Continuous Flow in General Practice

how to buy Plavix Lean Thinking – Efficiency and Reliability Part Two (cf Part One)

Value and the Red Zone

Lean Thinking requires us to identify value from the customers point of view.
The Value in General Practice is the time patients spend with clinicians ‘in the red zone’, focusing on issues that are important to the patient. ‘The Red Zone’ is where improvements in health are made – partnering in decision making and improving patient and carer self management skills. Activities that do not support this ‘value stream’ are ‘muda’, and should be decreased or eliminated.

Continuous Flow

Our aim is to make the Value Stream capable of ‘continuous flow’. We can do this by eliminating bottlenecks, bringing value adding steps closer together (in terms of both physical distance and time) and by eliminating batching (stacking activities and doing them all at once)

The benefits of continuous flow are improvements in productivity (more patients seen in less time), quality(easier to spot variation) and efficiency (with optimisation of staff and resources, and reduced costs)


Interruptions to continuous flow are called constraints
Examples of constraints at the physician level include interruptions and distractions, performing tasks that could be done by others (paperwork!), waiting (for forms,results, information), waiting for patients to get into rooms.

A tally sheet can be used to measure interruptions. (cf attached from

Leveraging Constraints

The overall efficiency of a process. is determined by the ‘weakest link’. Focusing on that ‘leverage point’ can have very significant improvements in outcome. Some examples for activities to improve constraints

* Standing orders
* Simplify the work – templates for simple care, responsibilities for phone, patient flow, paper flow
* Organising staff around Key Core Processes

* Clear roles and responsibility
* Shift work within the team,
* Identify where staff are not being used to their fullest capacity/licensure
* Cross train to expand capacity and capability
* Coordination of scheduling,
* Max pack visits
* Document encounter with/between patients

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Common High Yield Constraints

The table linked below (from IHI) shows some common constraints and how you might ‘leverage’ them.

Process Mapping

A process map is a visual aid for picturing work processes which show how inputs, outputs and tasks are linked

Key Concepts

* Every process if perfectly designed to achieve the results it acheives
* 98% of problems are due to the process rather than people
* Variation is the driver of root causes of problems in a process

Process mapping is a formal task perfomed by the care team to map the way work is done. It can lead to a spotlight on problems (waste and constraints), can highlight gaps in care, can streamiline work processes, and promote deep understandin and build consensus in a team.

Process of Process Mapping

* Choose a process (time consuming, error prone and critical)
* Map the way work is currently done
* Identify gaps, waste and problem areas
* Brainstorm solutions

Simple Steps to Create a Process Map

• Use one sticky note for each step in the process
• Write down what happens in each step and who does it (and how much time it takes)
• Place arrows to illustrate the flow of the steps
• Map first, then go back and begin to review the process
• Identify missing steps and problem areas (waste)
• Brainstorm ideas to impact the problem areas identified (use the “Key Questions for Evaluating Process Steps”)
• Evaluate the ideas, then decide on one or two to start with

Asking the Right Questions: 5 “Whys”

• There is a line-up at the front counter. Why?
• Patients are all arriving at the same time. Why?
• Patients want to show up early. Why?
• Patients who show up earlier get through clinic faster. Why?
• Patients “drop-in” and don’t usually keep scheduled appointments. Why?

Change Ideas for Optimal Efficiency

• Don’t move the patient
• Increase clinician support
• Create broad work roles
• Exploit technology
• Match capacity with demand
• Prepare for the expected
• Get all the tools you need
• Organize care teams
• Communicate directly
• Start all visits on time
• Identifybottlenecks
• Do today’s work today
• Ruthlessly eliminate needless work

Further reading

Process mapping – A guide for health services staff

Understanding the Patient Journey – Process Mapping

Lean Thinking in Healthcare

Martin LA, Neumann CW, Mountford J, Bisognano M, Nolan TW. Increasing Efficiency and Enhancing Value in Health Care: Ways to Achieve Savings in Operating Costs per Year. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2009.

Dartmouth Microsystem
Greenbooks and other workbooks:
(mirrored at

Practice Improvement
Looking Lean through Muda Glasses
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