar 

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Acknowledgements

Professor S Chopra was an outstanding teacher of lean management principles in the Kellogg School of Management. Professor M Lariviere also taught many of these concepts at the Kellogg School of Management.

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Authors and Affiliations

  1. JT Casey is a Urology Resident at McGaw Medical Center, Northwestern University, TS Brinton is a fourth-year medical student at Feinberg School of Medicine, Northwestern University, and CM Gonzalez is an Associate Professor of Urology, Northwestern University, Chicago, IL, USA.,

    Jessica T Casey, Thomas S Brinton & Chris M Gonzalez

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  1. Jessica T Casey
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  2. Thomas S Brinton
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  3. Chris M Gonzalez
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Correspondence to Chris M Gonzalez.

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Casey, J., Brinton, T. & Gonzalez, C. Utilization of lean management principles in the ambulatory clinic setting. Nat Rev Urol 6, 146–153 (2009). https://doi.org/10.1038/ncpuro1320

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