Avoiding waste: a LEAN approach to primary care
If you’ve been around any major business for very long, you may well have heard of LEAN. LEAN is the Toyota Production System’s approach to improving processes by eliminating waste wherever possible. In my case, the “process” is “providing patient care”. I’ve only had a little bit of formal training in LEAN so far, but what I’ve seen of it makes a great deal of sense to me.
If you’re interested, here are the general categories of waste identified in LEAN, and how I try to reduce various forms of waste by the way I run my practice. If you have additional insights or suggestions for me, I’d be grateful for your input– I’m always interested in figuring out how to make things better.
|Type of Waste:||The Slower Medicine Approach|
|Transportation – extra movement of products (or people, in my case!) that is not actually required by the process.||Reduce number of actual office visits a patient needs by (1) addressing as many issues as possible during each visit and (2) communicating by other means (text, e-mail, video conferencing, telephone) when there is no good reason (e.g. a physical exam) for an actual office visit.|
|Inventory – raw materials, work-in-progress (WIP), or finished goods; represents a capital outlay that has not yet produced an income either by the producer or for the consumer.||I provide services rather than produce products. As such I have minimal inventory aside from modest quantities of medical supplies and pharmaceuticals that are prudent to have on hand for routine patient care and for emergencies.|
|Motion – people or equipment moving or walking more than is required to perform the process.||The elimination of medical insurance reduces the amount of pointless motion in my practice to nearly nil. Physicians and staff in other practices have to engage in a great deal of extra mouse-clicking and typing in their computers in order to document patient visits in a form that will maximize their revenues from insurance companies. The extra motion of having to submit and resubmit claims to insurance companies (particularly claims that are routinely denied by some insurers the first time they are submitted) is a huge waste often suffered by other practices.|
|Waiting – Whenever goods (people, in my case) are not in transport or being processed, they are waiting.||I have identified (and virtually eliminated) several different types of waiting that are common to most medical practices: #1: Except on the rare occasions that I am out of town (generally for a week at most), I offer same-day or next-day visits for urgent situations. Non-urgent situations will still generally be scheduled within 2-3 days (or at your preference when that’s too soon.) #2: I offer direct access to me via e-mail and telephone (the latter is preferred when you need a quick answer). #3: I schedule my appointments so that there is usually plenty of time both during the appointment and between patients – thereby reducing my risk of falling behind schedule. If I do seem to be falling significantly behind (rare, usually only due to unexpected emergencies) I’ll make an attempt to call or text you to let you know the situation. Nonetheless, sometimes stuff happens. If you do find yourself waiting for any length of time in my waiting room, it has WiFi, a computer, and printer access so you can still get things done. #4: Once I bring you back, I’m yours; I won’t make you wait for me in an exam room without a good reason (e.g. I’m giving you a moment to change). #5: Except for lab results that will be reviewed during an upcoming comprehensive visit, I will generally communicate your lab results within a day of receiving them. I won’t make you wait to come into the office to discuss them with me without a particularly good reason.|
|Over-processing – occurs any time more work is done beyond what is required by the customer.||Making my patients my customers instead of the insurance companies has enabled me to eliminate a huge amount of over-processing waste. Other practices commonly employ staff to ask patients a large number of questions that usually add little value to the patient experience and are almost always the result of insurance or Medicare documentation requirements. Other medical providers commonly have to waste a lot of time (both in their notes and in their visits) focusing on the specific things that will allow them to get paid. By contrast, my notes are written only for me, for you, and for communicating clearly with other providers who may need to assist in your care. I don’t have to waste time putting in a bunch of extra verbiage or looking up medical codes that exist only for insurance billing purposes. Similarly, by charging patients up front for my services I don’t need to waste money employing a small army of coding or billing specialists (or a practice manager to oversee them).|
|Over-production – production ahead of demand.||This is a type of waste that is not as obviously applicable to a service provider as it would be to someone who manufactured goods. Perhaps at some point in the future, the fields of cancer treatment and human rejuvenation will have advanced to the point where “too early” provision of services could be seen as a form of waste. I don’t anticipate either of them happening within my practicing lifetime. (Well, not unless I manage to keep going for another 30 years or more; those are “problems” I wouldn’t mind having at some point!)|
|Defects – when products or service deviate from what the customer requires||My desire to provide my patients with an abundance of time is as much about my doing my best to prevent “defects” in their care as it is about anything else. Accuracy in diagnosis is particularly important. Preventable medical error is a catastrophic problem; it results in an obscene number of human tragedies and arguably wastes hundreds of billions or even trillions of dollars annually (it can be hard to assign a monetary value to a person’s needless suffering or lost life). I think this diagram summarizes the situation fairly well.|
|Skills – waste of talent||I’m fortunate to have a part-time “Jill-of-all-trades” office assistant who takes care of a lot of my day-to-day office chores for me – freeing me up to spend more time caring for patients and studying the sorts of things that make me a better doctor. As my assistant is quite insightful and skilled in her own right, I don’t want to waste her talents, either — she’s got a ongoing mandate to speak up when she spots opportunities for us to improve.|
|Resources – failure to make efficient use of electricity, gas, water, etc.||I use energy-efficient LEDs for office lighting. My heating/cooling requirements are modest and my water consumption is fairly minimal.|