I work in a general practice based in Dundee. When I started, we had a high rate of missed appointments and a high level of demand for urgent care. If we had a full day of booked appointments and a significant number of patients turned up without appointments, we would need to move appointments in order to increase our capacity for those needing urgent treatment. Much time and effort would then be spent trying to rebook patients into clinics which were already busy.

This was inconvenient for patients and unsustainable for our practice. We needed a better system.

We decided to take a look at the Lean management approach which focuses on how to deliver better value for the customer, or in this case, patient. The first principle of Lean states:

specify value from the viewpoint of the end-customer

The Lean approach measures every activity against how it is delivering value from the customer’s perspective, as a way of eliminating waste and instilling a culture of continuous improvement.

What our patients needed was high quality, timely care, regardless of whether they were urgent or booked. How could we adapt the way we were operating to better meet this requirement?

What does ‘value’ mean to patients?

The first thing we needed to understand was what “value” meant from the perspective of our patients. Analysing the data we had on attendance patterns helped us to do this. We were able to create a rich and detailed picture of the types of care our patients needed and when they needed it.

We could see, for example, that demand for urgent care was highest on Mondays and Fridays. This type of insight enabled us to reorganise ourselves as a team. We matched the number and type of clinicians to best meet the likely demand of that particular day. This helped to standardise workload for clinicians working on different days.

A Lean toolkit for healthcare providers

During our learning journey we identified tools for managing both urgent and longer term care demand. Most of these can be implemented by using an organisation’s existing resources more efficiently.

• Data analysis. Our practice activity data was invaluable. This gave us visibility about which types of care our patients needed and, crucially, when they needed it.
• Two-way communication system for bookings. While it takes some investment and effort to put this in place, having effective two-way communication with patients empowers them and can reduce time lost to missed appointments. A health care provider must have a robust notification system and up to date patient contact details in order to enable effective two-way communication with patients. When a patient is due to be seen, the booking team needs to be alerted so that they can offer the patient an appointment, usually two weeks in advance. Patients can then choose to accept the appointment or advise if they need to change it.
• Buffer slots. A buffer slot is a designated clinic appointment or slot that is kept free, allowing an unplanned arrival to be conveniently slotted in without disrupting the schedule. A clinic may have more than one buffer slot spread over a session and patients are not necessarily seen during this time.
• Hybrid approach. In our practice, we use a hybrid system that includes a mix of First In First Out (FIFO) and booked appointments. As a general rule, if over ten percent of the workload is identified as unplanned, then mixing unplanned and planned work is not practical. In such cases, one option is to create a separate work stream for unplanned work. That work stream can be located in a different area or provided by a different team. If that is not possible, another strategy is to set aside a block of time at the end of the designated clinic to see patients without booked appointments on a FIFO basis.

Getting the balance of appointments is challenging. A data-driven overview of attendance patterns can help with making informed decisions about how best to align the number and types of clinicians to the pattern of demand.

Learning and improving in a post-pandemic world

Lean is proving to be a powerful methodology we can use to continually review our processes and activities to see what is working well for patients, and where we can innovate.

While COVID-19 introduced unprecedented challenges in the health care system, our practice has used this as an opportunity to revisit what value means for our patients – such as new ways to make appointments more accessible and convenient.

By aligning ourselves to a single purpose – providing high quality, timely care for our patients – we have become a more resilient, focused, and flexible organisation equipped to respond to a changing and uncertain world.