The management philosophy of “Lean” is the process of efficient operations originating from the Toyota Production System in the mid-20th century.¹ The goal is to add value while eliminating waste—both in services and resources—by empowering individuals within the organization to maximize their contributions and ultimate potential to the organization.

Based on the kaizen principle of continuous improvement, Lean seeks to eliminate all waste in delivering a product or service. There is a specific five-step process for Lean implementation, including:²

1. Define the service of value
2. Identify all steps in the service process
3. Create value adding steps in a tight and logical sequence
4. Allow stakeholders to realize the value from each activity
5. Modify and repeat, removing wasteful steps, aiming for perfect value with no waste

WHY GO LEAN IN RETINA?

Where does Lean fit into ophthalmology? Waiting time is the top patient complaint, especially in busy retina practices, where surprises and emergencies are the order of the day. As practice employees bear the brunt of patient complaints, employee satisfaction and frustration are the logical extension of patient wait times.

As reimbursement fails to keep pace with practice overhead cost inflation, and for some procedures is declining, practices must increase efficiency simply to maintain financial parity with past years. Lastly, COVID-19 has forced many practices, perhaps unknowingly, to adopt Lean principles given social distancing requirements and the inability to have a waiting room full of patients.

As we are now seeing our pre-COVID-19 patient volumes under new rules and restrictions, practice survival has necessitated taking a Lean approach to patient care.

HOW DOES LEAN APPLY TO A RETINA PRACTICE?

Under the Lean principles of minimizing waste both in time and resources, practices can reduce both physician and patient wait times by creating a patient-centric office experience. Teamwork is necessary, ideally utilizing a set team of technicians, scribes, and imagers, who travel with the physician to each office during the week.

In doing this, communication becomes seamless to the point that the team is a collective brain or hive mind, with team members in most circumstances already knowing their physician’s preferences or answers to basic questions. Quality and safety are paramount in a retina practice and should never be compromised in the pursuit of efficiency.

Let data drive decisions rather than impressions or gut feelings. Time-motion studies can identify where the bottlenecks in clinic flow occur, such as waiting for testing, screening, for a room, or for the physician. Numbers don’t lie. Make the effort to collect data and base workflow changes on that data. Then, remeasure to make sure the implemented changes are having the desired effect.

Small trials are also helpful in driving decisions. Start small, perhaps with one physician implementing a particular change or new process. Trial it for a week or two and reassess. Ideas that sound great during a team meeting in the conference room may not work out so well in a busy clinic.

PUTTING LEAN TO WORK

While do-it-yourself projects are popular, Lean implementation is not as easy as assembling a table purchased at IKEA. Hiring a Lean consultant is itself a Lean initiative, making the process more efficient and reducing wasted time by both physicians and staff. A consultant has a cost, but increased efficiencies should quickly provide return on investment.

» Communicate + Map.

When beginning Lean, schedule weekly team meetings, letting managers and staff lead the discussion with the physician in more of a background role providing support and feedback. Map out your clinic flow using spaghetti charts reflecting each step in the process of managing various clinical scenarios: new patient, routine follow-up, post-op, and injection-only. That way each step in the process is defined and times can be measured.

» Identify + Change.

Identify solutions to measured bottlenecks or wasted steps. Rather than changing everything at once, prioritize changes by what is easy and of high value, avoiding what is difficult to change or of low value to the overall process. For example, a high value and easy to implement change might be checking visions before OCT or vice versa, depending on availability of each space and staff, eliminating an unnecessary wait. Difficult changes are repurposing office space, which may involve construction. Other examples include the injection numbing protocol, use of dilation or not for injection-only patients, multipurpose rooms to screen, check visions and pressures, and receive an injection, eliminating patient movement and waiting for a room.

» Follow Up.

Don’t just make a change and forget it. Measure times to see if the changes are producing the desired effect, or if they are making things worse or causing other unintended consequences. Apply the scientific method of creating a hypothesis, collecting data, then modifying the hypothesis if the results are off, until the hypothesis predicts outcomes with a high degree of accuracy. Each process change should be followed by data collection and analysis, repeated in a continuous cycle of self-improvement.

OUR LEAN EXPERIENCE

At our Colorado retina practice, patient, staff, and physician satisfaction are at an all-time high. This is not because we assume everyone is smiling behind their masks, but because we measure this through surveys. We can now see more patients in the same amount of time, often with more patient-physician face-to-face time due to improved upstream efficiencies.

In this era of COVID-19, we have been able to maintain appropriate social distancing through the Lean-created efficiencies that we began before the pandemic. Using multi-purpose rooms, patients arrive to the office and have few stops before seeing the physician for an exam or injection. This keeps the waiting room relatively empty and doesn’t rely on sub waiting rooms or other areas of congregation.

We have applied Lean principles to all areas of our practice, including billing, call center, triage, and front desk. Many staff work remotely from home, a few in other states, freeing up local office space for increased clinic efficiencies.

Ideas are trialed and implemented by physicians and their teams. What works is offered to other clinical teams, knowing that not every process that helps one team will help all teams, given the personalities and styles of each physician Lean team.

FINAL THOUGHTS

Lean is not a one-time event, but instead a process of experimentation, modification, discovery, and improvement based on the scientific method all physicians are familiar with. Improving efficiencies and reducing wasted time makes everyone happier, from patients to physicians, from staff to managers. Be patient with the process and allow everyone a voice as the best ideas may come from unexpected sources.

While COVID-19 has forced many changes upon us, as well as society as a whole, it is not all nuisance and disruption, and may have inadvertently introduced many retina practices to Lean processes. Necessity is the mother of invention, according to an old proverb. Take advantage of current circumstances and adaptations to learn what can become part of your practice long into the post-COVID future. NRP

REFERENCES

1. Skhmot N. What is lean? Available at: https://theleanway.net/what-is-lean ; accessed Oct. 7, 2020.
2. Principles of lean. Available at: https://www.lean.org/WhatsLean/Principles.cfm ; accessed Oct. 7, 2020.