Paging Dr. Lean

In the new Paging Dr. Lean series, Patricia E. Moody asks lean experts to answer your lean questions. This forum allows industry leaders to speak to the lean issues or questions you come across each day.

Dear Dr. Lean:
Why is it that when I go to the doctor I feel like a car going down an assembly line? I check in at the reception desk, check in at a health benefits booth, sit down and wait in a massive staging area, walk across the reception area after my name is called and am led down a hallway and into an X-ray waiting area where I sit and wait some more. Sometimes, I am forced to listen to CNN news updates. I have X-rays and am then led back to the examination room, where I wait for the doctor who is at a central desk reviewing films. When he becomes available, I drop my crutches and demonstrate walking. Then we talk.

On other visits, I stop in at "the crutch room," which is run by a different company. It is about the size of a gas station restroom and it's where people are fitted with crutches or canes. The crutch attendant has three or four clients in various positions at different stages of repair. He goes back and forth between patients, measuring, fitting, refitting and observing. To me, it seems like I am in a critical bottleneck area and I may or may not get out of there with proper instructions and/or fitting. It's scary.

Sometimes, I go directly to the MRI center. I check in and an attendant takes me through the entire process — fitting the headphones, choosing the music, answering questions about the machine and helping me get onto and off of the table.

My question to you, Dr. Lean: Is this type of process flow efficient or profitable, and is it the best or only way to "process" patients? What would Toyota do?

Yours truly,
Been There

Dear Been There:
No, this is not an efficient or profitable system. Instead, it is all designed around the doctor. In fact, most processes are designed around the providers of care, not the customers they serve.

If the doctor and his team had studied the patient experience with value stream mapping, they would realize that more than half the steps you describe in this experience are a waste from the patient's perspective. Registering more than once, for instance, shows a process is designed around each provider's financial needs, not the patient's.

And why can't we have all services in one place rather than have you walking around on crutches? We call this silo thinking — each caregiver only thinks about his part of the process.

An orthopedic center that puts patient needs first can be as profitable and busy as ThedaCare, an integrated health delivery organization in Appleton, WI, with its Orthopedic Plus program. Every service a patient needs — rehab, casting, X-ray, etc., is in one place and patients only register once to see more than 10 different providers. Patients love it, and business is growing.

We can fix customer problems using the lean methodology but we, as physicians, need to change our thinking so as to deeply understand patient needs.

Dr. John Toussaint

John Toussaint, MD, is CEO emeritus of ThedaCare and CEO of the ThedaCare Center for Healthcare Value. Toussaint is an AME 2012 Hall of Fame inductee. He was the founding Chair of the Wisconsin Collaborative for Healthcare Quality and of the Wisconsin Health Information Organization, as well as the non-executive leader of the Partnership for Healthcare Payment Reform in Wisconsin. Dr. Toussaint's health care improvement work using Toyota Production System principles has been well documented in articles published in Health Affairs, the Harvard Business Review blog and Frontiers in Health Management. His just released second book, Potent Medicine, The Collaborative Cure for Healthcare, describes the three core elements necessary to transform health care and deliver better value: delivery of care designed around the patient; transparency of treatment quality and cost; and payment for outcomes.

Dear Been There:

Wow, sounds like you're being walked around like a broken-down Chevy.

First of all, lean health care is about figuring out what's best for the patient. Fortunately we've learned from Toyota and lots of great health care examples that a few simple lean tools make all the difference. Take teams, for instance, and workplace design, and value stream mapping and kaizen suggestion systems. All of these techniques work in manufacturing, and they transfer well to health care.

In the best health care setups, it's not all about volume because moving patients doesn't guarantee profitability. My prescription? Take a clipboard and a stopwatch, and sit and observe. Then map it, share it on a whiteboard and validate the work with other workers. Then problem-solve the experience toward ideal care. I'll bet you'll remove 60 percent of the wait time and wasted movement out of the system. And of course, you're going to uncover many other specific problems. Be prepared to respond to them.

Cindy Jimmerson

P.S. Take a look at this YouTube video, “If Air Travel Worked Like Health Care." It says it all.

Cindy Jimmerson is a pioneer of lean for health care, having initiated her lean work with a grant from the National Science Foundation from 2001 to 2004. She is the founder and president of Lean Healthcare West, a corporation composed of expert health care and industry professionals that offers education in and implementation of lean principles in hospitals, clinics, long-term care facilities, other health care facilities, physician office practices, community health care programs and health care insurance companies. She is the author of A3 Problem Solving for Health Care, Value Stream Mapping Made Easy, The reVIEW Course and Manual, as well as many journal articles. Jimmerson brings passion, insight and creativity to lean health care based on 30 years as a trauma system developer and emergency health care provider.