Lean Thinking In Medical Practices. Innovation, Action and Quality Improvement

1. Lean Thinking In
Medical Practices
Innovation, Action and Quality Improvement
Michael Crosnick

2. What Is Lean?
• Elimination of waste
– Toyota Production System (TPS)
• Philosophy
– Produce only what is needed, when it is
needed, with no waste
• Methodology
– Determination of value added in the process
• Tools
– Five Ss, kaizen event, standardized work, etc.
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3. Types of Waste (Muda)
• Overproduction
• Waiting
• Transportation
• Inventory
• Motion
• Over Processing
• Defects
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4. Kaizen Philosophy
• Employee-led continuous improvement
• Five steps
– Specify value
– Map and improve the value stream
– Flow
– Pull
– Perfection
• Even if it isn’t broken, it can be improved.
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5. Value Stream Mapping
• Process map of the value stream
• Includes information processing and
transformational processing
• Value-added steps: ―Would the customer be
willing to pay for this activity?‖
• Non-value-added steps
– Necessary
– Unnecessary
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6. Value Stream Mapping
Suppliers : Payer Customers: Accounting,
Physicians, Appointment Physician Office
Payer, Physician (chart)
Scheduling Software
102 Patient visits/day
Prep patient,
Verify insurance
Revisit authorization,
Exam and Rx.
SOAP note
Discharge summary
Transcripts
Check in, Copy to Report to
Prep patient,
Registration letterhead, Physician &
Review packet,
Insurance forms Proof read Fax revised Proof read signature med records,
Verify insurance,
First draft draft to second draft Close chart, Submit claim
Exam and Rx.,
transcription File report or invoice
New Evaluation Soap note
Evaluation summary
& plan
3 2 3
1 3 3 3
2 5-15 m P/T 0-1 m
P/T 1-3 m P/T 10-60 m P/T 1-10 m P/T P/T 0-15 m P/T
P/T 5-15 m 0-1 m
W/T W/T 0-15 m W/T 7-50 m 1-10 d W/T 1-20 d W/T 14-90 d W/T 1-10 d W/T 1-20 d
0 98% W/T 50%
FTQ 90% FTQ FTQ 98% FTQ 98%
FTQ 99% FTQ 20% FTQ 98% FTQ
Current State Metrics
P/T = 21-120 min. (average: 71 min)
W/T =18-150 days (average: 84 days)
6 FTQ = 10%

7. Value Stream Mapping
Suppliers : Payer Customers: Accounting,
Physicians, Appointment Physician Office
Payer, Physician (chart)
Scheduling Software
102 Patient visits/day
Prep patient,
Verify insurance
Revisit authorization,
Exam and Rx.
SOAP note
Discharge summary
Transcripts
Check in, Copy to Report to
Prep patient,
Registration letterhead, Physician &
X
Review packet,
X X X
Insurance forms Proof read Fax revised Proof read signature med records,
Verify insurance,
First draft draft to second draft Close chart, Submit claim
Exam and Rx.,
transcription File report or invoice
New Evaluation Soap note
Evaluation summary
& plan
3 2 3
1 3 3 3
2 5-15 m P/T 0-1 m
P/T 1-3 m P/T 10-60 m P/T 1-10 m P/T P/T 0-15 m P/T
P/T 5-15 m 0-1 m
W/T W/T 0-15 m W/T 7-50 m 1-10 d W/T 1-20 d W/T 14-90 d W/T 1-10 d W/T 1-20 d
0 98% W/T 50%
FTQ 90% FTQ FTQ 98% FTQ 98%
FTQ 99% FTQ 20% FTQ 98% FTQ
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8. Tools
• Takt time • Standardized work
• Throughput time • Kanban
• Five Ss • Single minute
exchange of die
• Spaghetti diagram
(SMED)
• Kaizen blitz or event
• Flow
• Jidoka
• Pull
• Andon
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9. Takt Time
• The speed with which customers must be served to
satisfy demand for the service.
Available work time /day
Takt time
Customer demand/day
• Cycle time is the time to accomplish a task in the
system.
• System cycle time is equal to the longest task cycle
time in the system—the rate at which customers or
products exit the system, or ―drip time.‖
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10. Throughput Time
• Time for an item to complete the entire process,
which includes:
– Waiting time
– Transport time
– Actual processing time
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11. Clinic Example
Cycle, Throughput, and Takt Time
Patient check-in Move to examining room
3 minutes 2 minutes
Wait 15
minutes
Nurse does Physician exam
preliminary exam and consultation Visit complete
5 minutes 20 minutes
Wait 15 Wait 10
minutes minutes
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12. Clinic Example
Cycle, Throughput, and Takt Time
• Patient check-in cycle time = 3 minutes.
• System cycle time = cycle time for longest task =
physician exam and consultation = 20 minutes.
• Throughput time = 3 + 15 + 2 + 15 + 5 + 10 + 20 =
70 minutes.
• 8 physicians 5 hours/day
Takt time
100 patients/d ay
0.4 physician hours/pati ent
24 physician minutes/pa tient.
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13. Clinic Example: Value-Added Time
• Valued-added tasks:
– Nurse preliminary exam
– Physician exam and consultation
• Non-value-added steps, necessary:
– Patient check-in
• Value-added time = 5 minutes (nurse preliminary
exam) + 20 minutes (physician exam and
consultation) = 25 minutes.
• Percentage value-added time = 25 minutes/70
minutes = 35 percent.
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14. Kaizen Blitz or Event
• Determine and define the objectives Act Plan
• Determine the current state of the process
• Determine the requirements of the process Check Do
• Create a plan for implementation
• Implement the improvements
• Check the effectiveness of the improvements
• Document and standardize the improved process
• Continue the cycle
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15. Standardized Work
• Written documentation of the way in which
each step in a process should be performed
• Not a rigid system of compliance, but a
means of communicating and codifying
current best practices
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16. Jidoka and Andon
• Jidoka is the ability to stop the process
in the event of a problem.
– Prevents defects from passing from one step
in the system to the next
– Enables swift detection and correction of
errors
• Andon is a visual or audible signaling
device used to indicate there is a
problem in the process.
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17. Kanban
Signal Signal
patients echo patients CT
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18. Single Minute Exchange of Die (SMED)
• Used to reduce changeover or setup time, which is
the time needed between the completion of one
procedure and
the start of the next procedure
• Steps
– Separate internal activities from external activities
– Convert internal setup activities to external activities
– Streamline all setup activities
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19. Advanced Access
• Patients are unable to obtain timely primary care
appointments.
• Advanced access scheduling reduces the time
between scheduling an appointment for care and
the actual appointment.
• The goal is swift, even patient flow through the
system.
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20. Advanced Access: Advantages
• Decreases no-show rates
• Improves patient satisfaction
• Improves staff satisfaction
• Increases revenue
– Higher patient volumes
– Increased staff and clinician productivity
• Promotes greater continuity of care
– Increased quality of care
– More positive outcomes for patients
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21. Advanced Access: Implementation
• Advanced access challenges established practices
and beliefs.
• Balance supply and demand:
– Obtain accurate estimates of supply and demand.
– Reduce or eliminate backlog.
– Minimize the variety of appointment types.
– May need to:
• Adjust demand profiles.
• Increase availability of bottleneck resources.
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22. Lean Sigma
Lean and Six Sigma are focused
on continuous improvement of
the system.
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Lean Six Sigma
Eliminate waste Eliminate defects
• Achieve flow • Reduce
and pull variation in
processes
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