Access to endoscopy is essential for achieving high rates of colorectal cancer screening. Last-minute cancellations and no-shows are relatively common for outpatient endoscopic procedures, yet filling these vacated appointment slots the same day is challenging. Unfilled spots result in decreased revenue, decreased productivity, and worsened access to endoscopy. Our lean performance improvement project aimed to decrease the no-show rate of ambulatory endoscopies at a large Veterans Affairs hospital endoscopy unit with a baseline no-show rate of 16% per day. We performed a root-cause analysis to identify factors contributing to procedural no-shows. We included both colonoscopies and upper endoscopies in our analysis; endoscopic retrograde cholangiopancreatography and endoscopic ultrasound procedures were excluded. Using a standardized interview guide, we interviewed patients who had not shown for endoscopy appointments over a 2-month period from December 2016 through January 2017 to derive barriers to attendance and establish behavioral patterns across the patient population. Using this data, combined with a value-stream map, we identified hypotheses and possible solutions for the no-show problem. Utilizing rapid-improvement cycles, we tested hypotheses and analyzed the impact on no-show rates. Patients reported difficulty contacting the office staff to cancel the procedure in 15% of cases; not knowing they should call to cancel in 41% of cases; and unforeseen issues, such as difficulty with preparation, acute illness, and transportation issues, in 44% of cases. Generally, patients were aware the procedure had been scheduled (89%) and had received a reminder letter and/or phone call (93%). Based on the root-cause analysis, we implemented 2 key interventions: first, streamlining the phone system within the endoscopy unit to remove barriers to patients who wished to cancel procedures; and second, highlighting the importance of cancelling procedures in advance in all pre-procedure phone calls to patients. After the implementation of these interventions, the no-show rate dropped from 16% in December 2016 to 7.8% in May 2017 (Figure 1). The improvement was sustained in subsequent months of follow-up, through September 2017. Lean methodology can be effectively leveraged to solve operations problems in endoscopy suites. Using a root-cause analysis and rapid-improvement cycles, we reduced the composite colonoscopy and upper endoscopy no-show rate by 50% over a 6-month period at a large Veterans Affairs hospital.