Using Lean processes to improve patient satisfaction, quality of care and patient cycle time at the University of New Mexico Hospital’s neurosurgery outpatient clinic by developing a standardized process that provides a continuous flow of information throughout each patient visit

Muller, Elizabeth

Ramierz, Pedro

Stippler, Martina

English

University of New Mexico

10 University of New Mexico
Lean Process to improve Quality of service in neurosurgery clinic
objective
Using Lean processes to improve patient satisfaction, 
quality of care and patient cycle time at the 
University of New Mexico Hospital’s neurosurgery 
outpatient clinic by developing a standardized process 
that provides a continuous flow of information 
throughout each patient visit. 
Background 
Lean management is a philosophy derived from the 
Toyota Production System that has been shown to 
make companies more efficient for decades. It has 
more recently been adapted to healthcare where it 
has been shown to be effective in improving patient 
care while lowering healthcare costs. The goal of 
Lean is to increase efficiency, decrease waste, and use 
empirical methods to differentiate value added and 
non-value activity. Value added activity is considered 
when an action occurs that is of value in the eyes of 
the customer or patient. Non-value added activity 
includes all the steps done that do not add value to 
the customer or patient. 
At the University of New Mexico neurosurgery 
clinic, department leadership partnered up with the 
Lobo Quality Improvement Process department and 
established a core working group of representative 
faculty and staff to address inefficiencies in the clinic 
process The team used Lean principles to look at clinic 
processes with the goal of implementing department-
wide changes resulting in better patient care, 
increased productivity and capability, and improved 
patient and staff satisfaction.  
Methods 
A work group was created that included attending 
physicians, nurses, medical assistants, residents, 
and the Lobo Quality Improvement Process Team. 
This group used Lean’s structured, methodical, 
and systematic approach to capture the baseline 
state of operations in the neurosurgery clinic. Over 
four sessions this group analyzed the baseline data 
they collected and identified problems in patient 
scheduling, patient flow, and discharge. After 
identifying areas for improvement, interventions 
were taken to address the following issues between 
August and October 2012:
Scheduling of patient visit
•	 Created a referral scheduling check list to reduce 
errors in scheduling and avoid missing information.
•	 Identified areas for improved performance of 
medical assistance during scheduling process to 
decrease scheduling errors and the need of post 
–scheduling check of charts.
•	 Created a communication system between 
attending and clinic nurses for add-ons to schedule 
from PALS calls to reduce the number of walk-ins 
to our clinic.
•	 Reviewed schedules one-week prior to visit 
to allow for necessary rescheduling and/or 
completion of diagnostic studies if needed.
•	 Finalized schedules only after talking “live” to 
patient or caregiver.
•	 Scheduled post-op appointments in advance and 
organized a systematic communication system for 
hospital discharges to reduce double booking of 
patients.
Patient flow 
•	 Improve check-in time and triage processes.
•	 Reduce in room wait time by decreasing 
unnecessary clinical information from the referral  
and limiting the number of patients seen by 
a resident prior to presenting to an attending 
physician.
•	 Computers in examining rooms logged into 
intranet at all times, with imaging access to be 
reviewed with patient in their room.
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Journal of Quality improvement in healthcare  11
•	 Added clinic for nurse practitioners to see 
identified post-op patients and ED referrals.
•	 Created a system for early/late clinic arrivals in 
order to continue flow of schedule and still be able 
to provide timely services to these patients.
•	 Made all forms used by providers (i.e. consent 
forms) during patient visits easily accessible.
•	 Timely review of records and patients by residents 
and between residents and attending physicians.
Discharge process
•	 Started in room discharge to decrease waiting at 
front desk, have medical assistants available on the 
clinic floor, and have other staff helping out with 
discharge processes.
results
Patient complaints were reduced significantly to only 
1 complaint in September from an average of >5.
Additionally, there are preliminary results of clinic 
surveys suggesting improved employee satisfaction.
figure 1: Neurosurgery patient cycle time showing the areas of time reduction during patient visits
figure 2: Waiting time after triage, demonstrate the time reduction during the resident portion of the visit
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12 University of New Mexico
figure 3: pals walk-ins without prior notification to staff, showing the effectiveness of 
communication between the attendings and the clinic staff.
figure 4: Number of overbooked appointments show the reduction of the overbooking of the clinics, 
this was reduced by adding time blocks to the nurse practitioners to evaluate patients.
figure 5: referral file check with up to 98% of files with no errors, this allowed us to eliminate the 
need of file checks and freed an extra person for clinical activities. 
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Journal of Quality improvement in healthcare  13
summary of results 
With Lean processes we were able to reduce patient 
wait time by 30% (15 min/visit total) (Figures 1 and 
2) , reduce the number of patients arriving to clinic 
without any prior notification from 3 to 0 (Figure 
3), reduce physician overbooking rate to an average 
of <2 patients per day compared to an average 
>6 per day prior to our intervention (Figure 4), and 
reduce the number of times patient’s were missing 
documentation in referral files by implementation of a 
referral file check list (Figure 5). 
A reduction in patient complaints and improved 
staff morale were seen in by tracking the number of 
patient complaints and in preliminary analysis of staff 
surveys (MA, nurses and providers). 
discussion 
Lean processes have been shown to be effective in 
health care delivery through identifying and reducing 
non-value added activities. Here at the University of 
New Mexico, the Department of Neurosurgery was 
able to utilize the Lobo Quality Improvement Process 
Department to effectively identify areas of non-value 
added activity leading to decreased patient and 
staff satisfaction and higher costs. Areas of change 
were identified by looking at all steps in the process 
of caring for ambulatory patients: the scheduling 
of patients, the patient flow while in clinic and the 
discharge process of patients. 
This lean project has helped decrease non-value 
added activity, and has increased communications 
across the neurosurgery department and ultimately 
improved the morale of the clinic team that led to 
the success of the project. This was achieved at no 
extra cost to the department. We continue to make 
improvements by adhering to the Lean principles 
of regular documentation and benchmarks while 
tweaking the processes on a quarterly basis. 
Conclusions 
The department of Neurosurgery conducted a Lean 
project in an effort to improve patient wait time and 
satisfaction by developing a standardized process 
through Lean processes. Through targeted changes 
supported by analysis of activities in scheduling, 
patient flow and patient discharge, the neurosurgery 
clinic can now focus on meeting the needs of patients 
resulting in improved patient care, improved patient 
and employee satisfaction, an increase in produc-
tivity and capability, and potential better financial 
performance. Our Lean project is now being used as 
a model for other medical clinics within the University. 
The ambulatory quality metrics of the initiative have 
shown improved value to the patient, and are being 
monitored and sustained.
PeDRO RaMiRez, MD, eLizabetH MULLeR, RN aND 
MaRtiNa stiPPLeR, MD
Department of Neurosurgery,  
University of New Mexico
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Lean Process to Improve Quality of Service in Neurosurgery Clinic

https://digitalrepository.unm.edu/cgi/viewcontent.cgi?article=1006&amp;context=cir_jqih

Lean Process to Improve Quality of Service in Neurosurgery Clinic

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