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Quality Improvement and Leadership Capacity Development Through Lean Methodology
Lisa M. Nicolaou, RN, MSNI

Quality Improvement and Leadership Capacity Development Through Lean Methodology

Lisa M. Nicolaou, RN, MSNI
“Lean” methodology creates quality improvement and leadership capacity, which is currently missing in ambulatory care settings. Failure to create this capacity will minimize transformation efforts.

Objectives: Implementing “Lean” methodology as a way to build requisite skills, enhance collaboration, and eliminate complicated work patterns for positive outcomes (eg, lowered costs, improved patient wait times).

Study Design: Case-control study.

Methods: A Lean learning project, facilitated by a locally sourced Lean learning organization, is documented at an autonomous internal medicine practice with the goal of improving patient wait times throughout the practice. Lean learning principles are modified to accommodate ambulatory care settings. Barriers to physician and practice involvement are minimized to encourage physician and practice engagement.

Results: Initial quantitative results showed improvement in patient flow through the practice and time/cost savings that will continue to accumulate over time. Qualitative results show greater change management skill and capacity, as well as awareness and appreciation of team members and collaborative work in this ambulatory care setting.

Conclusions: The increase in change management skill and capacity is critical to the success of transformation efforts in ambulatory care and finding ways to reduce barriers to direct physician involvement and physician practice involvement must remain high priority.
Transforming healthcare is a favorite topic in newspapers and professional journals, with the promise of reformed care delivery methods, improved quality, and patient satisfaction, while reducing overall costs.1 Achieving this Triple Aim in healthcare is essential to ensuring the long-term health of our population and the stability of the economy.2 There is consensus that the patient-centered medical home (PCMH) model of care holds the greatest potential as a road map for the transformation of clinical care; however, implementation of the PCMH model requires significant change to care delivery structure, culture, payment models, and traditional leadership. Ambulatory care settings currently incentivized to advance the PCMH model lack significant leadership and quality improvement (QI) capacity.3 Incentivizing practices to move forward with transformative efforts without prerequisite skills to manage change effectively is counterproductive and may be the reason more significant success has yet to be achieved. Extending the PCMH model into a robust and cooperative patient-centered medical community (PCMC) is the vision that must be achieved in order for sustainable and meaningful transformation to occur.

Impeding adoption of the PCMH model are complicated work patterns developed over years in response to extrinsic demands by the system, patients, and payers, as well as a lack of methodology to effectively manage change. Elimination of these complicated work patterns is a critical first step, and cannot be done without investing in change management, leadership, and QI skill development in autonomous ambulatory practices. These skills, robustly developed, render organizations capable of enduring transformation, rather than simply making brief problem-oriented adjustments. “Lean” methodology is a way to build requisite skills and eliminate complicated work patterns in a single initiative.

Northern Physicians Organization (NPO), in Traverse City, Michigan, believes that investment in the development of Lean thinking in autonomous practice settings is of prime importance to realizing the goals of transformation and quality care for patients. NPO is a physician-led provider organization representing over 500 physicians in northern Michigan, assisting practices of all sizes in the move from fee-for-service to fee-for-value. NPO believes the practices it represents are well suited to Lean methodology for QI, as Lean builds leadership and improvement skills in the individuals who perform the work through the entire vertical structure of the organization. NPO, in partnership with the Northwestern Michigan College (NMC) Training Services Department, is bringing Lean thinking to ambulatory office practices, and one project case study is described in this paper.

Case Study

Thirlby Clinic is a 9-physician adult internal medicine practice in Traverse City, Michigan, which opted to pursue a Lean learning initiative at the encouragement of NPO. Although Lean is gaining momentum in healthcare, according to Heather Fraizer, PhD, of the NMC Training Services Department, the majority of Lean projects are initiated within large organizations and acute care facilities. These larger initiatives become less about transferring long-term skills and more about solving specific problems by reproducing institutional solutions. Thirlby Clinic’s business manager, Louise Kilmer, has been party to large institutional and system changes in her 40-year healthcare career. She believes that employee empowerment resulting from Lean is most beneficial to businesses like hers. Deb Schepperly, the clinical quality manager, was “sold on Lean principles,” as she believed, for the first time in many years, that changing the landscape of healthcare was possible.

With a Lean project on the agenda, the practice identified a physician champion in Peter Alvarado, MD. Physician champions are critical for healthcare change demonstrations,4,5 yet they are often the most difficult element to secure. This lack of engagement is driven by many factors, including a deep sense of personal autonomy that frequently conflicts with principles of quality improvement, a culture of blame that can result if mistakes happen and priorities for quality seem at odds between the system and individual care perspectives.6 Physician support signals value and significance for the process to all team members in a powerful way. “The physician’s role is central, and the commitment and drive must come from the physician level.”4 Dr Alvarado secured consensus that practice physicians would not impede the efforts of the team, despite varying levels of physician enthusiasm and readiness to participate. Leading by example and assisting the practice to implement change systematically and incrementally was Dr Alvarado’s strategy to allow Lean to spread through the practice culture.


A 10-person multidisciplinary team—formed with representation from physician, administrative, clerical, clinical, billing, and laboratory staff—was tasked with the broad goal of improving patient flow through the practice. This goal allowed the team to determine problems using Lean methodology, which, in turn, helped them to avoid anchoring to preexisting conceptualizations of problems and their origins.

With project roles, scope, and purpose clarified through a project charter, the team proceeded to an introductory simulation of how Lean could impact a different healthcare setting. The simulation brings team members together onto a “level playing field,” where individual team members’ positions or status in the practice is not important to the work they do in the simulation. Gayle Gwizdala, MD, the second participating physician, felt that this leveling effect was important for their team, as it created a true collaborative environment.

Dr Fraizer met with the team for 2-hour sessions, roughly every 2 weeks, following the simulation, accommodating shorter work periods that minimize disruption to patients and nonparticipating office staff, while remaining true to Lean principles of coaching teams where the work is performed. To analyze their current work process, the team created a value stream map (VSM) of each patient’s journey through the practice, with the task of improving patient wait times. VSM is a paper-and-pencil tool that helps teams to visualize and ultimately understand the flow of material and information as the patient moves through care (the “value stream”). The VSM takes into account not only the activity of the patient, but the management and information systems that support the process. The information gathered in this tedious but critical step represents more than just the assigning of time or collection of metrics. According to Dr Gwizdala, the mapping process results in a deep appreciation for the work of others on the team and for the rollover effect that process changes in one aspect of care have on other team members. This forging of interdisciplinary respect and team mentality was believed by both Dr Gwizdala and Ms Schepperly to be the biggest benefit to the VSM process.

Using the VSM and a multidisciplinary team, problems were identified in the process that create bottlenecks to patient flow. The team then quantitatively ranked these problems based on the impact that change would have on the value stream and how easily the problem might be solved. The ranking approach allowed priority problems to surface that decrease the value to the customer, while de-emphasizing totally disruptive, across-the-board change; Dr Fraizer refers to this as the sweet spot of change. The quantitative approach reduced individual perceptual and emotional biases and brought the team to consensus with greater efficiency, resulting in the identification of 4 clear problems that the team could focus on improving.

Work groups formed for each identified problem to develop solutions using rapid development plans, known as Plan/Do/Study/Act (PDSA) cycles with guidance from Dr Fraizer. Constant refinement of solutions kept the impact of change minimized. During this time in healthcare, where change fatigue is a real danger, Lean returns a sense of control to physicians and staff members.


Lean thinking continues to grow at Thirlby Clinic, and results are already evident. Tangible effects, both quantitative and qualitative, are further discussed in the context of the 4 identified problems:

1. Improve Scheduling Patient Appointment Availability

The clinic was not able to achieve the 30% availability of open access appointments as part of their PCMH functions in the past. This had been an elusive goal, with physicians expressing concern that open appointments would remain open and subsequently become lost income potential. Dr Alvarado was instrumental in securing a 15-minute open same-day care (SDC) appointment for every half-day worked from each of the clinic’s 9 providers. Previous attempts by administrators to make this change failed due to a lack of true buy-in by physicians. Late morning and afternoon appointments were typically kept open, although the physicians do control where open appointments are placed based on individual needs. Electronic scheduling software that tracks appointment openings, permits easy changes, and provides quantitative feedback to team members as the process is refined.

 One problem identified almost immediately was the absence of a clear definition or shared understanding of what constituted an SDC appointment. Some believed SDC appointments were to be used for acute care visits only, and were therefore usually booked a day or 2 in advance. The team developed a clear definition of the term and disseminated this definition to the entire practice. The clinic also stopped screening calls to see if appointments were deemed as “necessary,” instead employing the now-universal operational definition that an SDC appointment accommodates the patients’ needs. “It is needed by our patients and this is what matters. We don’t judge why our patients want a same-day appointment because we don’t live in their world,” summarized Deb Schepperly. Patients were educated about the changes through signs in the waiting and exam rooms, messages on the website, closed-circuit TV messages, and recorded telephone reception messages, as well as through direct discussion with office staff. Patients were happy to see their usual provider rather than being sent to urgent care.

The clinic now offers 20% SDC appointments and estimates that 6 minutes are saved per open appointment, largely due to the elimination of administrative coordination overhead between front staff and physician or clinician. With 12 open appointments per day, this equates to 72 minutes of time saved every day that can be repurposed. With the 20% SDC process standardized, Thirlby Clinic is moving forward to eventually meet the 30% SDC requirement. Physicians have found that open appointments are rarely unused, and so it paves the way for the practice to more easily increase the fraction of open-access appointments up to 30%. The team prioritized the value of the patient’s time, thereby generating substantial time savings for the practice and increasing patient satisfaction.

2. 5S Methodology Application

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