• Ellen J Van Vliet, Eelco Bredenhoff, Walter Sermeus, Lucas M Kop, Johannes C A Sol, and Wim H Van Harten.
• Centre for Health Services and Nursing Research, School of Public Health, Faculty of Medicine, Catholic University Leuven, Leuven, Belgium. ellen.vanvliet@student.kuleuven.be
• Int J Qual Health Care. 2011 Feb 1;23(1):83-93.

ObjectiveTo compare process designs of three high-volume cataract pathways in a lean thinking framework and to explore how efficiency in terms of lead times, hospital visits and costs is related to process design.DesignInternational retrospective comparative benchmark study with a mixed-method design.SettingThree eye hospitals in the UK, the USA and the Netherlands participated in this study. All are major international tertiary care and training centres in ophthalmology.ParticipantsData on all patients who underwent first eye cataract surgery in 2006 were used.InterventionsThe study related six operational aspects of lean thinking in the process design to efficiency.Main Outcome MeasuresMeasures of lean aspects were operational focus, autonomous work cell, physical lay-out of resources, multi-skilled team, pull planning and elimination of wastes. Efficiency was measured with lead times (access time plus waiting time for surgery), hospital visits and direct costs.ResultsOperational focus was influenced by external circumstances leading to different orientations on efficiency. Pull planning with integrating activities in one-stop procedures conducted by multi-skilled nurses as well as eliminating wastes reduced both the number of hospital visits and costs. Short lead times were associated with the use of a general outpatient clinic and a high-volume cataract surgery clinic.ConclusionsThe environmental context and operational focus primarily influenced process design of the cataract pathways. When pressed to further optimize their processes, hospitals can use these systematic benchmarking data to decrease the frequency of hospital visits, lead times and costs.

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