How a manufacturing process transformed healthcare delivery

Let me tell you how “Lean,” also known as the Toyota Production System, transformed my clinical practice from a hectic, stressful, and unpredictable experience to one that runs smoothly and became a paragon of efficiency, safety, and quality.

I used to have both good days and bad days in our clinic. On good days, my patients were seen in a timely fashion, they smiled when I entered the exam room, and the clinics ended on time. On bad days, patients waited a long time, clinic flow was disrupted by unpredictable events, and there were frequent interruptions in my care of patients.

Despite working as quickly and as continuously as possible, I would be greeted with frowning patients to whom I offered numerous apologies for delays that were out of my control.  I became good at excuses like, “We’ve had some emergencies,” or “We are down a few staff people today,” or “Sorry, that last patient had some serious problems that took some time to sort out.”  Some were true and others were wishfully so.  Either way, it affected the whole physician-patient interaction. Does this sound familiar to you?

For the past 25 years, I have tried to remedy these problems. Despite attempts at adjusting scheduling templates and improving efficiency of various clinic steps, we failed to achieve any breakthrough in changing the patient experience. This, despite my clear understanding of some of the challenges we faced. These included (1) having patients with problems of varying complexity that required different tests and evaluations of various durations, making patient flow problematic; (2) encountering factors outside of my direct control such as scheduling, personnel pay structures, and job descriptions; and (3) the frequent problem of add-on patients for whom I was frequently consulted as to where they should be placed in the clinic schedule. (I was later to find out the physician is probably the worst person to consult for this on a properly functioning clinic team.)

REVELATORY AND TRANSFORMATIVE
I was skeptical when approached by our business administrator with the suggestion that we attempt a “Lean transformation.” I had heard of Lean as it applied to manufacturing processes. But I was unaware of its application to healthcare delivery. So began a journey that was a revelation to me and transformative to my medical practice.

What is “Lean?”  It is a manufacturing approach that considers the expenditure of resources for any goal other than the creation of value to be wasteful. In healthcare delivery, “value” can be defined as those steps that potentially improve patient health, such as physician-patient face-to-face time, technician time, or image acquisition time.  Patient wait times are a key metric in determining how efficiently a practice is run and is an indicator of the amount of “waste” in the process.¹

I soon learned that Lean principles do not just apply to manufacturing, but any process that attempts to add value. The Lean “toolbox” includes value stream mapping, the use of 5S principles (sort-stabilize-shine-standardize-sustain), visual cues, spaghetti-diagrams to eliminate wasted movement, and “just-in-time” resource delivery. These tools are critical to taking waste out of a process.

Using these tools, we markedly reduced patient changeover time, characterized in my clinic as wasted physician activity that did not add to healthcare “value.” These included activities such as excessive documentation time, completing billing forms, searching for supplies, giving directions on where to get scheduled for tests or the next appointment, etc.  

Eliminating these activities maximized my time available for direct interaction with the patient, and relieved the bottleneck effect of unproductive physician activity.  We established a team leader position, assumed by a lead technician (notably NOT a physician) who worked with schedulers to ensure that patients were scheduled at appropriate times so that there were no delays predestined from the start.  We enhanced visual communication through the use of a clinic whiteboard depicting where each and every patient was located in the process, allowing the team leader to level workflow to the physician and provide him or her a steady menu of tasks but without the backups.

EFFICIENCY PRINCIPLES WORK
We used 5S workplace efficiency principles to make the practice user-friendly, and redefined staff roles to allow multitasking for either technical tasks or providing “just-in-time” value added service. This meant relocating our imaging specialists (ancillary staff) to a workspace closer to patient exam rooms to reduce excessive movement ,and removing two small divider walls in our clinic to enhance our visual cues as to when changeover activity begins.

Despite the same size clinic footprint, each of two doctors in this area now has added space within which his own core team can coordinate his clinic without interference from others. We did all this by engaging the workers in a nonhierarchical “bottom-up” fashion, allowing them to use their own observations and skills to improve flow in ways no physician alone could imagine.

So what happened in my practice after these changes? One patient stated to me that “this is the first time that I was seen so quickly and efficiently in the 20 years that I’ve been coming here.”  Just this week, my technicians overheard a patient in the lobby say at 11 a.m., “Now’s about the time of day when doctors get behind and we have to wait.” My team’s sentiment: “Not in Dr. Han’s clinic!”  My patients are uniformly seen in a timely fashion and our clinics always end on time.

NUMBERS TO BACK IT UP
Are these changes real? We have the numbers to prove it. Our patients have experienced an 85% reduction in non-value added patient wait time, a “top box” patient satisfaction rating in 97% of our responses (“strongly agree to recommend this doctor’s office to others”), a 25% year-over-year increase in relative value units production and 41% increase in payments due to increased physician availability.  

By eliminating numerous wasted steps, I now have more time to spend face-to-face with my patients, and my technicians are not rushed through important quality procedures. We work deliberately, steadily, and with fewer interruptions or periods of high stress that can lead to missed steps and errors. My patients are happier and I have the opportunity to provide the best care I know how to give.  

In an institutional setting, these accomplishments cannot be obtained through the efforts of a single entity or group, nor mandated from upper level management. A Lean transformation requires buy-in from persons at both administrative and operational levels. It requires full administrative support from the authority that holds the purse strings, be it the lead physician practitioner in a private setting, or the head of a major healthcare institution.  Why?

In our practice, changes such as redefining workers’ roles required authoritative instruction for creativity in the human resources area-it was appropriate to incentivize and reward persons who took on the role of a team leader. Small outlays for minor infrastructure changes yielded major benefits, but they also required support from those in authority to pay for them. It also meant engaging someone familiar with implementation of Lean tools in the healthcare setting.  This can be an outside consultant or someone with expertise internally. Finally, at the operational level, a core team of workers (the doctor and his helpers) must be educated in “lean thinking” and must be motivated to search for opportunities for improvement, then implement them and sustain those gains.

THE BIGGEST CHALLENGE
A physician’s willingness to try new things and be flexible is critical for Lean transformation to occur. This can be the biggest challenge. I’ve found that most physicians tend to agree consistently with only one person-themselves. And because the physician has historically been considered an authority figure, his or her mandates can inhibit the process of engaging all workers in a nonthreatening and emotionally safe manner.  Nevertheless, the physician should be assured that he or she won’t be asked to change medical management without good medical evidence upon which to base such a request.  Changes are approached without fanfare, but with a spirit of empiricism, because new ways seem unnatural until they become old.

Though physicians are knowledgeable in the science of patient care, they are largely ignorant of the science of patient care delivery. These concepts are taught at engineering and business schools, but not at medical schools. Yet they contain elements critical for providing excellent healthcare delivery.

Unless you are knowledgeable in terms like value stream mapping, standard work, 5S, “takt” time (available production time per day divided by customer demand per day ) and cycle time, percent load, event dependency, and theory of constraints, you are unaware of important concepts in the science of value-added processes, healthcare being the one we as physicians are charged to lead.

In what settings can a Lean transformation occur? It can work in large institutions, small private practices, and everything in between. For institutional practices, a major strength is that it can cross departmental lines to transform delivery from that of being “service-centered,” in which patients are shuttled from one service type to another, to being “patient centered,” in which the services are centralized spatially or logistically around each patient.  For example, we are trialing placement of frequently-used retinal imaging instruments within the physician exam room pod to reduce wasted patient movement.
“Lean” can also help to revamp staffing to match worker skill levels to appropriate tasks.   We had some workers who were unmotivated or lacked sufficient organizational skills to be team leaders.  We could objectively identify such persons and move them to positions more suited to their abilities.

FAILURE NOT OFF THE TABLE
Attempts at Lean transformation can fail. Usually key steps are omitted, such as value stream mapping to systematically identify waste.  Intuition alone is not effective, nor will key players agree on where the waste is occurring.  For example, we had not realized how much time our imaging specialists spent walking to process patients until we timed their movements with a stopwatch.  Our measurements indicated that they each walked about 80 hours per year in total-2 work weeks per year of totally wasted time.   They had no idea because they were used to it. A cause of failure is attempting to apply efficiency measures too broadly without concentrating on an individual process. It is important to concentrate on one doctor’s practice at a time.

Another reason for failure is the absence of high-level institutional support, as mentioned above.  Achieving a Lean transformation also will be a distinct challenge unless you choose individuals who are motivated to succeed and provide a shining example to less enthusiastic coworkers who may eventually “see the light.”  Finally, a Lean consultant with experience in a healthcare setting is essential because no other process in the manufacturing world encompasses the unpredictability of illness and humanistic aspects of patient care.

RETURN ON INVESTMENT
What are the economics of implementing Lean? Its main expense includes the cost of the consultants or internal expertise, and the need to take workers off-line to learn Lean concepts and collaborate on process improvement. In my practice, this was done one-half day twice a month over a period of 10 months, each session of which was quickly followed by a trial of Lean practices in a live clinic.

For a typical medical practice, return on investment (ROI) is estimated to be two to 10 times the expense (100% to 900% ROI), depending upon the operating margin of the practice or process, and market demand. Notably, we have not increased staffing and have, in fact, reduced the number of exam rooms and waiting area needed given our increased efficiency and throughput. But most importantly, Lean processes provide my staff and me the satisfaction of delivering excellent care to patients and hearing their expressions of gratitude.

Reference
1.  Suneja A, Suneja C, Lean Doctors, 2010, ASQ Quality Press, Milwaukee. ISBN 978-0-87389-785-3.