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Using Lean tools to improve the efficiency of awake fibreoptic intubation setup. BACKGROUND: Awake fibreoptic intubation is a complex advanced airway technique used by anaesthesiologists in the management of a difficult airway. The time to setup this important procedure can be significant which may dissuade its use by some providers. In our institution, the awake intubation setup process was highly variable and error prone. METHODS: We deployed Lean methods to improve the efficiency and accuracy of the awake fibreoptic intubation setup process. A 2-day improvement event with a multidisciplinary team addressed the setup process, tested solutions and created standard work documents. Twenty awake fibreoptic intubation simulations were conducted before and after the intervention to quantify gains in setup efficiency and error reduction. RESULTS: Variability in the setup process, including clinical locations visited, was reduced through creating a standardised process. The average time to for an awake fibreoptic intubation setup was reduced by approximately 50%, from 23 min to 11 min (p<0.001). In addition, awake fibreoptic intubation equipment set out without error increased in the postintervention simulations from 59% to 85% (p=0.003). CONCLUSION: Using Lean tools, we were able to make the setup of awake fibreoptic intubation not only more efficient, but also more accurate. A similar methodological approach may have value for other complex anaesthesia procedures.