Toward a Lean Intravitreal Injection Clinic

Embracing lean principles in your practice will increase throughput and improve efficiency.

By Dennis P. Han, MD

This article describes a whole new way of looking at your clinic process—the lean way. The lean approach can make you more productive with less effort. It has worked in many health care settings and is perfect for the delivery of intravitreal injection therapy. And patients will love you for it.


The term lean is used in manufacturing to describe a method of production founded on the elimination of wasted effort and resources. The concept has its origins in the Toyota Production System, which was designed by executives at the automotive production company and has been used in its regular practices since the 1940s. Due to its success in revolutionizing the auto industry’s efficiency, lean principles have since been implemented in other industries.


Intravitreal injections now occupy a large amount of retinal physicians’ time. Although an injection takes only moments, the whole process may include testing with optical coherence tomography (OCT), interpretation of the images, and patient counseling. Considering the amount of time patients spend in the clinic for an intravitreal injection and the ever-increasing number of them, it becomes clear that retina practices are conducive to the implementation of lean philosophy.

Why should you consider lean in your practice? Patients appreciate efficiency. They equate it with quality, and rightly so. Taking care to perform tasks without rushing and without skipping important steps reduces the risk of error. Gaining efficiency requires change: Doing things differently— not simply faster—eliminates waste in a system. The various forms of waste can remembered using the mnemonic device “WISDOM TO change” (Table).

Another key principle of lean practices is kaizen—the quest for continuous, unending improvement. To achieve this, you need a core of workers that are flexible, capable, and motivated. Having workers with all 3 attributes is ideal—and, most important, this includes the physician!


Becoming a lean practice involves a change in logistical philosophy. If you want to be as efficient as possible, consider the following steps.

Establish an Injection Clinic

Schedule patients who are to receive or be evaluated for an injection together and in a more compressed period of time. See patients with more complex needs in another part of your clinic. In an injection clinic, your staff will get into a rhythm, and that pays dividends in terms of increased throughput. Your patients will have less wait time, and more patients can be treated—creating more clinic availability in other parts of your day or week. You can still do injections at other times, if needed. This is a win-win situation for the retina specialist, staff, and patients.

Follow the Just-In-Time Principle of Lean Philosophy

One of the core principles of the Toyota Production System is the so-called Just-in-Time Principle, the goal of which is to improve return on investment through inventory reduction and elimination of carrying costs. To do this, the amount and timing of application of resources directed toward a process step are optimized. A similar pragmatic approach to patient processing can be implemented in retina clinics.

How can this be done? Move patients through your processes in parallel with each other using multifunctional rooms (ie, screening, examination, testing, and injection in the same room) and a team of staff that can provide all the steps the patient needs. In this way, patients can receive attention rather than waiting for the patients ahead of them to free up resources. In the conventional clinic model, patients move sequentially in a preset order in series between rooms designated for a single purpose that is carried out by a specific staff member. This is a process in which both walking and wait states are built into the system— wasting time for both staff and patients, and wasting space because of the need for multiple stations and a larger waiting area (Figure 1).

Level the Workload Across Your Team

Idle staff and patient bottlenecks are sure signs of an uneven workload. If you find a few workers whose time commitments to the process are larger than others’, try to redistribute the workload among the team or concentrate on making their tasks more efficient. Technicians who can be flexible to do what is needed when it is needed can help balance the workload and keep the clinic’s operation humming. It should not be forgotten, though, that the physician is part of the same team, and he or she must adhere to the same principles of shared responsibilities. The physician should also be flexible and allow staff to attend to what is most needed at any point in time, be it helping the physician directly or leaving him or her to get other patients ready.

Evaluate Your Attitudes

You should evaluate your attitudes on the frequency of imaging and the dilated fundus evaluation. Does each episode of imaging or dilation contribute to your patient’s eye health? These add significant variation to the process. Are they needed at each and every visit?

Avoid Linear Thinking

Every positive intervention has a negative consequence of some sort. It is the overall result that counts. For example, if you decide to move an OCT machine closer to your patients and decentralize it from other imaging equipment, it may mean that your photographer might have to walk a longer distance. But at the same time, it might mean that he or she will not have to spend time fetching the patient from a waiting room, and the change might actually save the photographer time. You need to think in multiple dimensions when evaluating a change to lean practices. Negative aspects can often be managed, so do not let the naysayer in you or any of your staff members discourage you from trying something different.

Engage Your Staff to Experiment With Your Processes One Step at a Time

Creating change requires brainstorming, a trial-and-error mentality, and, most important, a team approach with front-line workers involved from the beginning. Ideas that workers generate are ideas they are more likely to try. We estimate that about half of our improvement ideas come from front-line staff, not the physicians or clinic managers. If an idea does not work out, just backtrack and try something else. Make the process of trial and error clear to your team.


Here are some examples of what my team and I did to reduce waste in our injection clinic process. Every clinic is different, so not all of these ideas might work for you. You will have your own unique solutions, too.

We keep all supplies immediately available, well stocked, and neatly organized in a standard, uniform arrangement so they can be found whenever they are needed. This is 1 of the easiest ways to experience quick gains.

We created space in the examination pod, into which we moved our OCT device, shortening the walking time of staff and patients.

Walking and waiting were reduced by having the patient brought directly from one activity to another without use of a waiting room (Figure 2). For example, a receptionist can bring patients directly from the registration desk to a screening or OCT room, and patients are moved directly from the OCT room to the examination room and back without the need for a waiting room most of the time.

Each examination room is multifunctional. This reduced examination room requirements and produced extra space for the OCT machine.

We reduced dependency issues—the OCT could be done first, last, or any time between the technician screening and the physician examination.

We use a protocol approach to informed consent documentation. This allows us to obtain a single consent document for a series of possible injections, eliminating extra paperwork at subsequent visits.

When we implemented electronic health records (EHRs), we adapted the electronic system to our workflow, and not the other way around. We have seen no productivity losses from EHR implementation.

We designed a new instrument, the RAVI (Rapid Access Vitreal Injection) Guide, to reduce the number of physician steps in the injection procedure itself, enhancing patient comfort and freeing physician time for other valued activities.


Through implementation of lean philosophy, my practice reduced average patient waiting time between valueadded steps from 45 to 14 minutes (69% reduction) and increased capacity from 18 to 24 patients per 4 hour clinic session (33% increase). This is no small feat when you consider I work with only 3 clinic rooms, 2 technicians, a shared photographer, and 1 imaging room. I also now get top patient satisfaction scores from more than 95% of my patients.

Consider the words of the late Shigeo Shingo, a Japanese industrial engineer and a leading expert in lean manufacturing principles: “Improvement usually means doing something that we have never done before.” If you follow his example, you are likely to succeed.

Dennis P. Han, MD, is the vitreoretinal section chief and director of clinical imaging services at the Medical College of Wisconsin in Milwaukee, Wisconsin. He is an author, lecturer, and consultant on clinic efficiency and received Lean Healthcare Certification from the University of Michigan College of Engineering. He is a consultant to FlowOne LLC, a health care efficiency firm. Dr. Han may be reached at


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About New Retina MD

New Retina MD delivers cutting-edge content to retina specialists in their first 15 years of practice. Each issue provides fresh insight from younger physicians plus established mentors on clinical and nonclinical issues affecting ophthalmologists in the earlier stages of their careers. NRMD features surgical pearls, clinical research endeavors, practice management, medical reimbursement and policy, continuing educational requirements, financial planning, innovations, and more.