Moving patients effectively from check-in to check-out results in savings of time and money for a rural group practice.
Using lean principles allows a clinic’s physicians to see more patients in a given time period while decreasing wait times and finishing the day in a more timely manner.
The importance of flow in the medical office is critical for the solvency of the office. Increasing patient volume through process improvements can provide necessary revenue to successfully run a medical office without compromising patient care.
Eliminating wasteful steps in an office-based medical practice is one way to improve throughput. Lean manufacturing, derived from the Toyota Production System, removes points of waste in the flow of value to the customer, so the organization can produce value for the customer using the least amount of resources.
Lean manufacturing or lean production systems were initially shown to be effective in the automotive industry, but have recently been successful in other professional arenas such as the medical field.1
Lean manufacturing principles apply to a medical office because a medical office represents similarities to a production system where smooth, efficient patient flow is of value.
THE PROBLEM: Opening a new medical practice is fraught with many different and difficult challenges. Hiring a staff, setting up the office and developing the software processes are just a few. A key aspect of setting up a new medical office is the actual process of moving the patients effectively from check-in to check-out.
Many times there is an assumption that patients will naturally flow through the office. However, key patient information must be obtained in proper order.
Although patient care isn’t compromised, time wasted waiting for information can impede patient flow. When patient throughput is compromised through inefficient information flow, it leads to decreased patient volume and patient satisfaction, longer wait times, more paid overtime for staff and longer hours. In a medically underserved area this can lead to decreased access and more costly care.
The lean principle of Single-Minute Exchange of Die (SMED) is being adapted and implemented in a rural urology practice to improve information flow and ensure the practice can efficiently and effectively continue to maximize care, growth and revenue.
SMED is one of the many lean production methods for reducing waste in a manufacturing process. It provides a rapid and efficient way of converting a manufacturing process from running the current product to running the next product. This rapid changeover is key to reducing production lot sizes and improving flow.
For example, suppose you had a plastic molding machine that molded plastic markers and plastic marker tops. Plastic markers and marker tops are very different. One is long and slender and one is short and round. However, because of the capital needed to purchase a plastic molding machine, only one machine was purchased.
The machine can produce both the plastic marker and the plastic marker top. However, it cannot make both at the same time. A mold is inserted into the machine that has cavities shaped like a plastic marker or shaped like a plastic marker top. Only one mold can be used in the machine at a time. If the plastic markers are being molded, then the tops cannot be molded until the mold is changed.
SMED is designed to set up a method of changing the mold (Die) in one minute. Normally an unorganized changeover of this size takes much longer than a minute. In a manufacturing facility, a machine’s sole purpose is to add value. In our example it is to mold plastic markers and plastic marker tops. The only time this machine is not adding value is when it is not scheduled, it is broken, or it is shut down to change over to another type of part.
VALUE STREAM MAPPING: A key measure to the success of the flow of value, also called the value stream, is the lead-time of value through the system. This can be illustrated using the value-stream mapping tool provided by Mike Rother and John Shook in their 1998 book Learning to See. Though the book was originally written for manufacturing processes, the value stream-mapping tool is applicable in many other processes.2
The value stream map also can be used to choose a place in the value stream where improvements need to be made. The first step for the urological medical office was to discuss the value stream map to better understand the problems causing inefficiency in patient flow (see chart).
Through discussions of the value stream and discussions about the office, the most inefficient step was found to be after a patient was placed in the exam room. The reason this was identified as a problem was because of the range of time, between 15 and 45 minutes, when the physician was present with the patient.
This is considered value-added “touch” time with the patient. The goal is to have all of this time focused on the diagnosis and treatment of the patient. However, this was not the case, as the lack of patient information inhibited the physician from efficiently and effectively diagnosing and treating the patient. The problem stemmed from not having the necessary information ready when the patient was taken to the examination room.
For example, a patient may be placed in the room without the results of their CT scan, making further evaluation difficult. Time was wasted not only by waiting on the scan to get faxed to the office but also because a room was being occupied inefficiently. To address these issues, SMED was used to ensure that in every case the same steps were completed the day before the patient arrives.
In a rural medical office, the physician is much like the machine in a manufacturing facility. This is because the goal is to optimize the physician’s time so that it is spent solely on diagnosing and treating the patient. To accomplish this task, many of the principles used in SMED are applicable to a rural doctor’s office.
The first step of the SMED process is to classify the work. The work can be classified into internal and external work.3
External work is work that must be done to change over the machine, but it can be done while the machine is running. For example, gathering the new mold to be inserted in the machine as well as all of the other hand tools that are needed to extract the current mold and install the new mold.
Internal work only can be completed while the machine is shut down. For example, removing the mold that produces the plastic markers is a task that can only be completed when the machine is not operating.
The reason for separating the work into these two categories is to optimize the changeover time by completing all of the external work before the machine has to be shut down.
External work in a rural medical practice is all of the tasks to be accomplished before the patient arrives in the office and before he is taken to the examination room. These include ensuring all patient records are present including physician notes, labs, imaging studies, and all items ordered from any previous encounter. If all of these tasks are completed by someone other than the physician, the internal work can be accomplished when the patient is in the examination room with the physician. Internal work includes diagnosing and treating the patient, which can’t be done efficiently without proper external work.
External work begins again after the doctor leaves the examination room as the staff must discharge the patient. This may include scheduling further tests and appointments, but the goal is to not have the physician do this type of work. The physician’s work should be internal value added “touch” time.
The next step in the SMED process would be to get better. This includes taking current internal work and making it external work.3 In a physician examination room this means taking an inventory of tasks done in an examination room by the physician and delegating those tasks to other members of the staff.
CASE STUDY RESULTS: To address the inefficiencies of the office, external work and internal work were appropriately identified. The office flow was analyzed and the biggest inhibitors to flow identified. The most significant impediment to flow was waiting on patient records after the patient was placed into the room waiting on external work to be finished.
By properly identifying external work and completing it before the value-added touch time, the office was able to significantly improve efficiency. Instead of working through lunch, the office finished the morning session on time and was able to have a lunch break. And the end of the day didn’t include staying 1.5 hours to 2 hours after the last appointment and paying significant overtime.
This process saved on average 1.5 hours to 3 hours per day, decreased patient wait time and increased physician touch time.
Chris Harris, DBA, is vice president of operations at Harris Lean Systems. Previously, he was associate professor of supply chain management at the University of Indianapolis School of Business in Indiana.
Andrew M. Harris, MD, is the endourology/robotics fellow and a clinical instructor at the University of Kentucky Medical Center.
- Womack JP and Jones DT. Lean Thinking. New York, NY: Simon & Schuster Inc., 2003.
- Rother M and Shook, J. Learning to See: Value-stream mapping to create value and eliminate muda. Brookline, MA: The Lean Enterprise Institute, 2003.
- Cakmakei M. Process improvement: performance analysis of the setup time reduction –SMED in the automobile industry. International Journal of Manufacturing Technology. 41(1-2):168-79, March 2009.