title: Lean methodology improves efficiency in outpatient academic uro-oncology clinics.
abstract: OBJECTIVE
  To determine if lean methodology, an industrial engineering tool developed to optimize manufacturing efficiency, can successfully be applied to improve efficiencies and quality of care in a hospital-based high-volume uro-oncology clinic.
  
  
  METHODS
  Before the lean initiative, baseline data were collected on patient volumes, wait times, cycle times (patient arrival to discharge), nursing assessment time, patient teaching, and physician ergonomics (via spaghetti diagram). Value stream analysis and a rapid improvement event were carried out, and significant changes were made to patient check-in, work areas, and nursing face time. Follow-up data were obtained at 30, 60, and 90 days. The Student t test was used for analysis to compare performance metrics with baseline.
  
  
  RESULTS
  The median cycle time before the lean initiative was 46 minutes. This remained stable at 46 minutes at 30 days but improved to 35 minutes at 60 days and 41 minutes at 90 days. Shorter wait times allowed for increased nursing and physician face time. The average length of the physician assessment increased from 7.5 minutes at baseline to 10.6 minutes at 90 days. The average proportion of value-added time compared with the entire clinic visit increased from 30.6% at baseline to 66.3% at 90 days.
  
  
  CONCLUSIONS
  Using lean methodology, we were able to shorten the patient cycle time and the time to initial assessment as well as integrate both an initial registered nurse assessment and registered nurse teaching to each visit. Lean methodology can effectively be applied to improve efficiency and patient care in an academic outpatient uro-oncology clinic setting.
authors.affiliation: Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada. Electronic address: Sean.Skeldon@uhn.ca.
authors.forename: Sean C
authors.initials: SC
authors.lastname: Skeldon
authors.affiliation: Shared Information Management Services (SIMS), University Health Network, Toronto, Ontario, Canada.
authors.forename: Andrea
authors.initials: A
authors.lastname: Simmons
authors.affiliation: Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Karen
authors.initials: K
authors.lastname: Hersey
authors.affiliation: Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Antonio
authors.initials: A
authors.lastname: Finelli
authors.affiliation: Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Jewett
authors.affiliation: Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Alexandre R
authors.initials: AR
authors.lastname: Zlotta
authors.affiliation: Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Neil E
authors.initials: NE
authors.lastname: Fleshner
mesh_terms: D000554:Ambulatory Care Facilities / Q000458:organization & administration* / Q000592:standards*; D017598:Efficiency, Organizational; D006801:Humans; D008284:Maintenance and Engineering, Hospital / Q000379:methods*; D008495:Medical Oncology; D011787:Quality of Health Care; D013997:Time Factors; D014572:Urology