BMJ Qual Saf 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.


  • 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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