Featured Articles: Quality Improvement

“Lean” and Waste Reduction in Primary Care

Monday, September 14, 2015   (1 Comments)
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Brian Boyette, President of Avior Group

Judy Stewart and Mike Testa, RiverStone Health


Editor’s note: These authors will be presenting at our Fall Primary Care Conference in October.


You may have had some exposure to using the principles of Lean and/or Six Sigma to improve processes, and you might have experienced some benefits as a result. If you do not know about “Lean” in particular, let’s explore some principles: How can it help you with your processes? How can it increase your ability to adapt to the rapid changes and regulatory demands you face every year.



With respect to process improvement, Lean has been defined many ways. Below is our simplified version. The idea is to maximize customer (External/Internal) value while minimizing “Waste.” Lean simply means creating more value for customers and reducing or removing factors that do not add value while continuously striving for perfection. When you start a project to eliminate waste, it is important to gather data about the current state so you can measure your success and sustain its benefits.


What is “Waste” from a Lean perspective?

We capture the eight elements of waste with this acronym: TIMWOODI.



How does this impact primary care health centers or any other organization? Consider examples of each type of waste.


Transportation waste

 Having to move patients from one location to another to perform a specific procedure because equipment is not available in the original room is a perfect example. This waste results in staff having to clean and prep two rooms instead of one. Another example is having a chest pain patient present for care at a primary care location instead of the ED.  Now the facility has to prepare the patient for transport to the ED.  The time wasted might negatively impact the patient’s health outcomes.


Inventory waste

An example of inventory waste is storing enough supplies in an exam room to last a year. The varying expiration dates and/or variation of products in each room can result in  time wasted trying to find and manage the supplies and increase costs for discarding expired items or cash necessary to purchase them upfront.


Motion waste

An example of wasted motion is staff moving from one area to another to use a printer, computer, or fax machine. Try to minimize the motion by moving equipment closer to where most of the work is being done. And we have all experienced the wasted time at a restaurant, waiting for the bill. Typically you have to request the bill from the server, they bring it to you, walk away, come back to retrieve it, and then process it and return it. Once you leave they pick it up and then enter the tip amount. This process involves significant valueless motion. You might have seen some restaurants using a mobile device to decrease this motion or some Chili’s restaurants using a kiosk to reduce some of the motion.


Waiting waste

In healthcare we build waiting rooms because we are not ready for the patients upon their arrival. In a true Lean world there would be no waiting, but we know that is not completely feasible. Think about how many times you order additional tests and wait for the results, keep the people in the room, or put the room on hold until the test results are back, or you get approval before taking the next steps in a process. Using Lean, we map out processes and capture all of the waiting for patients, providers, or staff and look for ways to reduce waiting waste.


Overproduction waste

Have you ever filled out a form in triplicate and filed two of the copies and wondered where the third one went? Or documented the same information in two or more computer systems? These are some examples of overproduction waste. When we over-produce we also create inventory waste such as additional paperwork or more systems to manage.


Over-Processing waste

When we ask or require someone to review work when it should have been done correctly the first time, we create over-processing waste. If systems are built to be mistake-proof, we do not need to have additional verification steps or have any system or person rework or revalidate. A good indication of over-processing is the presence of words with the letters “re” in front of them. (Of course reward and recognition are excluded.) 


Defect waste

Any procedure or process that does not meet customer expectations is considered a defect and waste. For example, if a patient is told her wait time will be 15 minutes but it becomes 30 minutes, this is a defect for our customer, the patient. A defect can also be an internal standard.  For instance, in healthcare any deviation from our Quality, Safety, Service, or Value objectives is considered a defect.


Intellect waste

Not using our human resources to their fullest capabilities is wasteful of their time and intellect. If a process can be performed by a person with the appropriate level of knowledge and licensure, we should maximize the use of that person.  Requiring that a provider document the same information in two systems or both dictate and transcribe are examples of intellect waste. This can lead to dissatisfaction and negatively impact retention.


Waste and Respect

“Waste is disrespectful of society because it wastes scarce resources … Waste is disrespectful of individuals because it asks them to do work with no value.”

            President, Toyota


“Waste is disrespectful to patients by asking them to endure processes with no value.”

                                                Denver Health


“Eliminating waste and unnecessary variation demonstrates respect and personal service excellence for our patients, guests and employees.” 

                                      Billings Clinic


Other Industries

Other industries are reducing waste to maximize their success.  For instance, both Redbox and Netflix reduced many of the eight elements of waste and consequently have survived and prospered, in contrast to Blockbuster Video, which did not.  Another example is Uber and the waste it removed from the transportation industry, including waiting, intellect, and inventory. Other companies are leveraging mobile apps to reduce waste.



We hope you have a better understanding of how waste can impact primary care. Return to your work areas and look for the eight elements of waste.  Meet with your leadership team to find ways to remove or reduce wastes and non-value-added activities so you can be the best in Quality, Safety, Service and Value.



NWRPCA welcomes and regularly publishes white papers and articles submitted by members, partners and associates with subject matter expertise. The appearance of any guest publication in our Health Center News database represents the views of the author and does not constitute endorsement by NWRPCA of the stated opinions or perspectives, nor does it suggest endorsement of the contributor's products or services.



Martha Mullins Bennett, Yakima Valley Farm Workers Clinic says...
Posted Wednesday, October 28, 2015
Hi, great article. In my Lean certification, we were offered another way to remember the 8 "deadly" wastes in healthcare as DOWNTIME. D(effects), O(verproduction), W(aiting), N(on-Utilized Resources), T(ransportation/Motion), I(nventory), M(issing Information), and E(xtra-Processing).

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