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Guide to the Phases of Lean for Clinical Redesign

Phase 1: Identify the Team
Including a representative from each part of the clinic process will ensure that all aspects of the process are addressed.

  • Directors
  • Drivers
  • Doers
  • Adaptive Reserve Explains how adaptive reserve develops, the types of issues each role faces and how these issues evolve as a physician organization goes through the Learning and Engagement Phases of clinical redesign.

Phase 2: Define a problem. What does your team want to fix?

  • Properly framing the problem aids in identifying the project objectives and the data that needs to be collected. The A3 is a single document that helps the team clearly describe the problem. Over the course of the redesign process, the A3 may need to be revised.

Phase 3: Scope the work

Creating a SIPOC (Suppliers, Inputs, Process, Outputs, Customers) is a structured way to take a high-level view of the problem you are addressing and decide the scope of that problem by identifying the:

  • Suppliers: Who provides input to the first step in the process?
  • Inputs: What things come into the first step in the process? Information provided by suppliers.
  • Process: What are the high-level steps to this process? Include clear start & stop points.
  • Outputs: What things come out of the last step in the process?
  • Customers: Who receives or benefits from the output of the process?

SIPOC template

Phase 4: Map where you are and where you want to go

  • Value Stream Mapping (VSM) is a technique that helps teams identify the waste and inefficiencies in the current state of the system of operations. The team maps out how work happens; defining the processes, people and outcomes of work (e.g., an ambulatory care visit). Measures are assigned to different aspects of the work, to help identify rework, delay time, and inaccuracies in the work flow. VSM is then used to map out the ideal future state.

Phase 5: Developing Goals & Action Plans

Goals define where you want to go (i.e., transforming the current state to the future state). Action plans organize what must be done to achieve goals. An action plan should first and foremost define a goal and the purpose of making the change. The plan should include the steps required to achieve the goal, how progress will be measured, a target date for completion, who is responsible for monitoring progress, and the status of each step (including progress and setbacks).

For the best results, members of the team should agree on the Goals & Action Plans before implementation work begins.

Phase 6: Doing the Work/Plan, Do, Check, Adjust (PDCA) Cycles

PDCA Cycles assess the status of change work initiated in your organization and provide a framework to make needed adjustments.

It is important to evaluate your Lean for Clinical Redesign work with metrics to make sure the initiated changes are producing the desired results. Examples of metrics include patient satisfaction scores, wait times, and number of patients in a registry. When the data demonstrate that a course of action is not working as anticipated, it is time to make adjustments to the process.

Building Adaptive Reserve

Change is difficult, especially in primary care. Adaptive Reserve is crucial to sustaining the capacity for change. It includes “capabilities such as strong relationship system within the practice, shared leadership, protected group reflection time and attention to the local environment” Nutting, P. et al., Annals of Family Medicine, 2009; 7:254-260. Although an organization can start the Lean for Clinical Redesign process at any stage of Adaptive Reserve, it is important to recognize the importance of augmenting communication skills and collaborative relationships. Adaptive Reserve is what will help carry your organization through the Redesign process.


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