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Eight Elements of Waste (D-O-W-N-T-I-M-E)

How to Reduce Waste

To reduce waste while improving the experience of both patients and staff, at least two phases of workflow analysis are required.

There are eight categories of inefficiencies or "waste" according to Lean methodology. (To learn more about Lean, read an overview published in Family Practice Management).

The various types of waste, as well as examples typical to the primary care setting, are outlined below.

Any repair, rework, double-checking, or scrap

  • Sending requisitions to the lab with an ICD-9 code that isn’t appropriate for that lab test.
  • Sending medications to the pharmacy that aren’t covered by insurance.
  • Ordering referrals for specialists before required imaging has been performed.

Producing more product or service than is needed, or faster than is needed

  • Preparing next week’s charts today when 25% of patients may cancel and 25% of patients have yet to be added to the schedule.
  • Stocking patient handouts that are never given to the patient.

Idle time of people, machines, or information

  • Patients waiting in the waiting room or the exam room.
  • Providers waiting for their patient to be set up.
  • Nurses waiting outside an exam room for information from a provider.

Non-utilized people 
Not using staff to the greatest potential

  • Nurses taking vital signs only.
  • Clinicians faxing paperwork.
  • Pharmacists not engaging with patients.

Unnecessary movement of materials or patients

  • Transporting paper inpatient records to a central location to be scanned into the computer.
  • Printing patient records and faxing them so the specialist can scan them into the chart.
  • Sending patients first to the pharmacy to pick up their glucometers then back to the clinic to learn how to use them.

Supplies in excess of customer requirements

  • Ordering too many bottles of lidocaine so they expire.
  • Ordering too many vaccinations so they expire.
  • Ordering so many wrist braces that it’s impossible to find the right size.

Extra staff motion (travel or searching)

  • Providers leaving the exam room to find speculums, drapes, or other supplies.
  • Nurses walking across the clinic to chart their notes in the EHR.

Extra processing 
Redundant or unnecessary processing

  • Providers free-texting labs that were ordered when the EHR places that information on every note.
  • Choosing an ICD-9 code for a lab, then choosing it again for a referral written in the same progress note.

These examples were prepared by Qualis Health as part of our work as the Washington & Idaho Regional Extension Center, under grant #90RC0033/01 from the Office of the National Coordinator for Health Information Technology, Department of Health and Human Services. 2011