Quality improvement as a discipline originated in manufacturing. The Toyota Production System, developed from the 1950s under Taiichi Ohno, gave the world lean thinking, along with a vocabulary for describing waste, variability and overburden that turns out to apply almost everywhere, including general practice. Two frameworks have since taken the strongest hold in healthcare: lean thinking, which was adapted for clinical settings most notably by Virginia Mason Medical Centre in Seattle from 2002, and the Model for Improvement, developed by Associates in Process Improvement and promoted internationally by the Institute for Healthcare Improvement. Both borrow from each other. Lean can employ a Plan-Do-Study-Act (PDSA) cycle; the Model for Improvement can incorporate lean waste-reduction concepts. In practice, they work well together.
This article focuses on lean thinking and, in particular, on one of its most practical starting exercises for a general practice team: putting on your muda glasses.
What lean thinking offers to a GP practice
Lean thinking is built on the removal of waste, or muda in Japanese, a core concept in the Toyota Production System. Waste, in this context, refers to any process that adds little value: unnecessary movement, excess stock, waiting time, errors, over-servicing, and underused people. Eliminating muda is the foundation of lean. Applied to general practice, it means redesigning the practice environment and standard processes to improve patient flow, reduce friction for the team, and ensure resources are used where they actually matter.
The principle is as much about people as it is about systems. Automation can enhance productivity, but it is people who identify problems, design solutions, and make change stick. The most important question you can ask at the start is a simple one: what is the primary bottleneck or defect you are currently facing? The answer will tell you where to look first.
Putting on your muda glasses
In lean thinking, putting on your muda glasses means deliberately looking at your practice through the lens of waste. James Womack and Daniel Jones introduced this concept in their foundational text Lean Thinking (1996). The idea is to train yourself and your team to see what is normally invisible: the processes that consume time and resources but add nothing for the patient or the business.
The most direct way to do this is to ask your team to walk around the practice with a notepad and write down what they see as wasteful processes and their proposed solutions. Give them a framework. (Dr Tony Lembke from Alstonville introduced me to this exercise decades ago, suggesting we call it putting on your Dame Edna glasses. The image has stayed with me ever since.) The eight categories of waste below provide that framework.
The eight types of waste
Lean manufacturing identifies eight types of muda. All eight are findable in most GP practices.
- Transportation: unnecessary movement of materials, paperwork or equipment.
Keep items used most frequently in consultations within reach. Emergency resources, including adrenaline with dose aids, should be accessible at the point of care.
- Inventory: holding excess materials, work in progress or finished goods.
The nurse station is often a significant store of excess inventory, much of it uninvoiced. Keep stock to a minimum and track what you hold against what leaves.
- Motion: unnecessary physical or digital movements by staff.
If you need power for an ECG, check whether the power switches are at a workable height. Clicking through too many screens in the practice management system is a waste of motion; so is walking across the practice for equipment that should be at hand.
- Waiting: delays caused by bottlenecks, slow approvals or idle equipment.
Where possible, confirm bulk billing assignment of benefits at booking, ideally online. Waiting in reception is rarely invisible to patients; it is usually visible to reception staff as well.
- Overproduction: producing goods or services before they are actually needed.
If you sell products or supplements, do not hold more stock than you need. Over-ordering creates storage problems and ties up cash.
- Overprocessing: adding more steps or more costly materials than the patient needs or is willing to pay for.
Think carefully about the dressings and vaccinations you stock. Complexity in the consumables cupboard is rarely a sign of quality; it is usually a sign of poor decisions made over time without review.
- Defects: errors, poor processes or near misses.
Every error or near miss is an opportunity to review your policies. Did you have a policy? Was it fit for purpose? Did everyone know about it? Near misses that go unreviewed become the errors of next year.
- Skills: non-utilisation of the experience and capability your team already has.
Use your whole team. Reception staff see things clinicians miss. Nurses know where the friction is. A practice owner who runs every improvement process unilaterally is wasting the majority of the intelligence available to them.
These eight categories are a starting point. Your team's observations will always generate more.
Beyond muda: mura and muri
Waste reduction alone will not sustain quality improvements. You also need to address mura (unevenness) and muri (overburden), the other two Ms in the Toyota framework.
Mura describes variability in workload or workflow that creates inconsistent quality. Mondays are routinely busy in most practices; having additional on-the-day spaces available reduces pressure on the team as a whole. Midweek is typically quieter, making it a better time to schedule health assessments with the nurse. Friday afternoons need to be set aside for patients with urgent concerns they have been putting off all week. Mapping actual demand patterns across the week lets you staff and schedule based on how work actually arrives, not the theoretical average.
Muri describes overburden: pushing staff or equipment beyond capacity. No team performs consistently well under sustained overload. People need adequate time to do their work to standard. That said, addressing muri does not mean tolerating individual underperformance; those are different problems.
Taking action with lean tools
Once you have identified where waste, unevenness and overburden sit in your practice, lean provides a systematic approach to addressing them. The 5S framework is one of the most practical tools for organising the physical workspace.
- Sort (seiri): Remove all unnecessary items from the workspace. Keep only what is essential for daily operations.
- Set in order (seiton): Arrange necessary items so they are accessible, usable and returnable. Create a designated place for everything, with labels or colour-coding where helpful. High-frequency items within arm's reach.
- Shine (seiso): Clean the workspace and all equipment thoroughly. Use cleaning as an inspection: leaks, cracks and malfunctions are easier to catch when you are looking closely.
- Standardise (seiketsu): Create consistent procedures and visual checklists to maintain the first three steps. Document best practices so that every team member completes the same task consistently, reducing defects and variation.
- Sustain (shitsuke): Build a culture of discipline so that practices hold over time. Train new staff during induction and embed the framework into daily work, not an occasional project.
Alongside 5S, kaizen, the principle of continuous improvement, encourages frontline staff to make small, incremental changes to process workflows on an ongoing basis. The most effective lean practices treat improvement as part of daily work rather than a periodic initiative.
Start with the question: what is the primary bottleneck or defect you are currently facing? The answer will tell you where to look first, which waste categories are most relevant, and which tools to pick up.
Acknowledgement: Dr Tony Lembke from Alstonville introduced me to muda glasses decades ago.