The application of a “6S Lean” initiative to improve

workflow for emergency eye examination rooms

Samir Nazarali, BHSc,* Jaspreet Rayat, MD,† Hilary Salmonson, RN,‡ Theodora Moss, BNutD,§
Pamela Mathura, MBA,§ Karim F. Damji, MD‖
ABSTRACT ● RÉSUMÉ
Background: Ophthalmology residents on call at the Royal Alexandra Hospital identified workplace disorganization and lack of
standardization in emergency eye examination rooms as an impediment to efficient patient treatment.
Objective: The aim of the study was to use the “6S Lean” model to improve workflow in eye examination rooms at the Royal
Alexandra Hospital.
Methods: With the assistance of quality improvement consultants, the “6S Lean” model was applied to the current operation of the
emergency eye clinic examination rooms. This model, considering 8 waste categories, was then used to recommend and
implement changes to the examination rooms and to workplace protocols to enhance efficiency and safety.
Results: Eye examination rooms were improved with regards to setup, organization of supplies, inventory control, and maintenance.
All targets were achieved, and the 5S audit checklist score increased by 33 points from 44 to 77.
Conclusions: Implementation of the 6S methodology is a simple approach that removes inefficiencies from the workplace. The
ophthalmology clinic removed waste from all 8 waste categories, increased audit results, mitigated patient and resident safety
risks, and ultimately redirected resident time back to patient care delivery.

Medical residents face the challenge of integrating newly
acquired knowledge with providing high-quality and safe
care to patients. Tasks that are unfamiliar or performed
under pressure can be prone to error.1 In addition, the
incidence of these errors has been demonstrated to increase
with stress, fatigue, and heavy workloads, all common
during residency training.1
At the University of Alberta, ophthalmology residents as
well as staff on call experienced work-related stress as a
result of the inefficient setup and organization of patient
examination rooms at the Royal Alexandra Hospital
(RAH) in Edmonton, Alberta. These examination rooms
are used primarily for emergency eye care and to attend to
postoperative patients. On weekends and after hours,
residents and on-call staff use these rooms to provide
emergency assessments and perform minor procedures.
There was a concern among residents and on-call staff that
examination rooms were poorly equipped, resulting in
physicians leaving patients unattended to search for
supplies. This was found to delay procedures, reduce time
spent on direct patient care, and increase resident and staff
stress. Furthermore, issues with the physical organization
of examination rooms and storage of medications have
been shown to lead to serious consequences, including
instances of misadministered medications.2 Before our
improvement initiative, there were reported incidences of
misadministered or expired medications in examination
rooms, as well as resident falls while travelling between
rooms to locate supplies.
A quality improvement consultant observed the work-
flow in the ophthalmology department and found that
residents at the University of Alberta spent approximately
45 minutes per day on call searching for supplies and
moving between examination rooms. The organization of
examination rooms lacked standardization, and residents
had to open drawers multiple times to locate relevant
supplies. Prior to our investigation, there was no regular
inventory or maintenance control for supplies.
The “6S Lean” methodology is derived from a set of
principles developed by the automotive industry to
improve quality and efficiency.3 With objectives of elim-
ination of waste, continuous improvement, and worker
empowerment, this model has transcended industries and
has successfully been implemented in the health care
setting.4–6 Waldhausen et al. used a “5S Lean” approach
to address the challenge of high-volume surgery clinics.7
After the 5S improvements, face-to-face provider–patient
time increased, the number of patients seen in clinic
increased, and satisfaction scores improved. In another
study, lean techniques used in Pittsburgh General Hospital
to modify the procedure for intravenous line insertion
were shown to result in a 90% decrease in the number of
infections. Along with patient care improvements, this
resulted in a savings of $500,000 per year in intensive care
unit costs.8
The goal of this project was to evaluate and discuss the
implementation of the 6S Lean model to our emergency
eye clinic rooms to reduce redundancies and make the

& 2017 Canadian Ophthalmological Society.

Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jcjo.2017.02.017
ISSN 0008-4182/17

CAN J OPHTHALMOL — VOL. ], NO. ], APRIL 2017 1

—Nazarali et al.
Table 1—Steps in the 6S approach
Step 1 Determining and identifying the target area
Step 2 Identifying the purpose and function of the target area
Step 3 Developing a map of the area
Step 4 Identifying people in the workplace and equipment flow
Step 5 Performing a workplace scan and dot exercise
Step 6 Photographing problem areas (before and after)
Step 7 Developing procedures, checklists, visual cues,
and an audit process
Step 8 Developing a project display board with findings
patient encounter more efficient. Our target goals were
reduction of the amount of time residents spent looking
for supplies, standardization of eye examination rooms,
and a system of inventory control.
METHODS
Our team used the 6S Lean model and Alberta Health
Services Improvement Way (AIW) to examine the existing
operational processes of the RAH eye clinic rooms.9 The
5S model, commonly used in the automotive industry,
consists of 5 words translated from Japanese: sort, set in
order, shine, standardize, and sustain.10 Our team used a
variation of this model, 6S, to include safety.11 6S is a
method used to reduce waste and optimize productivity
through maintenance of an orderly workplace and use of
visual cues to achieve more consistent operational results,
Fig. 1 — Spaghetti map illustrating resident’s movement through rooms before 6S Lean initiative.
2 CAN J OPHTHALMOL — VOL. ], NO. ], APRIL 2017
while considering safety throughout. The AIW is a quality
improvement framework that offers quality improvement
tools and incorporates management of change.
Throughout the process, education was provided to the
team and included various topics, such as 6S, red dotting,
5S audit, 8 wastes, and spaghetti mapping. Education and
engagement were encouraged through department semi-
nars, emails, and posters within the ophthalmology unit.
The RAH Ophthalmology unit has 3 rooms that are
used for eye examinations/procedures by ophthalmologists
and residents. All eye examination rooms have a similar
physical layout but vary significantly in terms of location
of equipment and supplies within each room.
Initially, 3 meetings were held between two 6S admin-
istrators, 1 senior ophthalmology resident, and the unit
manager. The steps involved in the 6S approach are
outlined in Table 1. The first meeting outlined problem
areas and inefficiencies. Next, 3 mock patient encounters
were performed, in which administrators observed and
drew a spaghetti map of the residents’ workflow through
examination rooms (Fig. 1). The mock patient encounters
included red-eye issues, viruses/ulcers, and lid lacerations.
These patient scenarios were chosen because they repre-
sent the most common examinations performed in the
rooms, with red-eye issues accounting for 80% of cases.
6S administrators reviewed the spaghetti map for
 —Nazarali et al.

Fig. 2 — Eye examination room before (A) and after (B) kaizen.

inefficiencies and placed red dots on nonutilized equip- which refers to improvement, is used to describe well-
ment that were occupying space. The improvement defined improvement efforts over a specified number
strategy that was used was “kaizen.” The term kaizen, of days.
The kaizen 6S event was held on day 1 with 2 service
Table 2—Costs of 6S initiative workers and 10 residents and was led by clinical quality
consultants and the unit manager. During the event,
Resource Costs
Applanation tonometer tips (for 10) $1560.00
1 room was changed, and the other remained unchanged
Tonometer cases, including base, lids, matting (for 10) $207.50 so that layout comparisons could be made (Fig. 2). After
Processing carrying case for prism tips $412.99 the event, the other room was changed.
Slit-lamp light bulbs $81.36
Ishihara plate colour test $267.50
Sheridan Gardiner $102.00
Exophthalmometer $450.00
Refrigerator for agar $2000.00 Costs
Glass cabinet $260.00 Costs of the initiative included project team labour
Miscellaneous items (bins for eye drops, $85.00
file holders, labels)
costs and supplies (lenses, prisms, glass cabinet, refrige-
Wall-mounted glove boxes $120.00 (for 2) rator), which amounted to $8546.35. Labour costs
Team labour (quality consultants) $3000.00 comprised fees for quality consultants and accounted for
Total $8546.35
$3000 of the $8546.35 spent on the project. Detailed

Table 3—Key findings from each phase of 6S

Sort 5S audit tool Overall score ¼ 44
Areas for improvement: correct quantities of supplies; label drawers; visual controls; keep checklists for maintenance
Red dotting Red dotting completed by the resident, unit manager, and patient care manager
Areas for improvement: remove equipment that is not required
Inventory holding Expired medications and excess supplies discarded
Areas for improvement: label drawers; control inventory
Set in order Three observers tracked movements of residents regarding excess motion and search for supplies based on 3 simulated patient encounters. The
results were summarized in the form of a spaghetti map.
Areas for improvement: reduce time spent searching for supplies; reduce excess movement within rooms; designate areas for sterile and dirty
instruments.
Waste table completed with information gathered during interviews with resident, unit manager, 5S audit, red dotting, and spaghetti mapping. Twenty-
seven areas of waste identified in all 8 waste categories.
Shine Service workers and unit manager cleaned rooms and labeled drawers.
Standardize Areas for improvement: inventory list, label drawers
Assigned staff to stock and maintain rooms
Sustain Audit checklist to be completed every 3 months and communicated to staff
Safety Areas for improvement: reduce time patients are left unattended in examination rooms; designate areas for sterile and dirty instruments

CAN J OPHTHALMOL — VOL. ], NO. ], APRIL 2017 3

—Nazarali et al.

Table 4—Key solutions from each phase of 6S RESULTS

Sort Examination rooms cleaned
Excess equipment/supplies removed
The key findings from each phase of 6S are outlined in
Set in Order Designated areas for sterile and dirty instruments Table 3. The information gathered from the 6S steps and
Labeled drawers improvement tools helped determine room arrangement,
Centralized microbiology chart
Fridge installed
labelling, equipment requirements, and staff duties. The
Medications arranged per accreditation standards key solutions implemented are highlighted in Table 4.
Open medications labelled and placed in resident
By May 2016, all targets were achieved, and the 5S
medication basket
Gloves placed on wall mounts audit checklist score increased by 33 points from 44 to 77
Shine Seminars and emails to educate physicians and residents (Fig. 3). A spaghetti map demonstrated that movements
of room layout changes
Standardize Eye examination rooms arranged in an identical manner
within the room decreased with improved organization
Service worker assigned complete inventory and stocking (Fig. 3). Following reorganization of rooms, there were no
Daily room maintenance checklist with assigned unit staff
incidents of misadministered medications or injuries.
Sustain Visual cues established
Labelled drawers Thus, reduced risk of injury and increased safety resulted,
Quarterly 5S audit completed by unit manager as patients were no longer left unattended and supplies
Safety Designated area for sharps and used instruments
Hand sanitizer stations
were organized and within reach. (Fig. 4)
Call bell signage posted

costs of the initiative, which are shown in Table 2,
were determined on the basis of the results of spaghetti
mapping and recommendations from quality consul-
tants. Costs to sustain improvements included a
service worker and assigned unit staff responsible for
stocking and daily maintenance checks of the fridge
and rooms.
DISCUSSION
Medical residents face numerous challenges throughout
their training. These challenges include acquiring specialty
knowledge, improving surgical skills, clinical decision mak-
ing, and managing emergencies on call. The ophthalmology
call service at the RAH is demanding, requiring residents to
put in long hours. On numerous occasions, residents stated
that the lack of standardized organization of eye

Fig. 3 — Pre- (A) and Post-5S (B) audit checklist scores.

4 CAN J OPHTHALMOL — VOL. ], NO. ], APRIL 2017


Fig. 4 — Spaghetti map illustrating resident’s movement through rooms after 6S Lean initiative.
examination rooms, combined with lack of support staff on
call, made it difficult to manage and deliver patient care.
The department chair and the patient care manager there-
fore decided to engage AIW consultants to figure out a
solution.
Implementation of 6S and AIW organizational method-
ologies was effective in enhancing room organization and
safety. Spaghetti mapping demonstrated that movements
within examination rooms were aligned with workflow
and showed a reduction in the frequency of opening
drawers—from 18 at baseline to 2 after the project.
Organization of examination rooms also improved safety
measures, as residents did not need to leave patients
unattended for extended periods.
The organization of examination rooms was improved
with regard to setup, arrangement of supplies, and
inventory control and maintenance. Opened medications
were labelled and placed in a resident basket, thus
mitigating the risk of administration of outdated medi-
cations. Designated areas for placement of hand sani-
tizer and dirty instruments improved infection control.
As a result of improved organization and labelling,
residents now open only 2 drawers to access necessary
supplies and do not need to leave the patient alone in
the room.
Intangible improvements included better room appear-
ance, enhanced patient and provider experience, more
—Nazarali et al.
efficient room organization and workflow, and reduced
risk of resident injury and patient safety incidents.
The above improvements have been made sustainable
through development of checklists and assignment of
certain duties to unit staff. In addition to team account-
ability for workplace organization and safety, residents
now experience an improved working environment. As a
result, residents can focus their time and efforts on
learning and managing patient care. In the long term, this
will improve workflow and develop consistency in the
workplace, which is effective for sustainability, as well as
for creating a good environment for visiting ophthalmol-
ogists and learners.
To sustain the improvements, it was recommended that
the unit manager organize a room orientation session for
residents and physicians such that all staff members are
acquainted with the room setup and the accountability
process. Furthermore, the unit manager was advised to
inform the staff about the changes. Conducting a quarterly
5S audit to determine further improvements and sustain-
ability and keeping a daily maintenance log to monitor
fridge maintenance and temperature checks were also
advised. Service workers were advised to periodically
update the stocking list and procedure.
A limitation in our study was that baseline data were
drawn from 3 mock patient encounters (red eye, virus/
ulcer, and lid laceration). Although these represent the
CAN J OPHTHALMOL — VOL. ], NO. ], APRIL 2017 5
—Nazarali et al.
most common patient care encounters, with red eye
representing 80% of patients, both examination rooms
were organized for the workflow of these scenarios. In the
future, we may need to reorganize or accommodate our
rooms as the needs of our services change.
Overall, application of the lean methodology is not
uncommon in medicine. It provides an efficient way to
evaluate current processes while making recommendations
for improvement. Application of the 6S methodology
identified inefficiencies within our ophthalmology service
and provided recommendations for improvement and
sustainability.
CONCLUSIONS
Overall, implementation of the 6S methodology is a
simple approach that removes inefficiencies in the work-
place with a focus on safety. The RAH ophthalmology
team removed waste from all 8 waste categories, increased
audit results by 33 points, mitigated patient and resident
safety risks, and ultimately redirected resident time back to
patient care delivery.
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Footnotes and Disclosure:
No author has a financial or proprietary interest in any material
or method mentioned.
We would like to thank the ophthalmology staff and residents at
the Royal Alexandra Hospital and the University of Alberta for
their input in this project.
From the *Faculty of Medicine, University of Ottawa, Ottawa,
Ont; †Department of Ophthalmology and Visual Sciences, Fac-
ulty of Medicine & Dentistry, University of Alberta, Edmonton,
Alta; ‡Royal Alexandra Hospital, Edmonton, Alta; §Alberta
Health Services, Edmonton, Alta; ‖Department of Ophthalmol-
ogy and Visual Sciences, Faculty of Medicine & Dentistry,
University of Alberta, Edmonton, Alta.
Originally received Nov. 12, 2016. Accepted Feb. 22, 2017.
Correspondence to Karim F. Damji. Department of Ophthal-
mology and Visual Sciences, Faculty of Medicine & Dentistry,
2319, 10240 Kingsway Avenue, Edmonton, Alta. T5H 3V9
kdamji@ualberta.ca