Imagine if you, the allied staff member, got to help call the shots on practice processes. Now, imagine these processes created excitement at work, encounters with happy patients and a workday that finishes on time. At Colorado Retina Associates, a six-location ophthalmology practice in the Rocky Mountain region, the staff doesn’t have to imagine this, thanks to the implementation of Lean. Lean is a program designed to create value for customers — in this case, patients — via staff determining how to minimize waste (i.e. effort, energy, and time used, see “Lean Resources,” p. 12).

“Lean is the opposite of a top-down approach to practice management, making it a culture change. And this is a culture of continuous improvement,” says Alan E. Kimura, MD, MPH, president of the practice, who learned of and implemented Lean in 2018 to become more competitive and alleviate patient wait times. “The idea is, who best knows how the practice operates; the doctors or the allied staff members who are with the patients throughout their appointments? The answer is the allied staff members, so we listen to their ideas for improving patient care.”

Lean has generated a fervor to make practice operations as smooth as possible for patients and clinical teams, says Carol Olvera, COT, a clinical manager at the practice. Colorado Retina Associates has 13 clinical teams, each comprised of a doctor, screener, primary scribe (team captain), secondary scribe, and technician.

Murtaza Adam, MD, notes that implementing Lean has been helpful during the COVID-19 pandemic because it has kept patient time in the practice at a minimum. With reductions in both patient wait times and appointment duration, net promoter scores rose consistently to above 90 for all Colorado Retina Associates offices, says Dr. Kimura.

“We’ve gone from 2 to 3 hours for a visit to between 45 minutes and 75 minutes consistently, with patients who need injections alone finished in around a half hour,” he says. “Additionally, this time savings has enabled us to fit in more patients than before comfortably.”

Here, Colorado Retina Associates staff explain some of the positive changes they’ve made (See “Refine by Design,” p. 13) and how they implemented Lean.

Positive changes made

Dr. Adam points out that the implementation of Lean at Colorado Retina Associates has resulted in a number of positive changes, some of which have saved 1 to 2 minutes per patient, which “really adds up.” Examples of these changes:

Reducing patient paperwork. “We [staff] discovered that patients were completing a lot of the same paperwork that we have them complete in the Phreesia patient-intake tablets, so we eliminated the paperwork,” acknowledges Elésha M. Burford, project support specialist at Colorado Retina Associates.

Decreasing patient transitions. “Patients were doing a lot of unnecessary walking,” explains Michelle Wagner, a clinical manager at the practice. “To solve this issue, we moved the imaging equipment closer to the exam rooms, and we began checking the patients out in the exam room so they wouldn’t have to return to the reception area to wait behind other patients.”

Reducing patient wait times for testing. Staff split patients into those who needed to be dilated and those who did not, and performed optical coherence tomography (OCT) first on those patients who didn’t require dilation, Ms. Wagner says.

Adding OCTs. “Staff identified that one OCT was not enough for three doctors, so we purchased an OCT per doctor,” describes Dr. Kimura. “For those doctors who may read this and sigh at this decision, remember that you can’t grow and increase revenue unless you’re investing.”

Relocating injectables. The practice’s storage area for injectables was “way across the clinic” from the exam rooms, so staff purchased mini refrigerators to relocate the injectables closer, says Dr. Adam.

Purchasing wall organizers. “The practice bought wall organizers to store exam room supplies, such as cotton-tipped applicators, betadine, alcohol prep pads, and numbing eye drops, vs. staff opening and closing an array of drawers,” says Ms. Olvera. “It’s just all right there on the wall and within reach, which saves staff and, therefore, patients’ time.”

Building the Lean foundation

To get the program off the ground, Colorado Retina Associates implemented steps that involved personnel at every level of the practice:

Achieving staff buy-in. “Leaders can’t simply say, ‘We’re going to do something called ‘Lean,’ and a consultant will be coming in to explain how it works.’ This approach creates staff anxiety and resentment,” asserts Dr. Kimura. “You need to lay out the purpose and staff benefits.”

Amanda Folse, a lead technician with Colorado Retina Associates, says hearing an unbiased opinion from the consultant helped to get the staff on board.

“Our consultant, from FlowOne Consulting, observed staff and the doctors, ran and presented data, showed us where our inefficiencies were, and what could work,” she says.

Employing value stream mapping. The value stream map, a Lean tool, is a flow chart that displays all the critical steps in a specific process (see example below). It enables staff to identify waste by (1) counting individual staff and patient steps throughout the entire patient journey and using a stopwatch for processes and (2) identifying redundancies and inefficiencies in work when used along with a spaghetti diagram. The diagram is a visual representation of practice flow that details the walking patterns of both staff and patients, distance throughout the clinic, the exchange of materials (injectables, medication samples, etc.) and patient wait times. (Spaghetti mapping gets its name from how the diagram looks after each staff member uses a line to illustrate their personal process.)

“Value stream mapping allowed staff to identify non-value-added time, or patient wait times,” explains Ms. Burford. “From there, team members began the process of coming up with ideas to cut down on this non-value-added time.”

Using A3 problem-solving. This is a Lean tool whereby, using a template, a staff member drills down to the cause of the non-value-added time to come up with a practical idea. This template provides prompts, such as problem, target condition, current condition, and solution to trial, for the staff member to consider.

“A3 gives the staff member the opportunity to think through the non-value-added time from all aspects, so she can come up with what she feels makes the most sense, solution-wise, while also being able to back the idea up to the team captain,” explains Ms. Wagner.

Holding idea trials. Once A3-problem solving is brought to the team captain, the team trials one or more ideas. “The idea could be something as simple as, ‘We are having a communication problem in the research department, and we think that walkie talkies could solve that problem,’” notes Ms. Olvera.

“Not all of the idea trials work, which is OK, and we’ll revisit the issue,” says Ms. Burford. “But for those that do, it’s fantastic.”

‘We’ve done it!’

Ms. Folse notes she was at an ophthalmology conference last year when she overheard someone say, “There’s just no way that patients can be seen in under 3 hours.”

“I just had to turn around and tell them, ‘I thought it was impossible too, but we’ve done it,’” she recalls. “Then, I told them all about Lean and how it provides this retrospective view of things staff do that they could be doing more efficiently and how the program benefited not only patients, but also the staff.” OP