Dr. Toyota

All physicians want their practices to work well for their patients, their staff and themselves. They want to deliver high-quality care at a reasonable price and meet the needs of their patients. But there are multiple challenges facing practices today including Medicare payment reductions, increasing financial pressure from managed care organizations, the rising cost of office operations, and increasing pay-for-performance models. These challenges aggravate existing issues such as the physician’s ability to effectively see sufficient volumes of patients to meet the financial requirements of the practice due to roadblocks from patient waiting times, gaps in the schedule, not having correct data available for the visit, etc.

It is generally understood that there is considerable waste in health care. Some estimates of physician productivity are as high as 60 percent, while others show that only 50 percent of a physician’s time is productive. This waste arises from unnecessary complexity, current practice models, a lack of focus on creating value for patients and systems and processes that do not function optimally. This waste is a major contributing factor to the cost of health care. According to Robert Mecklinburg, M.D., Chief of Medicine at Virginia Mason Medical Center, half of all health care dollars spent—$1 trillion—is wasted on poor quality care, safety issues and perverse incentive plans that reward mistakes.

Past approaches to solving these issues and improving performance often focused on these issues separately. We use one set of techniques to improve quality and other techniques to address financial issues, but with less than optimal results. This silo thinking can create solutions for one problem while aggravating others. A singular focus on cost-cutting can impact the quality of care and service. What is needed is a methodology that addresses these issues simultaneously to provide real improvement. This requires seeing the practice as a whole and understanding it in terms of systems, work processes and customer value.

The concept of “lean thinking” presents a powerful approach to creating efficient and effective offices. Lean thinking is the general term to describe the Toyota production system, which is built on a foundation of eliminating waste in all its forms, understanding value from the customer perspective and delivering that value to customers. Lean thinking is much more than a set of tools. It is a management system that enables physicians to see their practice as a whole system with interrelated processes designed to deliver value and eliminate waste (steps that do not deliver value). This approach concentrates on only doing activities that produce value. At its heart, it is relentless problem solving. The fundamental concepts of lean thinking are:

• Eliminate waste,
• Create continuous flow,
• Build quality at the source,
• Stabilize and standardize processes,
• Use visual controls, and
• Engage and respect everyone’s contribution.

Steps to create a Lean Office

Commitment

Creating commitment involves several steps. The first step is to develop a sense of urgency to change the way your practice works. This sense of urgency should focus on the care of patients as well as the financial health of the practice. The second step is to create a vision for the practice in these terms and communicate that vision to the staff and patients. The third step is to investigate lean thinking as a management system for your office. It is important that you understand what it is and what it demands from the physician leadership. If this approach appeals to you, then commit to it. The first commitment to your staff is that no one will be laid off as a result of creating a lean office. Their jobs may change slightly or completely, but being “lean” is not necessarily about having fewer people. Rather, it is about eliminating waste. Success will depend on the involvement and support of your staff. Lean is also seeing the entire system as a whole and ensuring that the entire system is optimized. You cannot optimize each step of a process and optimize the whole.

Educate everyone

Creating an educated staff is critical to a lean office. The first pillar of “lean” is “people” and giving them the knowledge and the tools essential to success. There is significant material on lean thinking available in books, articles and on the Internet.

Eliminate waste

The first step is to gain an understanding of what your patients want and need from your practice and what they see as valuable. This is relatively easy; ask them. There are a variety of survey tools available but perhaps the easiest is to talk with them during visits.

Value Stream Mapping

There are two steps to this component: mapping the current state and mapping the future state. Creating a value stream map or process flow map of the current process is done to understand exactly how the current process flows from start to finish. This process is essential to identifying waste. There are essentially seven types of waste:

• Overproduction,
• Transportation,
• Motion,
• Waiting,
• Processing,
• Inventory, and
• Defects.

Value stream mapping also enables you to identify which steps add value, which do not add value but are required, and which are not required and add no value. To do this well may require actually walking the entire process to visualize exactly how things work. The second step is to design and map the desired future state that eliminates the non-value-added, not-required activities.

Stabilize processes and create flow

The first step to real improvement is to ensure that processes are stable; that they are done the same each time. This is essential to improvement. You cannot improve unstable processes. Once processes are stabilized, the next step is to establish flow. The goal of flow is that patients move from one step to the other in the process without a break. In an office setting, one way to see this is to ensure that patients are never alone. They do not wait in the exam room for the next provider. When one provider leaves, the next one enters until the visit is completed. That would create continuous flow.

An example of creating flow can be shown in a diabetes clinic where patients are seen by four providers. Previously the clinic scheduled four patients in a four-hour period. Both patients and providers experienced significant waiting times. The redesigned model allowed the clinic to schedule and see eight patients in a four-hour period. The model changed several procedures and stabilized them and created structured flow from one component to another.

Build quality at the source

This approach ensures that defects or errors do not transfer to the next step in the process. In a practice setting one example of this would mean ensuring that all information is available for each visit. That could mean laboratory results, radiological results or others. In my experience, one of the largest areas of waste comes from not being prepared for a visit. If information is not available, the visit lasts longer than it should and the potential for error increases.

Use Visual Controls

Managing patient flow requires the ability of everyone to see and track where patients are in the care delivery process. While there are a variety of methods to utilize, it is important to use one. The increasing use of electronic medical records can provide a platform for patient tracking.

Another area of visual control is a “lean” tool called 5S, or sort, straighten, shine, standardize, sustain. This approach identifies optimal locations for tools, equipment and supplies so that the staff knows where things are and the items are always available. It ensures a clean, orderly workspace and eliminates wasted time searching for necessary items.

Lean Continuous Improvement

Once processes have been redesigned and stabilized, then they can be continually improved. As noted earlier, the heart of lean thinking is to engage your staff in relentless problem-solving. Each time the process is improved, it is then stabilized and standardized. Diagram 1 best demonstrates the ongoing lean improvement process.

Summary

Creating a lean office requires more than just implementing a set of tools. It is a management system that allows you to see the practice as a whole, engage your staff in relentless problem solving to increase the value for patients. As you eliminate waste in your practice, you will also create the opportunity to see more patients efficiently and effectively.

Patrick Shumaker is the Vice President, Healthcare Improvement for Gemba Research, LLC. Gemba Research is an international Lean Thinking consulting firm that has assisted organizations from a variety of industries including health care in transforming themselves into lean enterprises. Shumaker is a former hospital administrator and practice manager with over 25 years experience in developing high-performing organizations. He has consulted with health care organizations and physician practices since 2002.