“Lean” Improvement in the Quality of Patient Care in the Hospital Admissions Process

August 27, 2018
Patricia Bonachela Solás, BSc

José Bernabéu Wittel, MD

M. Nieves Romero Rodríguez, MD

Antonio Castro Torres, MD

Diego Núñez García, MD

The American Journal of Accountable Care, September 2018, Volume 6, Issue 3

The objective of this work is to improve the quality of patient care in the admission office service of the University Hospital Virgen del Rocío (HUVR) by standardizing and systematizing its procedures using Lean methodology. The results have allowed HUVR to achieve continuous improvement in the process, eliminating the elements that do not add value.


Objectives: Among the most important challenges that a healthcare system faces are money flow and the quality of the care provided to patients. Lean methodology (LM), as a management method in healthcare, has helped to improve the delivery of care and service to patients. In our hospital, the admission services were decentralized, heterogeneous, and perceived by patients and clinical staff as inadequate, which had an impact on patient care. Our objective was to enhance the quality of patient care by improving the admissions office service.

Study Design: The University Hospital Virgen del Rocío is a tertiary hospital with a reference population of about 554,097. Four admissions offices work independently to manage hospital/inpatient admissions, emergencies, surgery, and outpatient appointments.

Methods: To unify the admissions processes and systematize and standardize these procedures, LM was applied.

Results: Communication problems with patients and among staff groups involved in patient care were identified, and solutions were found and implemented. Patient pathways have been improved, with a resultant positive effect on patient perceptions of quality.

Conclusions: With the utilization of LM, the admissions services have put ongoing rapid improvements of the admissions process into place, eliminating elements that do not add value. Among the limitations found during this project were that some staff members had limited experience in LM and the time assigned to follow-up tasks was scarce. Thanks to the use of LM, it has been possible to achieve standardization and homogenization of the admission services’ processes, improving the quality of assistance provided to patients.

Am J Accountable Care. 2018;9(3):e1-e7In the last several decades, the concept of improved management has been introduced among healthcare providers, specifically to optimize the use of available resources and improve patient care. Although much progress has been made, it is still uncertain if this progress has had the expected impact on care provided to patients (ie, if the achievements or improvements should have been more significant).1

Currently, the public healthcare system in our region of Spain, the Andalusian Health Service, faces important challenges, including among others a continuous increase in demand, an aging population, and a shortage of resources. New management strategies are therefore required to improve efficiency, optimize resources, and improve quality of care.2

There is increased interest in the creation of effective healthcare teams trained in patient safety methods and involving patients.3 Lean methodology (LM) has gained popularity in the area of healthcare management as a way to improve patient care and efficiency by eliminating elements that do not add value.4

The Lean model is based on the Toyota Production System (TPS). At Toyota, the Japanese automobile manufacturer, car production was developed in accordance with the Lean manufacturing system instead of using the traditional method based on mass production. Taiichi Ohno, the engineer who pioneered TPS, characterized the key aims of the Lean system through 2 main principles: continuous improvements, such as improving efficiency by eliminating or reducing waste, and respect toward employees.5 The main purposes of TPS were to reduce the cost of the process and increase productivity, eliminating activities that do not provide any additional value to the product. TPS as an innovation in manufacturing management appeared as a response to both the lack of available resources and the financial pressures in Japan’s post—World War II economy in the 1950s. These factors, plus the fact that Toyota had overproduced vehicles that were sitting unsold, placed Toyota in a precarious financial situation.

Toyota’s initial approach to improve efficiency was based on the introduction of teams that were charged with finding the best ways to operate various aspects of production. These teams, the predecessors of quality circles and Kazen teams (continuous improvement), focused on working in small sets of people to develop a new system. This new system consisted of coordinating the flow of materials or parts so that each of them could be manufactured only if they were necessary in the next step of the chain. That system was called the pull system, or “just in time.” The key tool developed by Ohno was the Kanban (information card), which represented the link of the whole new system of production.6

Gradually, the concepts of TPS expanded beyond Toyota and became standard for production and management in the manufacturing industry. TPS combined the benefits of small sets of production, manufacturing according to customers’ orders, continuous upgrading of quality in both product and procedures, and economies of scale in manufacturing and sales.

TPS allows for continuous improvement in product quality and a dynamic production, management, and organization system. When the Lean system began to revolutionize auto manufacturing, interest worldwide intensified in the philosophy and concept of Lean manufacturing, due to its superiority in terms of quality measures, flexibility, and rapid responses.7 Today, extensive literature documents the success of the implementation of Lean techniques.8-10

After Lean philosophy succeeded in helping the manufacturing industry, it expanded into the service sector, including healthcare. Although substantial differences undeniably existed between the manufacturing industry and the provision of healthcare, the creators of Lean supported2 its use in healthcare systems, noting that the first step of implementation would be to place the patient first and to always consider patient comfort and care time as the keys to the system’s success.11

Appreciation of the Lean philosophy’s implementation in healthcare is growing substantially.12-22 Lean healthcare, as it is known, benefits healthcare in 4 major areas: improvements in safety and in quality, better clinical services, better efficiency, and impulse for continuous improvement. Along with any of those comes another significant benefit: elevating the morale of the staff.

Two additional advantages that come from implementing LM in healthcare are, first, that it helps to identify problems in the system and turn them into opportunities for improvement, and second, that it helps to demonstrate the causes of those systematic problems.2


Patient care is the result of the interaction of multiple clinical and nonclinical teams and systems; those teams and systems are responsible for both direct patient care and administrative services or procedures. The initial aim of our job for this ongoing project was to improve the services provided by the admissions team to our patients in the centers that form the University Hospital Virgen del Rocío (HUVR): General Hospital (HG), Traumatology and Rehabilitation Hospital (HRT), Women’s Hospital (HM), and Children’s Hospital (HI).

To achieve that goal, it was necessary to identify potential communication problems, track patients’ movements and pathways in the hospital, and define a unified admissions procedure to standardize the activities done in the 4 admissions offices.


HUVR is a tertiary-level hospital with a population of reference that rises up to 554,097 patients. It has 4 admissions points, 1 in each module of the hospital: HM, HI, HG, and HRT.

The admissions office at HUVR handles the administrative workload from elective hospitalization, surgery, emergency, and outpatient services. Different admission procedures were in place for each of these admissions offices, which operate independently.

To achieve the proposed objectives, LM was applied, using the following tools:

  • A3. A3 is the name of a structured problem-solving and continuous improvement tool, used by Lean practitioners for a simple, systematic, and structured approach to problem solving. A3 is deemed very powerful in improving processes because it helps to identify, define, and tackle potential problems in a simple and visual way.
  • Modeling. The modeling process known as value stream maps (VSMs) helps visualize the whole process from the patient’s admission to their discharge.
  • Standardization of procedures. This helped give complete and clear instructions and to organize different methods of working. By using standardization during the process, it was possible to create value flow maps of the current and future stages.

The use of A3 detected the problems in the admissions process, identified an action plan, and tracked the actions of any professional involved in the process, all in a simple, easy-to-comprehend, and easy-to-visualize way. Moreover, using standardization during the process made it possible to create the current VSM and design the future VSM.

Work was divided into 6 distinct phases.

Phase 1: Creation of a working team. The profiles of the key professionals involved in the admission processes that were going to be studied and analyzed were identified.

A multidisciplinary team of relevant professionals representing all the different roles involved in the admissions process and specially committed to this project was formed. The team included:

  • The deputy medical and management director from HRT, and the deputy medical director from HI, as coordinators and suppliers with resources to facilitate the change.
  • An admissions medical professional.
  • The hospital Lean Leader (LL), an engineer who works in the hospital, because she is a referee concerning the techniques of LM in organization matters, as coordinator and manager of the tasks carried out.
  • Other staff, including administration officers, chiefs of administrative staff, medical staff, heads of the clinical modules, nursing supervisors, and other staff who hold knowledge of the entire existing process.

Each member of this multidisciplinary team was given a specific role in the project and was able to provide a thorough and integrated view of the entire admission procedure from their own particular perspective.

Phase 2: Problem definition. This phase included the systematic search for relevant information on the admissions process, aiming to frame it within the historic and structural context of the entire organization.

Our project was initiated in response to the demand from patients and medical staff to improve the quality of the administrative services provided by the admissions office. There were 2 main objectives for this project: to provide a consistent and unified admission procedure throughout the 4 admissions offices in the hospital (HG, HI, HM, and HRT) and to unify administrative staff training and skills so that staff members could be rotated among the different admissions offices without affecting service quality.

Phase 3: identification of the value stream flows. A value flow is a map or diagram based on data collected with A3 that includes all activities and the information flow along a patient pathway. This value map includes information regarding value added and value not added to all of the activities included in the diagram.

The objective of this phase was to know and understand all value flows, and the intention was to collect information about current operational procedures and their attendant problems.

Data collection. Four observation teams were formed, 1 for each admissions office, and they initially collected data from systematic observation of all of the activities, tasks, and staff involved in the admissions process, with special attention to the sequence of events. In a later phase, meetings with the LL and the observation teams helped to structure the information and describe the current admissions models at the 4 offices.

These meetings followed the model of directed interviews, aiming to reach a consensus on future strategies or actions and to avoid areas of unclear or missed information.

Data analysis. Data collected from the meetings with the 4 teams were analyzed. The analysis allowed the identification of all actors involved in the admissions process, all activities/tasks performed, and problems and their potential solutions.

Phase 4: Creation of the value flow maps. The current VSM was done to include all activities/tasks in the admissions process and their value according to the Lean philosophy or model.

The current VSM was created by the LL based on the data collected by the 4 observation teams and the information obtained in the group meetings. It was then open to discussion among all members working in this project to correct potential mistakes and, finally, to validate the VSM.

Three VSMs of the current processes were obtained from the 4 centers. For these initial VSMs to inform the developed work, they were analyzed in depth by the LL to highlight all possible relevant information.

Phase 5: Identify and implement short-, medium-, and long-term improvements. After analyzing the current VSMs, which reflected the flow of the process in hospital admissions, we proceeded to identify several bottlenecks and possible areas for improvement in the short, medium, and long term. With this information, the project team created the future VSM, which included changes in procedures and patient pathways, and prioritized actions according to strategic impact, profitability, and feasibility.

Phase 6: outcome analysis. After implementation of the new admissions processes based on the future VSM, compliance with the new admissions process at the 4 different admissions offices was monitored and data were collected and analyzed to measure and understand the impact.

Initial monitoring (May 2016-October 2016) was done every 4 weeks to improve implementation and to detect potential communication disruptions or weaknesses in administrative staff training in the new process. Outcome data were collected and analyzed using the A3 LM tool.


Team and Patient Communication

The data collected during the initial phases of this project, the analysis of the information from the team meetings, and the study of the current VSMs demonstrated problematic communication issues. These represented potential threats to patient safety and significant impact on the services provided to both patients and healthcare professionals. Communication problems are described in Table 1.

Lack of effective communication caused the patients to walk around the center based on varying directions given by different staff members, which increased waiting times (problems with accessibility). Approaches in providing patient information that varied among admissions offices produced uncertainty in patient pathways, which was perceived negatively by both patients and healthcare staff.

Different identification procedures required patients to be identified at different steps in the same pathway, which involved repeated phone calls to admissions offices from operating theaters, wards, and other locations, causing work overload. LM made it possible to identify and register each entering patient in the same way as in the rest of the hospitals, by putting on the patient’s identification bracelet at the admission service itself and at the time of registration, an effective solution that could be rapidly implemented. After a patient provided identification at the time of initial patient contact and registration at the admissions office, a wrist band was affixed in place to complete the process.

When it came to communication among the different admissions offices, we found that information technology issues were barriers that prevented bidirectional communication among the offices.

Admissions Procedures

The analysis of admissions procedures based on the current VSMs and the development of the future VSM included the systematization and standardization of outpatient appointment and operating theater schedules. LM helped to develop new procedures and measure barriers and outcomes of its implementation.

Patient Pathways

The study of information from pathways followed by patients taken from the initial observation data demonstrated 3 different circuits or patient pathways, as shown in the eAppendix (available at ajmc.com): HRT (eAppendix Figure 1), HG (eAppendix Figure 2), and HM-HI (eAppendix Figure 3).

Similarities found in these 3 circuits served as the basis for creating a unified, standardized, and homogenous circuit, which was a main goal of this project (eAppendix Figure 4).

Project Outcomes and Follow-Up

To evaluate the outcomes of the future VSM implementation, outcome indicators were selected as described in Table 2. The results obtained from this monitoring, and the outcome measures information from May 2016 to October 2016, are shown in Table 3.

The most relevant outcomes found in our study were: improvement in service quality provided to patients, demonstrated by a reduction in waiting times; accurate patient information; circuit flexibility; patient safety, due to more consistent patient identification; and reduction in administrative services’ redundant tasks.

Information from the entire new patient admissions process was collected using the A3 tool, as shown in eAppendix Figure 5.


Implementation of LM in the healthcare management setting has been relatively scarce until recently, but the reported benefits in the literature have increased interest in it.23-33

The results and experience obtained with the use of Lean demonstrated in this admissions service project demonstrate that the tools (ie, A3) and methods (ie, VSMs, study teams, and structured team meetings) are as applicable in healthcare as they are in the manufacturing industry. Moreover, these tools can help to add value to care and services in patients’ eyes by reducing waste and waiting times.34

With the use of Lean tools and methodology, we revealed systematic problems in services provided, as well as their causes; this helped us postulate and create solutions.

We observed that a weak point of the method can be the lack of experience and formal training of the study team members in LM. Only 1 of the members of the team was well trained in this subject, and therefore, it was necessary to rely on her at all times to lead the process. To achieve the expected objectives, it was essential to implicate the whole staff, who made a great effort to understand the new philosophy in their job posts.

Some previous works on the application of LM in admission services can be found in the literature; however, previous reported experience has been focused on emergency care, hospitalization, and surgery. Our experience is the first, to our knowledge, to demonstrate the benefits of the use of Lean in the admissions service provided in a tertiary-level hospital in our environment.

There are study findings on the management of variability in admission and discharge procedures.35 The current analysis shows that LM permits multidisciplinary teamwork, providing flexibility within the team to work and plan to create the most efficient processes possible. The standardization of procedures for admissions and discharges guarantees a higher quality of patient care based on an effective, consistent admissions service. Moreover, average patient waiting time can be significantly cut; a study of a California hospital’s admissions process standardization with LM included data demonstrating that average patient waiting time was reduced from 106 to 89 minutes.36


Some limitations were found in the course of this project, including the short monitoring period to verify if the chosen models were sustainable over time, inexperience of the professionals in LM, and barriers in information technology systems that impaired communication among admissions services. However, there is ongoing recording of data from admissions, and further analysis will help to validate, improve, and report the outcomes from the admissions model proposed in this project.


Thanks to LM, it has been possible to begin achieving the successful standardization and homogenization of the work done in the HUVR admissions service. However, this is only the beginning of a continuous improvement project.


Special thanks and acknowledgments to the individuals who have been part of the different working groups: Dr Esperanza Varas Díaz, Dr Eusebio Jiménez Mesa, Dr Consolación Tagua Vega, Dr Andrés Morilla García, Dr Rosario Sánchez Quirós, Dr Manuel Pizarro García, Dr Sergia Jiménez Cardoso, Dr María Luisa García Llorente, Dr Juan Manuel Bancalero Molina, Dr Santiago Cardo Luna, Dr Luis Presa Cuesta, Dr Carmen Vidal Zambrano, and Dr José Antonio Herrera Fernández.Author Affiliations: Quality Unit (PBS) and Department of Dermatology (JB-W), Hospital Universitario Virgen del Rocío (MNRR), Seville, Spain; Hospital Universitario Virgen Macarena (ACT), Seville, Spain; Hospital San Juan Grande (DNG), Cadiz, Spain.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (PBS, JB-W, DNG); acquisition of data (PBS); analysis and interpretation of data (PBS, JB-W); drafting of the manuscript (PBS, JB-W, MNRR, ACT, DNG); critical revision of the manuscript for important intellectual content (JB-W, MNRR, ACT, DNG); provision of study materials or patients (ACT); administrative, technical, or logistic support (PBS, JB-W, MNRR, DNG); and supervision (MNRR, ACT, DNG).

Send Correspondence to: Patricia Bonachela Solás, Quality Unit, University Hospital Virgen del Rocío, Avda Manuel Siurot s/n, 41013, Seville, Spain. Email: patricia.bonachela.sspa@juntadeandalucia.es.REFERENCES

1. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU [erratum in N Engl J Med. 2007;356(25):2660. doi: 10.1056/NEJMx070020]. N Engl J Med. 2006;355(26):2725-2732. doi: 10.1056/NEJMoa061115.

2. Womack JP, Jones DT. Lean Thinking. Spanish ed. Barcelona, Spain: Gestión 2000; 2003.

3. Shortell SM, Singer SJ. Improving patient safety by taking systems seriously. JAMA. 2008;299(4):445-447. doi: 10.1001/jama.299.4.445.

4. de Mast J. Six Sigma and competitive advantage. Total Qual Manage Business Excellence. 2006;17(4):455-464. doi: 10.1080/ 14783360500528221.

5. Emiliani ML. Origins of Lean management in America. J Manage Hist. 2006;12(2):167-184. doi: 10.1108/13552520610654069.

6. Ohno T. Toyota Production System: Beyond Large-Scale Production. 1st ed. Portland, OR: Productivity Press; 1988.

7. Womack JP, Jones DT, Roos D. The Machine That Changed the World. Portland, OR: Productivity Press; 1991.

8. Yang TM, Su CT. Application of hoshin kanri for productivity improvement in a semiconductor manufacturing company. J Manuf Technol Manage. 2007;18(6):761-775. doi: 10.1108/17410380710763895.

9. Domingo R, Alvarez T, Peña MM, Calvo R. Materials flow improvement in a Lean assembly line: a case study. Assembly Autom. 2007;27(2):141-147. doi: 10.1108/01445150710733379.

10. Swank CK. The Lean service machine. Harvard Business Review website. hbr.org/2003/10/the-lean-service-machine. Published October 2003. Accessed July 2018.

11. Kollberg B, Dahlgaard JJ, Brehmer P-O. Measuring Lean initiatives in health care services: issues and findings. Int J Prod Perform Manage. 2007;56(1):7-24. doi: 10.1108/17410400710717064.

12. Martin LD, Rampersad SE, Low DKW, Reed MA. Mejoramiento de los procesos en el quirófano mediante la aplicación de la metodología Lean de Toyota. Rev Colomb Anestesiol. 2014;42(3):220-228. doi: 10.1016/j.rca.2014.02.007.

13. Aguilar-Escobar VG, Garrido-Vega P. Gestión Lean en logística de hospitales: estudio de un caso. Rev Calid Asist. 2013;29(1):42-49. doi: 10.1016/j.cali.2012.07.001.

14. Pineda Dávila S, Tinoco González J. Mejora de la eficiencia de un servicio de rehabilitación mediante metodología Lean Healthcare. Rev Calid Asist. 2015;30(4):162-165. doi: 10.1016/ j.cali.2015.03.002.

15. Gayed B, Black S, Daggy J, Munshi IA. Redesigning a joint replacement program using Lean Six Sigma in a Veterans Affairs hospital. JAMA Surg. 2013;148(11):1050-1056. doi: 10.1001/jamasurg.2013.3598.

16. Niemeijer GC, Flikweert E, Trip A, et al. The usefulness of Lean Six Sigma to the development of a clinical pathway for hip fractures. J Eval Clin Pract. 2013;19(5):909-914. doi: 10.1111 /j.1365-2753.2012.01875.x.

17. Chiodo A, Wilke R, Bakshi R, Craig A, Duwe D, Hurvitz E. Using Lean principles to manage throughput on an inpatient rehabilitation unit. Am J Phys Med Rehabil. 2012;91(11):977-983. doi: 10.1097/PHM.0b013e318269d748.

18. Deans R, Wade S. Finding a balance between value added and feeling valued: revising models of care. the human factor of implementing a quality improvement initiative using Lean methodology within the healthcare sector. Healthc Q. 2011;14(Spec No 3):58-61. doi: 10.12927/hcq.0000.22579.

19. Hawthorne HC 3rd, Masterson DJ. Lean health care. N C Med J. 2013;74(2):133-136.

20. Toussaint JS, Berry LL. The promise of Lean in health care. Mayo Clin Proc. 2013;88(1):74-82. doi: 10.1016/j.mayocp. 2012.07.025.

21. Poksinska B. The current state of Lean implementation in health care: literature review. Qual Manag Health Care. 2010;19(4):319-329. doi: 10.1097/QMH.0b013e3181fa07bb.

22. van Harten WH, Casparie TF, Fisscher OA. Methodological considerations on the assessment of the implementation of quality management systems. Health Policy. 2000;54(3):187-200. doi: 10.1016/S0168-8510(00)00110-X.

23. de Souza LB. Trends and approaches in lean healthcare. Leadersh Health Serv (Bradf Engl). 2009;22(2):121-139. doi: 10.1108 /17511870910953788.

24. Mazzocato P, Savage C, Brommels M, Aronsson H, Thor J. Lean thinking in Healthcare: a realist review of the literature. Qual Saf Health Care. 2010;19(5):376-382. doi: 10.1136/qshc. 2009.037986.

25. Poksinska B. The current state of Lean implementation in health care: literature review. Qual Manag Health Care. 2010;19(4):319-329. doi: 10.1097/QMH.0b013e3181fa07bb.

26. Loor G, Vivacqua A, Sabik JF 3rd. Process improvement in cardiac surgery: development and implementation of a reoperation for bleeding checklist. J Thorac Cardiovasc Surg. 2013;146(5):1028-1032. doi: 10.1016/j.jtcvs.2013.05.043.

27. Waits SA, Reames BN, Krell RW, et al. Development of Team Action Projects in Surgery (TAPS): a multilevel team-based approach to teaching quality improvement. J Surg Educ. 2014;71(2):166-168. doi: 10.1016/j.jsurg.2014.01.015.

28. Warner CJ, Walsh DB, Horvath AJ, et al. Lean principles optimize on-time vascular surgery operating room starts and decrease resident work hours. J Vasc Surg. 2013;58(5):1417-1422. doi: 10.1016/j.jvs.2013.05.007.

29. Hwang P, Hwang D, Hong P. Lean practices for quality results: a case illustration. Int J Health Care Qual Assur. 2014;27(8):729-741.

30. McCulloch P, Kreckler S, New S, Sheena Y, Handa A, Catchpole K. Effect of a “Lean” intervention to improve safety processes and outcomes on a surgical emergency unit. BMJ. 2010;341:c5469. doi: 10.1136/bmj.c5469.

31. Stuart R, Sweet E. A systems approach to an institutional laboratory ventilation management plan. J Chem Health Safety. 2013;20 (4):31-37. doi: 10.1016/j.jchas.2013.03.491.

32. White BA, Baron JM, Chang Y, Camargo CA Jr, Brown DFM. Applying Lean methodologies reduces emergency department laboratory turnaround times. Ann Emerg Med. 2014;64 (suppl 4):S9. Abstract 21.

33. Samuel L, Novak-Weekley S. The role of the clinical laboratory in the future of health care: Lean microbiology. 2014;52(6):1812-1817. doi: 10.1128/JCM.00099-14.

34. Lawal AK, Rotter T, Kinsman L, et al. Lean management in health care: definition, concepts, methodology and effects reported (systematic review protocol). Syst Rev. 2014;3:103. doi: 10.1186/ 2046-4053-3-103.

35. Ortiga Fontgivell B. La Dirección de Operaciones en un Hospital de Alta Tecnología: Medidas Para Incrementar la Productividad y la Eficiencia [master’s thesis]. Bellaterra, Spain: Universitat Autònoma de Barcelona; 2013.

36. California hospital streamlines admission process with Lean training. University of Tennessee Center for Executive Education.