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Reimbursement and Practice Management

Lean Thinking: Practical Applications

The philosophy of lean thinking is not new. Many medical practices are already practicing lean techniques to improve patient flow, reduce inefficiencies and improve the patient experience.

After reading this article you will understand how to:

  • List ways to identify wasteful processes in the practice
  • Define goals of lean management applied to medical groups
  • Identify ways to engage providers, managers and employees in lean thinking
  • Develop practical steps to reduce waste of clinic resources and increase value for patients

View related pearls

To physicians, “lean thinking” may sound like one more attempt to impose industrial, production-line management on medical practices. But the philosophy of lean thinking is decades-old — and you may already be practicing some of its techniques. The reason to learn more about lean thinking is that it holds the potential to improve patient flow in all types of medical practices, and ultimately, provide the platform to enhance patient care. A lean thinking approach can assure that your patients remain at the center of all processes in a practice.

Lean thinking aims to provide the best quality at the lowest cost, and in the efficient manner, through eliminating waste. Doing this effectively requires a sharp eye for waste, and that’s not as easy as it may sound. We can all spot the obvious types of waste: leaving too many lights on or using too many sterile swabs to clean a wound. The challenge is that waste comes in many forms: taking too long to respond to a patient’s message, including unnecessary steps in the scheduling process, or doing tasks out of sequence, such as not verifying a patient’s insurance coverage until after the service has been provided.

The waste that lean thinking sets its sights on is the amount of time and other resources that are spent on actions that do not optimize the patient’s experience — or medical care. It may be using a slow-speed scanner that adds three minutes to the act of processing a patient through registration, losing a positive test result in the shuffle of paperwork, or allowing last-minute cancellations and no-shows to reduce the daily capacity of the practice.

Now that we understand what waste is and are learning how to identify it, the challenge becomes eliminating it from our practice’s operations. Lean thinking encourages us to design our work flow processes around the patient’s needs, not the needs of our practice.

What would happen if someone visiting your practice, perhaps a consultant, asked your business office manager why new patient charges were entered only by the same person-- and only every other day? Would your business office manager respond by saying: "That’s the way we’ve always done it?" That answer doesn’t really get to the "why." Is the employee doing so because a manager who left two years ago wanted it done that way? What about other tasks and functions in your office? Why does your scheduler send calls regarding new patient appointments to voice mail so they can take care of them later? Why does your receptionist put the telephones on service at lunch? Why is there only one credit card machine in the office? Why does it take 72 hours to process a medication renewal? Why does it take three weeks to process a referral?

Why is their only one person who is "allowed" to schedule a surgery? Why does a patient have to write down their name, address and insurance five times on five different forms that are nearly illegible they’ve been copied so many times? Why do you have nurses take patients’ vitals instead of the medical assistants who escort patients to exam rooms? Too often, our patient flow is defined by how we’ve historically performed tasks, not necessarily what we are capable of doing — and streamlining — today. The lean approach teaches us to start asking questions — probing why we do things a certain way. Hearing the trite, and often defensive answer — "that's the way we've always done it" — signals an opportunity to eliminate waste!

Enough theory; let’s turn our attention to tactics you can deploy in your office to uncover and eliminate waste:

Create a "flowstation." After every third or fourth patient, designate an appointment with a virtual patient — an open slot on the schedule — just for the physician to deal with documentation, return telephone calls, manage assigned tasks, respond to questions from clinical assistants or handle other quick tasks. For optimal efficiency, a workstation for the physician should be positioned near the clinical space or reside on a portable COW (computer on wheels); indeed, title it the “flowstation” to ensure that everyone is keenly aware of its purpose. The work to be handled during the virtual patient visit should be clearly delineated and prioritized; employees must be trained on the most efficient ways to deliver the information to and from the flowstation.

Color-code cords. We no longer live in a world where one machine plugged into the wall is sufficient. Indeed, it seems that every computer today has multiple cords and cables emanating from it. Many of the devices that we transport between exam rooms also require wired connections. You could go wireless but the expense may be tough to justify, or there may be concerns regarding sacrificing speed. To eliminate the confusion that causes delays when using devices that require wired connections, use different colored zip ties to indicate their inputs and outputs. Even if cords are removed or must be transferred between machines, a standard color code makes correct reconnection a breeze.

Standardize exam rooms. The layout of the equipment in each exam room should be uniform; so, too, should the supplies, including their quantity, type and placement. Assign supplies and equipment to specific shelves and drawers in each room. Within the drawers, organize supplies in trays. Attach hooks with labels on exam room walls to hang the frequently used or awkwardly shaped equipment. Or, try drawing the outline of each piece of equipment in a drawer in each exam room. Label every storage area (shelf, drawer, wall, etc.) with the name of the item that belongs there. Place supplies and equipment that might be needed, but are not required in each room, on portable carts. Augment standardization and convenience by previewing charts daily to determine if special equipment or supplies are required beyond the standard assortment. None of this works unless employees are held accountable to make sure all equipment and supplies are in their proper places.

Develop universal exam rooms. Instead of assigning exam rooms to providers, make them available to all — open rooming increases the flexibility of the office while reducing the downtime inherent in reserving space for certain providers.

Photo opps. With the multitude of equipment and supplies used in every practice, it's no wonder that restocking is confusing. Labels are helpful, but consider snapping a photo of each item and hanging the photo adjacent to the label or on the shelf where the item resides. That way, if the label is removed — or the supply has run out — a photo of the item will still be visible. Plus, photos take the guess work out of the process, in essence, mistake proofing it, a key lean thinking concept. When supplies are stacked, place a photo near — but not at — the bottom of the stack. Seeing this will signal employees that it’s time to restock. Try combining this daily management system with a more sophisticated, automated inventory management system.

Maintain expiration dates. For supplies needed infrequently — your crash cart, for example — create the same system of labels and pictures, but add a log of expiration dates. Maintaining a log of expiration dates near the cart — ideally, attached to it — allows employees to restock without spending precious time sorting through every item in the cart. Whenever you find yourself checking for expiration dates, determine if the items can instead be logged and expiration dates kept centrally.

Obtain a cart. The days of needing drawers of forms in every room are over, but most physicians still require paper sometimes. It may be a requisition form to a reference lab required by the one insurer in your community that cannot yet accept electronic transmissions, or perhaps it's just a favorite patient education handout that is available only in printed form. Creating a roving cart full of needed materials, including equipment, offers incredible value to your practice. It saves time for employees but also for the physicians and patients who would otherwise have to wait while the employee fetches the items from elsewhere in the practice. Centralizing storage also allows employees to quickly identify restocking needs.

Create a bin. For devices that are used less frequently, organize a plastic bin large enough to also contain all items related to that device, including cords, cables, forms, logbooks, etc. Label the bin with the name of the device, as well as an accounting of its contents. Store the bin in a specific area along with other infrequently needed equipment. Having everything together makes the device easy to find and use when needed.

Use a checklist. Determine the ideal state of each exam room and develop a checklist that an employee reviews at the beginning of each session and the end of the day to assure that all rooms are in order. Consult with your employees to develop lists that are start, use the checklist to evaluate the readiness of each room — at a minimum, make sure that the exam rooms are clean and lit with computers are on before office hours start. Assign the responsibility for the task to one individual — an assignment that may rotate — or to each physician's clinical support team. Using a checklist to record exactly what needs to be ready means that not only do you start off on the right foot each morning, but you can establish accountability for tasks.

These may seem like minor process changes. You’re absolutely correct in your assessment, but the time and expense they save will add up to a tangible redesign that will improve the value your practice provides to patients. There is no magical solution to optimize your patient flow; you will need the assistance of your employees to locate the best opportunities to eliminate waste in dozens of processes as well as the many steps within each process. Once employees feel empowered to look for ways to improve, you’ll be pleasantly surprised by what they find. They’ll start to believe that it’s their responsibility — their duty — to find, expose and resolve the problems that reduce the value you want to provide to your patients. As with any new process, proceed with your initiatives knowing full well that there may be significant resistance to change. The resistance may come from employees or from other physicians. Be aware also that the resistance may be just as strong to relatively small changes as it is to large-scale changes. Expect also that the change management truism, "I’m all in favor of progress, it's change I don’t like," will apply.

Once the task of revising a process begins, don’t make the mistake of leaving out those who opposed the change; doing so may only harden their opposition. While including the opponents of change in the process is helpful, it is also important to make sure those who will be affected are involved in working out the details and providing feedback that can help you fine tune the new process for success. To eliminate waste and redesign flow, everyone must be involved.

Pearl 1/12/15

Lean Into Quality
Instead of relying on inspections of cars after production to determine their quality, Toyota integrates quality into the production process. This transformation in thinking helped Toyota become the market leader in its industry in terms of sales and market share. Ultimately, more buyers of automobiles perceive they get better value from purchasing a Toyota than other brands. How could a medical practice possibly look to an automobile manufacturer's experience to redesign its operations?  Learn about how to apply lean to your practice.

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