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Using Lean tools to reduce patient waiting time

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 Leadership in Health Services
Using Lean tools to reduce patient waiting time
Luciana Teixeira Lot, Alice Sarantopoulos, Li Li Min, Simone Reges Perales, Ilka de Fatima Santana
Ferreira Boin, Elaine Cristina de Ataide,
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waiting time", Leadership in Health Services, Vol. 31 Issue: 3, pp.343-351, https://doi.org/10.1108/
LHS-03-2018-0016
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Reduce patient
Using Lean tools to reduce patient waiting time
waiting time
Luciana Teixeira Lot
Liver Transplant Section, Campinas State University, Campinas, Brazil, and
343
Alice Sarantopoulos, Li Li Min, Simone Reges Perales,
Ilka de Fatima Santana Ferreira Boin and Elaine Cristina de Ataide Received 1 March 2018
Revised 8 April 2018
Faculty of Medical Sciences, Campinas State University, Campinas, Brazil Accepted 11 April 2018

Abstract
Downloaded by Miss Luciana Lot At 04:53 11 August 2018 (PT)

Purpose – This paper aims to address problems in patient flow and identify the reasons behind extensive
wait time at a public liver transplant outpatient clinic in an education and research hospital through the use of
Lean health-care theories.
Design/methodology/approach – This paper opted for the application of Lean thinking and action
research strategy. Data were collected through personal observations, interviews with users and team
brainstorming. A value stream map was developed, improvement possibilities were identified and non-value-
added activities were attempted to be eliminated.
Findings – Significant problems were identified and improvements were implemented and measured. The
major remedial measures were: change the scheduling pattern, create a flow chart and a Kanban visual guide
for medical students. In addition, an institutional change in the medical appointment scheduling software
collaborated in the reduction of time and in the patient’s displacement. The waiting time was reduced by 4.5 h,
and the per cent complete and accurate increased by 50 per cent.
Practical implications – The flow was redesigned, and a culture of continuous improvement was
introduced. Visiting the place where work was being done, leaders identified and created more value to the
process without significant costs. The Gemba Walk was a powerful tool, interacting with people and
processes in a Kaizen spirit.
Originality/value – Public health services in developing countries are one of the most deprived social needs
of good practice. It will be useful for those who need examples about how to apply Lean tools in health care.
Keywords Total quality management, Management, Customer satisfaction, Public health,
Health care
Paper type Research paper

Introduction
Extended waiting time has a negative impact on a patient’s perception, increases the feeling
of illness and is the main cause of dissatisfaction in health services. This is also directly
related to the stress of staff members, associated with work overload and decreases the
quality of service provided (Naidoo and Mahomed, 2016). Many hospitals around the world
have been searching for solutions to overcome the problem of long waiting times (Almomani
and AlSarheed, 2016).
For health managers, the perception about wait time and patient dissatisfaction has been
a frequently topic of discussion (Okuda et al., 2017). Increasing demand, limited resources
and necessity to invest efforts to prevent errors have made it necessary to reorganize health- Leadership in Health Services
care operations (Akdag et al., 2018). Vol. 31 No. 3, 2018
pp. 343-351
The considerable rise in health-care costs has pushed hospital services to reinvent © Emerald Publishing Limited
1751-1879
themselves to increase productivity, ensure quality of care and patient safety (Costa et al., 2017). DOI 10.1108/LHS-03-2018-0016
 LHS Therefore, information management, efficiency in data use, adequate use and distribution of
31,3 resources and process execution time are crucial for optimizing a patient’s journey and for
reducing the discomfort associated with waiting (Rohleder et al., 2011; Almomani and
AlSarheed, 2016).
Initiatives designed to improve the quality of health services and to make them more
valuable to the patients have a long history. Recently, these initiatives include total quality
344 management and business process reengineering, based on experience outside the health
sector (Ham et al., 2003). A successful example is Lean health care, which has been
introduced as a continuous improvement methodology based on the Toyota production
system. It is focused on adding client value, elimination of waste activities from the
processes and respect for all people (Naidoo and Mahomed, 2016). Lean comes to be a change
for the better, improved and value-based health care (Akdag et al., 2018). Within Lean
principles, value-added activities are used to describe any activity that contributes directly
to satisfy the client needs; all non-value-added processes are considered a waste (Waring
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and Bishop, 2010). By eradicating non-value-added elements from the processes, patients are
given greater value; furthermore, the improvement would provide a framework to reduce
costs and better quantify service utilization requirements (Langell et al., 2016). The solutions
depend mainly on the change of managerial vision at the core of the organization and staff
cultural change.
In practice, Lean methodology is the application of a range of approaches and tools
representing a new frontier about reorganization of health-care work. The sustainability and
scope of the improvements will depend in large part directly on the engagement of sponsors
and stakeholders. The implementation of Lean requires the development of leaders, both
decision-makers and people at local departmental levels (Waring and Bishop, 2010).
Patient flow is one of the most critical points in outpatient health-care services. Both
patients and professionals are involved in a variety of activities occurring simultaneously
within medical care, such as exams and multi-professional evaluations (Almomani and
AlSarheed, 2016).
The solutions presented in this article reduced waiting times by improving the patients’
flow at an outpatient clinic service, from a public educational and research hospital, by
using Lean health-care theories. Enhancing quality of health care delivered in public health
facilities in developing countries is a key to guarantee sustainability and eventual growth of
health-care services to the population.

Background
Orthotopic liver transplantation (OLT) is a treatment for patients with irreversible liver
damage (Mendes et al., 2016). This is one of the most complicated procedures of modern
surgery, which depends on a highly skilled multidisciplinary team and the complexity of
hospital structure (Mendes and Galvão, 2008). Patient follow-up is performed in outpatient
units, both in the pre-transplant and in the post-transplant period.
The number of patients waiting for a liver transplant is increasing worldwide. While
waiting for OLT, the individual with liver disease may develop several complications,
requiring strict outpatient follow-up with professionals such as psychologist, nutritionist,
physiotherapist, physician, nurse and social worker (Mendes and Galvão, 2008).
Brazil has one of the largest public health programs related to transplants in the world.
The health manager is responsible for improving processes that ensure the dynamic
evolution of this policy. Thus, projects related to the qualification of outpatient and hospital
care are at the base of economic and social development (Garcia, 2006).
 However, even with all the relevance of the assistance and logistic practices to support Reduce patient
the public policies related to transplantation services, in the past 20 years, an issue is waiting time
becoming more and more consistent when discussing the effects of increasing costs in health
and its growing demand. Although its benefits to public health are not denied, high-
complexity medical care is also responsible for a considerable increase in hospital expenses.
Thus, discussions about resource management, process improvements in the health area
and use of new management technologies are increasingly important to try to guarantee the
quality of care provided to patients and to enable sustainable practices in health-care 345
services.

Lean tools
Lean is not just a toolbox, but a change in organizational structure. Lean tools are critical for
achieving the desired improvements. Its purpose is to fundamentally change the way people
within an organization think and transform how the entire organization behaves in the face
of improvement needs.
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The A3 report is one of the tools that is systematically used as a problem-solving process
to document key findings and to promote improvements and a scientific method of looking
at the situation to a different standard. A3 provides status reports on projects in progress
and reports results to the team. It is an objective tool that integrates individual knowledge
and allows the team to identify actions that can be changed (Lee and Kuo, 2009).
The A3 is so named because it is written on an A3 sized paper, with subsections. Theme
and Background is the first section, where the problem is addressed and pertinent
background information is described to understand the extent and importance of the
problem. The next section is the Current Condition, which explains by a draw how the
system works. The author should quantify the extent of the problem and display it
graphically. In sequence, there is a Root Cause Analysis to deeply understand the issues
raised and their real meanings and origins. The next step is Countermeasures, which
describes how the system might be improved. The goal is to move the organization close to
an ideal state of providing exactly what the customer needs (Lee and Kuo, 2009).
The implementation plan is the next section, i.e. the steps that must be accomplished to
realize the target condition. The steps, times and person who is responsible are listed. The
Follow-up Plan is in the sequence to show how the team can recognize that the new system
is better than the older one, the results about this improvement and a prediction of the new
system performance (Sobek and Jimmerson, 2004).
The Gemba walk in health care is a direct observation of a patient’s journey to gain an
understanding of how the process works.
Another tool widely used to understand the current situation of a process is the value
stream map (VSM). It is a method of Lean management to improve complex workflows by
addressing a customer’s needs through visualization and quantification time process and
displacements (Nowak et al., 2017).
The VSM method includes the visualization of complex work flows, quantification of the
resources needed and restructure of the work flows into an improved version with focus on
the patient’s needs. Therefore, VSM aims to reduce unnecessary process steps.
Simultaneously, the essential process steps and time, which improve the quality of the
process for patients, are aimed to be increased (Nowak et al., 2017).
The 5 Why’s is an analysis tool that tries to find the root cause of a problem. About a
symptom of the problem is questioned why the event occurs this way, asking successively
why’s until the root cause becomes apparent, these techniques are usually robust and useful
(Reid and Smyth-Renshaw, 2012).
 LHS The 5W2H is a tool that has the purpose of representing how the following items were
31,3 defined for the activities to be performed to achieve a specific goal: what will be done (what);
when will be done (when); who will do it (who); where it will be done (where); why it will be
done (why); how it will be done and (how); and how much it will cost (how much) (Reid and
Smyth-Renshaw, 2012).

346
Methodology
To address problems at patient flow, decreasing non-value-added activities, such as
extended wait time at a public liver transplant outpatient clinic from an education and
research hospital, and the Lean health-care methods were used as a strategy. Both
quantitative and qualitative methods were used to understand the current situation.
Action research is a type of social research that is carried out in close association with an
action or with the resolution of a collective problem in which the researchers and
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participants represent the reality of situation to be investigated and are involved in a

cooperative and participatory way (Thiollent, 1985).
The action research methodology seeks to develop knowledge needed to strengthen
activities while proposing a process of intervention that must be carried out by professionals
as modifying elements of that institutional reality (Nunes and Infante, 1996).
Thus, to understand the patient journey and be able to develop a better flow, achieving
the aim of this study, the A3 thinking model was performed. The seven steps of the A3
thinking, namely. background, current condition, analysis, goals, countermeasures,
planning and follow-up, were applied (Shook, 2008).
Background was studied by face-to-face interviews with open questions to ten patients in
waiting room to identify their feelings about the service and waiting time. Face-to-face
interviews were also carried out with physicians, nurses and secretaries. In these interviews,
open questions were asked to make sure that the process had been well understood from all
the players involved, such as what do you think about the health service at this outpatient
clinic? If you could change something, what would it be? What else do you dislike while you
are in this health service?
All patients reported that, although they were very satisfied with the care of the health
team, prolonged waiting time was what bothered them the most. The professionals
interviewed were a doctor, a nurse, a psychologist and the secretary of the service, all
directly involved in patient care in the outpatient unit. The issues raised by them were lack
of compliance in patient scheduling documents that causes rework and extended waiting
time for the patient while resident physicians become familiar with each case and determine
the relevant medical conducts with their teacher. While they are trying to solve patient-
related issues, the staff’s perception of patients’ dissatisfaction with waiting time leads to
more staff stress and frustration.
The second step of the A3 was to show facts and data about the current condition. To
understand the current conditions, a VSM was created, collecting data such as number of
patients, wait time, time spent in each activity, time of interruption and correct and complete
patterns.
The search was performed in Gemba, that is, where the patient was and where the
situations occur. At different times, a registered nurse and a Lean facilitator accompanied
four patients from the time of arrival to the outpatient clinic until the release to their houses,
walking alongside patients without interference like a “shadow” and timing all the time.
After collecting the data, the team drew the VSM by adding the times.
 After mapping the current situation, the team performed the exercise of finding wastes Reduce patient
on the current state map. The wastes were found and analyzed by asking five times why waiting time
that problem happens to find the root cause of the problem.
After discussion with the interdisciplinary team, improvement goals were defined, the
countermeasures were identified and a plan was drawn. Finally, the improvement proposed
by the group was implemented and the results were followed up.
347
Analysis and results
The liver transplantation outpatient sector at the University of Campinas in Sao Paulo State
is responsible for 3,000 medical consultations per year between candidates for transplants
and post-transplant follow-up, with 870 transplants performed.
There are seven consultation rooms, a nursing room, a multi-professional room, a
nursing procedures room, an area of discussion of cases between the medical staff and a
waiting room for patients.
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Current situation – value stream map

Through the observation of all processes, the Lean team could identify situations that
needed improvements. From the time patients arrive to the clinic until they leave the
hospital complex, the process has many steps to pass through (Table I).
The need for improvements was identified from the Gemba Walk, which contemplated
the purposes of both the patient and the team. In daily work of the health team, there are
difficulties to identify improvement points, because of excessive workload and the need to
solve emergency situations that arise at any time (Martin and Osterling, 2007).
Assigning a moment to the Gemba Walk, it is possible to understand the real situation of
the process in which the patient and workers are involved. Also, when a better flow is
created, less emergency situations appears (Martin and Osterling, 2007).
Patients with their family used to arrive at 7 a.m., pick up a password and wait for the
nurse’s calls for screening.
The medical team starts the service after 9 a.m., because before that, medical students
have classes and scientific meeting. The major disagreements cited in some studies are the
early arrival of the patients and the late arrival of the doctors, confirming our findings
(Almomani and AlSarheed, 2016).
Medical consultation is performed first by a surgery resident student, who gathers the
necessary information to discuss the case with the chief. This stage takes time until the

Main process name Responsible Duration (min) Complete correct (%)

Patient gets one password Patient 1 100

Patient wait for nurse’s call Patient 1-90 60
Nurse calls for screening Nurse 3-10 80
Patient wait for doctor’s call Patient 45-90 80
Medical Resident calls for anamnesis Medical resident 10-25 80
Medical Resident discusses the case with teacher Medical resident 20-90 80
Medical Resident comes back to doctor’s office to Medical resident 5 80
explain the treatment
Patient wait for nurse’s call Patient 10-90 40 Table I.
Nurse gives to patient his appointments Nurse 15-60 60 Current situation
Patient displace to appointment’s sector Patient 20-180 60 (VSM)
 LHS resident is able to raise the patient’s medical history and identify his/her treatment needs.
31,3 During this period, the patient is waiting at the doctor’s office; this is one bottleneck because
there are one-two chiefs to discuss with four or five surgery residents.
During the discussion of the case with the teacher, information and theories are
exchanged between students and teachers, as well as the conduct to be taken in each case.
Therefore, it is a very important moment for the residents to learn and for the determination
348 of the patient’s treatment.
Later, the resident returns to the doctor’s office, where his patient awaits him and
communicates the decision of the medical board on the follow-up of the treatment.
Many applications for examination must be completed at this time, and residents do not
always know the bureaucracies involved in each requirement, so this demands more waiting
time for the patient. According to Cardoso et al. (2016), the bureaucracy systematizes the
organizational procedures and gives them a routine character, making clear the roles to be
played by the members of the organization. However, this type of management engages and
generates many rules and causes an excessive hierarchy of the system, culminating in
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slowness and high public expenses.

After the determination and explanation of the conduct to the patient and requested
examination, the patient waits to be called by the registered nurse, who will check if the
future examination and scheduling requirements are correct, and if there is any
inconsistency or need for change, the nurse returns to the resident physician for the
correction; this activity (mapped) is considered as a rework and wastes time.
Per cent complete and accurate is a quality metric used to measure the degree to which
work from a previous activity to the next is complete and accurate (or error-free).
At this point, we observe another bottleneck. When the nurse receives a low complete
correct, she always returns to the previous stage for corrections, besides being continually
interrupted by patients who wait to finish their care and by the residents who seek
information about the bureaucratic procedures.
When the nurse is able to release the patient, the scheduling procedure is performed
outside the clinic, in the hospital complex, in a centralized sector. The patient must wait in
long queues to be able to carry out the schedules and guarantee the continuity of the
treatment.
After all these stages, the patient can return to his/her home.
The main problems causing high waiting time have been identified: doctor’s late arrival,
early patient arrival and long discussion (time) between students and their teachers and
displacement and long queue to schedule future consultations (Table II).
Another organizational problem was the centralization of the scheduling of all
hospital care in a single sector, which generated huge queues and a long waiting time.
Aligned with the needs of improvements in the patient care process, an institutional
change in the medical appointment scheduling software collaborated with the reduction
in execution time and in the patient’s displacement to the accomplishment of his/her
schedules. Many hospitals around the world have proposed solutions to overcome the
long waiting time problem in outpatient clinics investing in software (Almomani and
AlSarheed, 2016).
The improvements implemented in the process were able to achieve a reduction in
waiting time of up to 4 h.
The scheduling pattern was changed to approximate the beginning of the consultations,
and a flowchart was created to assist resident physicians in relation to the bureaucratic
demands and the flows before the different treatments were proposed. A Kanban was also
done to provide the team with visual management of care.
 Problem Effect Counter measure Benefits
Reduce patient
waiting time
(1) Patient An increase of two hours To schedule the time for Reduce patient wait time
arrives at 7 a.m in waiting time arrival at 9 a.m Decreased chaos and long
queues
Less stressful atmosphere
(2) Case Increases patient waiting To create a new flowchart More efficient work for
discussion takes time doctors 349
a long time Clearly and more
informative
communication with the
patient
(3) Low Rework, stress and an A visual clinical guidance Less workload for the
percentage of increase in patient waiting flow chart to assist the nurse
“complete and time resident doctor Reduce wait time
correct” for the Less stress between
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nursing nurses and doctors

consultation
(4) Large Discomfort and stress for The institutional change Reduce patient waiting
Displacement the patient by in the medical time
and extensive displacement and appointment scheduling Increase interaction
queue to carry increased waiting time software between patients and
out scheduling Higher feeling of illness team
after consultation Scheduling inconsistency Reduce displacement Table II.
Decrease scheduling Improvement
errors suggestion

The schedules of future consultations began to be carried out in the outpatient clinic itself
after an institutional change in the medical appointment scheduling software, reducing the
patients’ displacements and bringing them closer to the health team that performs care, as
the interaction between the two patients increased.

Conclusion
Initially, improvement measures seem to be obvious and simple. But, the exercise of
stopping daily activities to observe the patient journey provides a deeper knowledge
regarding what the patient and the professional experience through the process and what
are the main opportunities for improvement. Thus, this study allowed to start the
implementation of continuous improvement to provide a greater patient experience and
increase professional satisfaction.
The effort was not only of the team but also of the institution as a whole in improving a
patient’s experience by using the scheduling software and reducing the waiting time.
The literature on outpatient clinical flow and the waiting time associated with the
application of Lean theories shows an improvement in the time of execution of activities and
elimination of waste. With this, it is possible to guarantee an increase in the level of
satisfaction of the patients in relation to the services provided.
For employees, there is a reduction in stress and an improvement in the organizational
environment, reducing teaming and rework. In addition, when a professional perceives an
increase in the degree of satisfaction of his client, it reflects in his own motivation to look for
more improvements.
Sharing the results obtained with all team members helps in transforming an
organization into a culture of continuous improvement.
 LHS With a more efficient flow, the incidence of emergencies and unexpected situations
31,3 decreases, creating a less chaotic work environment and reducing the incidence of errors.
Lean tools helped identify problems, develop solutions and implement them in a
structured and sustainable way, making it clear to the team that it was not just about
changes but rather improvements. Based on the findings, it is recommended that the Lean
philosophy be increasingly used to improve processes related to public health. Similar
350 actions are expected to ensure the sustainability of public health systems.
The actions taken to achieve the objective of this work did not require monetary
investment for the institution. Officials and senior management have a false conception that
large monetary investments are needed to achieve good gains in process improvement.
However, working using the Lean methodology shows that there are improvements that can
be made and that do not require budgeting, but rather commitment, teamwork, resilience
and knowledge.
In addition, it is suggested that other units of the hospital complex can benefit from
this knowledge, from the development of leaders who act as a multiplier of good
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practices.
In practice, the authors understand that this study is the first step in the implementation
of the culture of continuous improvement in the organization. From this work, new demands
have been identified and will be addressed in future studies.

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Corresponding author
Luciana Teixeira Lot can be contacted at: lulot@unicamp.br

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