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    Lean and Six Sigma

    These process improvement strategies from the business world can be used effectively in your office.

    Clinicians' efforts to help our patients are increasingly being hampered by the global systems in which we practice. Metrics addressing quality, cost, and patient satisfaction often conflict with our desires for work-life balance, appropriate financial remuneration, and job satisfaction. Add to this the never-ending changes in healthcare reimbursement, billing and documentation requirements, and regulatory considerations, and it is not surprising that a majority of clinicians in the United States report flagging morale.1

    More: The tortuous road from innovation to market

    Significant changes in how we practice medicine are urgently needed if we are to continue to provide compassionate, high-value care to our patients and their families within our current healthcare environment. While global healthcare reform may be beyond the scope of most clinicians, changing how one's practice operates and addresses the aforementioned issues is something that is more realistic and achievable.

    How do we as front-line care providers bring about significant change within our practices without formal training? The unfortunate reality is that healthcare operations are not typically taught during medical training, yet have increasingly become a part of our professional lives. This article is a high-level, non-MBA primer on the concepts of Lean and Six Sigma process improvement techniques-concepts that may be increasingly referenced in your day-to-day administrative discussions. The concepts of Lean and Six Sigma can be used by clinicians on the front lines to begin to change how their practices operate. Improving the efficiency of our office practices by working smarter and not necessarily harder can enhance the experiences of our patients, provide them with high-value care, and improve the financial performance of our organizations.

    Process improvement: The bigger picture

    Lean and Six Sigma do not stand alone. Rather, they are essential components of a global approach to workflow and efficiency improvement. Table 1 is an example of a systematic approach to process improvement. Within this approach, Lean and Six Sigma reside within the "process improvement" phase.

    Standardization is the foundation for any process improvement initiative. Significant clinical variation is the enemy of efficiency. This is not to say that clinicians should not individualize care for select patients; however, the starting point for most patients should align with consensus-driven, evidence-based protocols. How to accomplish that is beyond the scope of this article, but progress on this issue needs to occur prior to addressing process efficiency.


    Lean production was initially developed by Taiichi Ohno at Toyota after World War II and originated from the company's just-in-time production practices as part of the Toyota production system. The conceptual origins of Lean can be traced back through history, from the standardized manufacture of crossbows seen under the Chinese emperor Qin Shi Huangdi in 221 BC to the automobile production lines developed by Henry Ford.2 Lean is fundamentally based upon the philosophy of kaizen, Japanese for "improvement." Kaizen involves employees at all levels working collectively toward incremental improvements. Since its introduction, the Lean production approach has been widely adopted in many commercial fields and it has also spread to healthcare.

    Lean's kaizen objective is to create a seamless flow to the production process by reducing wasteful steps that contribute to inefficiency. Within the Lean system, waste (known as muda) can take numerous forms (Table 2). When Lean process improvement is applied to healthcare, the steps involved in care delivery are individually examined as to whether they either 1) add value to the end goal, or 2) are wasteful and do not add value to the process. The ultimate goal of Lean process optimization is to eliminate those steps that do not add value to the delivery of care in your clinic-leading to a more streamlined, efficient workflow.3

    Many concepts and tools within the Lean lexicon of process optimization can assist in identifying and eliminating waste. The following are a few basic tools to consider using as you start to minimize inefficiency.

    NEXT: Value-stream mapping

    Thomas Lee, MD, MBA
    Dr Lee is a maternal-fetal medicine specialist at Northwest Perinatal Center, Women’s Healthcare Associates, LLC, Portland, Oregon.


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