The document summarizes a case study of a patient clinic visit process improvement project at Herrestad Clinic in Sweden. It describes the current state process which included long wait times, rework, and high process time. A future state map and implementation plan was created using lean tools to streamline the process. This included doing lab tests before visits, standardized forms, checklists for physicians, and a lab test calendar. The results were reduced process time and wait times, increased quality, and more patient visits per month. The goal of creating a less stressful workplace was achieved through cross-functional collaboration and process improvements.

1. Case Study
Herrestad Clinic
Uddevalla, Sweden
Patient Clinic Visit Process
September 2003 – April, 2004
Process Owner: Dr. Per Kjellson
Project Sponsor: Irene Svenningsson
Lean Practitioners:
Paula Braun
Peder Sjogreen
Robert Kessiakoff
John Long

2. Herrestad Patient Clinic Visit Process
Current State Map
Suppliers :
Physicians, PAT
Input: visit/need
Secretary
writes
journal
Physicians
visit
Evaluate
Test answers
Dictate
Physician
Visit prep.
Patient
exam.,
Dictate
Pigeon-hole
Prescriptions
Registering
Payment
receipt
External consult
Lab tests
Physician
signature
Current State Metrics
P/T = 21-120 min. (average: 71)
W/T =18-150 days (average: 84)
FTQ = 10%
Customer: Physicians, Patient
Healthcare board
Out put: Journal(=knowledge)
Certif. Submission, Invoice
Medi
doc
Medi
doc
Medi
doc
Suppl.work
Complete journal
Certificate
Consult
colleague
Secretary.
documents
physician
signature
Information / Medidoc
Unannounced
needs
of patient
Lab Dr. Receipt Journal
3
0-1 m
1-20 d
98%
2
5-15 m
1-10 d
98%
2
5-15 m
1-10 d
98%
3
0-15 m
14-90 d
50%
3
1-10 m
7-50 m
20%
3
10-60 m
0-15 m
98%
3
0-1 m
1-20 d
90%
1
1-3 m
0
99,5%
P/T
W/T
FTQ
P/T
W/T
FTQ
P/T
W/T
FTQ
P/T
W/T
FTQ
P/T
W/T
FTQ
P/T
W/T
FTQ
P/T
W/T
FTQ
P/T
W/T
FTQ

3. Root Cause Analysis
Waste
Identified
Root Cause Improvement
Idea / Solution
Rework Secretary rework due to unclear
dictation,
and requirement that physician proof-
read and approve before signing.
Physician often sees patient twice each
visit to review lab test results.
Journals written by physician immediately
after patient visit. Eliminate dictation, proof-
reading and hand-over for signature.
Lab tests done before physician sees patent.
Simplified invitation letters.
Motion Secretary fetches dictation tapes piling
up for typing in physician’s office.
Secretaries must find physicians to
correct dictation errors for summary
report.
Eliminate these process steps.
Inventory Dictation tapes piling up in batches for
typing. Journals waiting to be signed
Institute one-piece flow to eliminate stock of
dictation tapes.
Over-
production
Patient often sees physician before and
after lab tests.
Lab tests done before physician visit.
Waiting Patient waiting for lab tests. Lab needs test taking calendar which
enables sorting according to priorities to
decrease waiting and backlog.

4. Herrestad Patient Medical Clinic Visit Process
Future State Map
Suppliers :
Physicians, PAT
Input: visit/need
Physician
Visit prep.
Patient
exam.,
Dictate
Pigeon-hole
Prescriptions
Registering
Paym./Recipt
External
Lab consultant
Customer: Physicians, Patient
Healthcare board
Out put: Journal(=knowledge)
Certif.,Submissions,Invoice
Medidoc Medidoc
1st supplemental
work
Watch-list
2nd supplemental.
work
Watch-list
Information / Medidoc
Lab
A
B
C
D
E
F
7% 3%
Lab Dr Receipt Journal
Medidoc
Kaizen activities
A)create standard forms
B)create forms for labs
C)improve lab-equipment
D)simplify journals; checklists
E)doctors write journal
F)watch-list
3
0,5 m
1-14 d
9%
3
0,5 m
14-90 d
1%
3
11 m
0-15 m
90%
1
11m
0
99,5%
P/T
W/T
FTQ
P/T
W/T
FTQ
P/T
W/T
FTQ
P/T
W/T
FTQ
Future State Metrics :
P/T: 23 min
W/T: 15-104 days (mean 60)
FTQ = 90%

5. Data Metrics
Attribute/metric Current State
Performance
Future State Goal Actual Result
Process time
(minutes)
22-120
(average=71)
23 6 – 65
(average = 35.5)
Wait time Internal = 2-30
days (average:
16)
Total = 18-150
min
(average: 84)
Internal = 0-15 min
(average: 7.5)
Total = 15-104
days
(average: 60)
90% Internal =
1-15 min
Total 1-90 days
(average: 45)
First time
quality
10 % 90 % 90 %
Number of
process steps
5-8 2-3 3
Number of
patient visits
per month
650 750 850

6. Implementation Plan
• Standard forms
• Lab tests done before office visit
• Test-calendar for laboratories to improve planning
• Checklists for physician journal-writing
• Watch-list for external consultations
• The goal of the Project was to to create a better, less stressful workplace. The result was
more productivity, less stress and a 24 % increase in patients visits.
• Lean metrics used to measure Current State performance, set Future State goals and
give an systems view of the process.
• Cross functional workgroups doing Value Steam Mapping and Kaizen Events increased
understanding, co-operation and collaboration.
• One-piece flow reduced rework, wait time and number of process steps.
• A lab calendar leveled work load and reduced wait time for lab results.
Learnings/ Teaching