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Ciulla, Thomas A., MD, MBA*,†,‡; Tatikonda, Mohan V., PhD, MBA; ElMaraghi, Yehya A., MBA; Hussain, Rehan M., MD; Hill, Amanda L., MBA*; Clary, Julie M., MD, MBA†,‡; Hattab, Eyas, MD, MBA†,§

doi: 10.1097/IAE.0000000000001761
Original Study

Purpose: Ophthalmologists serve an increasing volume of a growing elderly population undergoing increasingly complex outpatient medical care, including extensive diagnostic testing and treatment. The resulting prolonged patient visit times (“patient flow times”) limit quality, patient and employee satisfaction, and represent waste. Lean Six Sigma process improvement was used in a vitreoretinal practice to decrease patient flow time, demonstrating that this approach can yield significant improvement in health care.

Methods: Process flow maps were created to determine the most common care pathways within clinic. Three months' visits from the electronic medical record system, which tracks patient task times at each process step in the office were collected. Care tasks and care pathways consuming the greatest time and variation were identified and modified. Follow-up analysis from 6 weeks' visits was conducted to assess improvement.

Results: Nearly all patients took one of five paths through the office. Patient flow was redesigned to reduce waiting room time by having staff members immediately start patients into one of those five paths; staffing was adjusted to address high demand tasks, and scheduling was optimized around derived predictors of patient flow times. Follow-up analysis revealed a statistically significant decline in mean patient flow time by 18% and inpatient flow time SD by 4.6%. Patient and employee satisfaction scores improved.

Conclusion: Manufacturing industry techniques, such as Lean and Six Sigma, can be used to improve patient care, minimize waste, and enhance patient and staff satisfaction in outpatient clinics.

Enhancing patient flow through clinic is a key issue in practice management, not only to maximize revenues in the face of declining reimbursements and rising expenses, but also to maximize patient satisfaction. Manufacturing industry techniques, such as Lean and Six Sigma, can improve patient care, minimize waste, and enhance satisfaction.

*Retina Service, Midwest Eye Institute, Indianapolis, Indiana;

Kelley School of Business, Indiana University, Indianapolis, Indiana;

School of Medicine, Indiana University, Indianapolis, Indiana; and

§School of Medicine, University of Louisville, Louisville, Kentucky.

Reprint requests: Thomas A. Ciulla, MD, MBA, Retina Service, Midwest Eye Institute, 200 West 103rd Street, Indianapolis, IN 46290; e-mail:

None of the authors has any financial/conflicting interests to disclose.

© 2018 by Ophthalmic Communications Society, Inc.