BMJ Qual Saf 21:63-69 doi:10.1136/bmjqs-2011-000173
  • Original research

Lean thinking transformation of the unsedated upper gastrointestinal endoscopy pathway improves efficiency and is associated with high levels of patient satisfaction

  1. Timothy M Trebble1
  1. 1Department of Gastroenterology and Endoscopy, Portsmouth Hospitals Trust, Portsmouth, UK
  2. 2Department of Gastroenterology, King George's Hospital, Ilford, London, UK
  1. Correspondence to Dr Timothy M Trebble, Department of Gastroenterology and Endoscopy, Portsmouth Hospitals Trust, Southwick Hill, Portsmouth PO6 3LY, UK; tim.trebble{at}
  • Accepted 2 August 2011
  • Published Online First 13 September 2011


Background Upper gastrointestinal (UGI) endoscopy is a routine healthcare procedure with a defined patient pathway. The objective of this study was to redesign this pathway for unsedated patients using lean thinking transformation to focus on patient-derived value-adding steps, remove waste and create a more efficient process. This was to form the basis of a pathway template that was transferrable to other endoscopy units.

Methods A literature search of patient expectations for UGI endoscopy identified patient-derived value. A value stream map was created of the current pathway. The minimum and maximum time per step, bottlenecks and staff–staff interactions were recorded. This information was used for service transformation using lean thinking. A patient pathway template was created and implemented into a secondary unit. Questionnaire studies were performed to assess patient satisfaction.

Results In the primary unit the patient pathway reduced from 19 to 11 steps with a reduction in the maximum lead time from 375 to 80 min following lean thinking transformation. The minimum value/lead time ratio increased from 24% to 49%. The patient pathway was redesigned as a ‘cellular’ system with minimised patient and staff travelling distances, waiting times, paperwork and handoffs. Nursing staff requirements reduced by 25%. Patient-prioritised aspects of care were emphasised with increased patient–endoscopist interaction time. The template was successfully introduced into a second unit with an overall positive patient satisfaction rating of 95%.

Conclusion Lean thinking transformation of the unsedated UGI endoscopy pathway results in reduced waiting times, reduced staffing requirements and improved patient flow and can form the basis of a pathway template which may be successfully transferred into alternative endoscopy environments with high levels of patient satisfaction.


Upper gastrointestinal (UGI) endoscopy is a commonly performed hospital procedure for investigating UGI symptoms, and is the primary modality for diagnosing cancer of the oesophagus and stomach. The procedure can be safely performed without sedation. The UGI endoscopy pathway is composed of defined, identifiable steps suggesting suitability for process redesign to improve efficiency and quality.

Lean thinking transformation is a method of process redesign that originally developed within manufacturing,1 and subsequently established itself in healthcare.2 3 It proposes that processes should be fundamentally centred on ‘value’ as defined by the customer (eg, the patient).4 Young and MClean propose that value can be considered as clinical (achieving the best outcome for the patient), operational (primarily the cost effectiveness of a service) and experiential (relating to the quality of the healthcare experience for patients, and their carers).5 The importance of understanding value from a patient's perspective is supported by the established association between addressing patient expectations and preferences of their clinical management and improved treatment compliance6–8 (that lead to improved clinical outcomes) as well as higher levels of patient satisfaction.9–12 Finally, there is evidence that improving clinical processes themselves (in addition to the outcomes) is essential to positively influencing patient's evaluation of their healthcare experience.13

Redesigning services through lean thinking transformation may offer other benefits to healthcare organisations, including economic, for example, reduced staffing requirements; increased performance in terms of patient flow and reducing administration costs; fewer complaints as a result of reduced waiting times and patient focused care; and improved engagement from staff with more efficient and appropriate use of their time and skill mix.

Lean thinking transformation is relevant to patient pathways consisting of identifiable steps between two points that can be determined as being value adding or non-value adding (‘waste’) to the patient outcome and from the patient perspective. The patient journey can be mapped for the minimum and maximum time taken for each step (known as value stream mapping), bottlenecks (rate-limiting steps which can result in delays) and handoffs (staff–staff interactions). If successful, the resulting pathway analysis and redesign is patient centred with improved patient ‘flow’, increased ‘pull’ (to reduce waiting time and inefficiency) and reduced errors (eg, ‘perfection’).14

Lean thinking transformation of healthcare pathways has been effectively performed by clinicians within the clinical environment, with published examples including cataract surgery15 and emergency hospital admissions.16 Benefits of its use have however been demonstrated across a range of different healthcare disciplines, for example, a literature review of 33 healthcare studies encompassed nine different specialities, diagnostic services and non-medical services, including nursing and pharmacy pathways,17 and reported high levels of achievement in improved efficiency and error detection rate.

Study aims and design

The aims of this study were to:

  1. Redesign the patient pathway for unsedated UGI endoscopy using lean thinking transformation and to demonstrate the efficiency and quality of the redesigned service.

  2. Develop a pathway template that was transferrable to other healthcare environments and to demonstrate if it fulfilled patient's expectations and determinants of patient satisfaction after implementation.

The steps involved in the service redesign exercise for the UGI endoscopy patient pathway using lean thinking transformation are summarised elsewhere.18


The study was undertaken in a large endoscopy unit at the Royal Haslar Hospital, Portsmouth, where more than 3000 UGI endoscopy procedures are performed per year, approximately half of which are performed unsedated. The endoscopic procedures are undertaken by trained medical or nurse endoscopists.

A review of the published literature was performed to determine patient preferences and factors influencing satisfaction (eg, value adding) with respect to the UGI endoscopy process. This identified a number of prioritised aspects of care from the patient's perspective,19–21 including: time patients spent with the endoscopist; technical skill and control of discomfort; pre-procedure explanation; manner of the nursing staff; and short waiting times. A key objective of the service redesign was therefore to improve patient–endoscopist/staff interactive factors, including discussions before and after the procedure and the time for the procedure itself (that may allow increased focus on patient preparation, thoroughness of the examination and control of discomfort).

The investigative team consisted of a consultant gastroenterologist, two junior doctors whose role was to perform data collection and draw the process map, and a member of the Trust's performance team. After a preliminary planning meeting, a ‘walk the patient's journey’ method of data collection was chosen. This has the advantage of direct observation and timing of the patient's movement as well as allowing interviews with patients and staff within the clinical environment. The start point was the admission to the endoscopy unit and the completion point was patient discharge. The individual steps of the patient's journey were used to create a value stream map (figure 1).

Figure 1

Value stream map of the current state of the upper gastrointestinal endoscopy pathway.

Current (traditional) state patient pathway

The patient pathway for the current state is described (table 1). A total number of 22 steps were identified (19 once the patient had entered the department). The total patient journey time (lead time) ranged from a minimum of 52 min to a maximum of 375 min. The variation principally reflected waiting times occurring prior to the five bottlenecks and three handoffs. Only nine steps were considered to add value and only five of these (5, 13–16) were considered to be essential on the day of the procedure, for example, providing patient information and obtaining consent could be carried out prior to the patient arriving in the department. The value adding time ranged from 24 to 90 min, giving a value/lead ratio of 24% (90/375) to 46% (24/52) (table 2). When considering only value steps essential to the day of the procedure, the value adding time reduced to a minimum of 10 min and a maximum of 22 min, giving a value/lead ratio as low as 6% (22/375).

Table 1

Current state patient journey for unsedated upper gastrointestinal endoscopy

Table 2

Efficiency improvements for the upper gastrointestinal endoscopy pathway using lean thinking transformation

Analysis of the current state value stream map revealed fundamental inefficiencies inherent to the design of the pathway, resulting in long waiting times and pressure on highly valued endoscopist–patient interaction time. This was associated with a high proportion of low value steps, bottlenecks and unnecessary paperwork and travelling within the department. The route cause of this appeared to be the use of a generic pathway for all endoscopic procedures, that is, patients and staff followed the same pathway for an unsedated UGI endoscopy as for a sedated colonoscopy, including paperwork.

Patient pathway redesign

The current state process map was re-engineered to a lean thinking system with a redesigned patient pathway through the endoscopy unit (figures 2A,B),18 increasing time spent on value adding aspects of care while reducing waste (waiting times, bottlenecks, and travelling distances). The process redesign reflected a number of organisational changes to the physical route taken by patients and staff, the location of steps and the admission and discharge (box 1).

Figure 2

Workflow diagrams of (A) current state and (B) lean endoscopy pathways. Previously published in the BMJ: Process mapping the patient journey: an introduction. TM Trebble, N Hansi, T Hydes, MA Smith, M Baker. BMJ 2010;341:C4078. Permission for publication granted by TM Trebble.

Box 1

Changes implemented in service redesign of the upper gastrointestinal endoscopy pathway

  • Reduced administration within department

    • Home consent forms, health questionnaire and information leaflets introduced

    • Dedicated paperwork designed to avoid repetition

    • Fast-track flowchart-based admission process to the department

  • Patient's route changed to a ‘cellular’ model with reduced patient and staff travelling distances

    • Removed need for recovery suite as pre-procedure observations performed in endoscopy theatre (post-procedure observations checked only as required (non-sedated procedure))

    • Discussion of results and discharge moved from the end of the process to immediately after the procedure in the procedure room or in a waiting area immediately outside

  • Patients discharged directly from the endoscopy theatre/ante-room with their report

  • Increased patient–endoscopist interaction time

    • Review of patient's medical questionnaire and indications for referral untaken by the endoscopist—prior to procedure instead of at admission by admitting nurse

    • The discussion of the results was undertaken by the endoscopist instead of the discharge nurse

The new patient pathway was piloted for 2 months and the data collection exercise was repeated (see online appendix). Re-engineering of the unsedated UGI endoscopy pathway resulted in a reduction in the number of steps from the patient entering the department to discharge from 19 to 11, the number of bottlenecks reduced from five to three and all three handoffs were eliminated. The lead time reduced to between 29 (minimum) and 80 (maximum) min with value adding times of 16 to 39 min (table 2). The removal of the need for a recovery unit from the process resulted in a 25% reduction in nursing staff requirements. The value/lead time ratio increased to between 49% and 55% as a result of increased endoscopist–patient interaction time during the pre-procedure discussion and post procedure for discussion of results and discharge (table 2).

Transferability of the pathway template and quality assessment

In order to test the transferability of the lean thinking endoscopy pathway, it was templated and implemented in a second endoscopy unit at Gosport War Memorial Hospital, Gosport, where approximately 2000 unsedated UGI endoscopy procedures are performed per year. The implemented pathway utilised the same steps, paperwork and staff numbers and followed a similar cellular design.

After a 12-month period, an assessment of the quality of care of the templated redesigned patient pathway was assessed through a formal patient questionnaire study. A validated healthcare questionnaire was used21 to assess patients' experience, satisfaction and whether the patient expectations and preferences identified had been addressed. The questionnaire was in a self-explanatory format and completed independently by patients presenting for elective day-case unsedated UGI endoscopy on randomly chosen days. Exclusion criteria included cognitive impairment and patients younger than 18 years of age only.

A total of 178 patients were selected of whom 166 agreed to complete the questionnaire, and 149 patients expressed a satisfaction score. The average age was 59 years and 63 of 149 (42%) patients had undergone an UGI endoscopy previously. Of the 148 who replied 76 of 148 (51%) were women and 72 of 148 (48%) were men. High levels of positive satisfaction were achieved overall (142 of 149, 95%), with most patients (116 of 149, 78%) being very satisfied.

High levels of satisfaction were achieved in all of the areas previously identified as being of value to patients from the literature review (table 3). Of those who replied, the majority of patients (94 of 144, 65%) were discharged within 1 h and the remainder within 2 h; 135 of 144 (94%) felt this time was just right, while the remaining 9 of 144 (6%) felt it was too long.

Table 3

Patient satisfaction scores for upper gastrointestinal endoscopy following lean transformation


This study describes the service redesign of the unsedated UGI endoscopy pathway using lean thinking transformation. This information was used to create a pathway template that was successfully introduced into an unsedated UGI endoscopy service in a second unit.

The lean thinking pathway was designed to be patient centred with respect to the aspects of care that patients considered to be of most value, principally reflecting aspects of patient interaction with the endoscopist. Lean thinking redesign of the unsedated UGI pathway resulted in improvements in patient flow and short waiting times. The lean thinking pathway increased the total patient–endoscopist interaction time, despite the time taken to discuss results being shorter when performed by the endoscopist compared with the nursing staff (ie, a maximum of 15 min compared with 30 min in the current state (pre-transformation) pathway), however this was felt to be sufficient among the majority of patients (94%). These changes also eliminated two bottlenecks (steps 9 and 22, table 1), which led to a substantial reduction in total maximum waiting times. As a result of the service redesign, the maximum lead time reduced by 79% from 375 to 80 min. In addition, the removal of the use of a recovery area for unsedated patients eliminated the need for a whole-time equivalent nurse and reduced overall nursing requirements by 25%. Reviews of the patient experience following implementation of the templated system in the new unit recorded high levels of patient satisfaction with the process and outcome.

Although undertaking studies of lean thinking service redesign can be relatively straightforward, sustained implementation of any form of service redesign can be problematic as a result of entrenched staff behaviour. First, there may be a lack of interest or resistance to change and inflexibility with respect to adapting new staff roles. However, the nature of lean thinking transformation encourages staff involvement within the process and can therefore improve engagement, as it did here. Second, the physical layout of the department can be a hindrance because the reduction of travelling times for both patients and staff are often dependant on being able to bring different areas in the patient pathway closer together, for example, developing a cellular model. This was relatively easy to achieve in this study because unsedated patients were mobile and required relatively little observation post procedure and prior to discharge; furthermore the new second unit permitted the implementation of a cellular model based on the pathway template. The only disadvantage experienced using the cellular model was that patients could share the same waiting area before and after the procedure, although in separate sections. This did not affect patient confidentiality because the health questionnaire and results of the procedure were discussed in the procedure room or staff took patients to a separate room in the event of breaking bad news.

In order to test the validity of the templated lean thinking UGI endoscopy pathway, an assessment of the patient experience was undertaken in a second unit following implementation. This second unit differed in size, physical layout and staffing. With respect to the assessment of the patient experience, it is recognised that directly assessing changes to the patient experience, for example, personal manner of the staff, skill of the endoscopist and patient levels of discomfort, can be complex and difficult to power to confirm significant improvements. The use of sequential patient surveys can be of value and may have been helpful before and after service redesign, however the aims of this part of the study were limited to confirming that a lean thinking process that had improved efficiency of the patient pathway but could also achieve high levels of patient satisfaction and address the high-value steps identified by patients themselves.

Second, it may be argued that the positive patient experience recorded in the second unit reflected the new environment. However, the positive results from the patient questionnaire principally reflected interactive factors not environmental factors. In addition the results of published patient questionnaire studies suggest that the environment of the endoscopy department is relatively unimportant compared with the endoscopist–patient interactive factors that formed the basis of this service redesign.19 The authors recognise that studies are required to review implementation of the template in other units in order to further confirm the validity of this lean thinking patient pathway. Work subsequently undertaken in a larger main unit again suggested the possible benefits of lean transformation. For example, it was found that the total endoscopy nurse travelling time per day was 176–288 min.22 This might be substantially reduced through service redesign.

In conclusion, lean thinking transformation appeared to prove successful in improving patient flow and efficiency of staff utilisation in this study. It formed the basis of a pathway template that was associated with short waiting times and high levels of patient satisfaction on implementation in a new unit. Further work is indicated in a wider variety of units, with respect to size and organisation.


  • Competing interests None.

  • Ethics approval The study was reviewed by the Portsmouth and South East Hampshire Research Ethics Committee who granted approval as a service evaluation, and for which formal ethical approval was therefore not required. The study and its results were reviewed and accepted by the Clinical Governance Committee for Portsmouth Hospitals Trust.

  • Provenance and peer review Not commissioned; externally peer reviewed.


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