the lean doctors workbook : an application guide for transforming outpatient clinic systems

The Lean DoctorsWorkbook

Also available from ASQ Quality Press:

Lean Doctors: A Bold and Practical Guide to Using Lean Principles to Transform Healthcare Systems, One Doctor at a Time Aneesh Suneja with Carolyn Suneja

Quality Function Deployment and Lean Six Sigma Applications in Public Health Grace L. Duffy, John W. Moran, and William Riley

The Public Health Quality Improvement Handbook Ron Bialek, John W. Moran, and Grace L. Duffy

Root Cause Analysis and Improvement in the Healthcare Sector: A Step-by-Step Guide Bjørn Andersen, Tom Fagerhaug, and Marti Beltz

Solutions to the Healthcare Quality Crisis: Cases and Examples of Lean Six Sigma in HealthcareSoren Bisgaard, editor

On Becoming Exceptional: SSM Health Care’s Journey to Baldrige and Beyond Sister Mary Jean Ryan, FSM

Journey to Excellence: Baldrige Health Care Leaders Speak Out Kathleen Goonan, editor

A Lean Guide to Transforming Healthcare: How to Implement Lean Principles in Hospitals, Medical Offices, Clinics, and Other Healthcare Organizations Thomas G. Zidel

Benchmarking for Hospitals: Achieving Best-in-Class Performance without Having to Reinvent the Wheel Victor Sower, Jo Ann Duffy, and Gerald Kohers

Lean-Six Sigma for Healthcare, Second Edition: A Senior Leader Guide to Improving Cost and Throughput Greg Butler, Chip Caldwell, and Nancy Poston

Lean Six Sigma for the Healthcare Practice: A Pocket Guide Roderick A. Munro

Lean for Service Organizations and Offices: A Holistic Approach for Achieving Operational Excellence and Improvements Debashis Sarkar

To request a complimentary catalog of ASQ Quality Press publications, call 800-248-1946, or visit our Web site at http://www.asq.org/quality-press.

The Lean DoctorsWorkbook

An Application Guide for Transforming Outpatient Clinic

Systems with Lean

Aneesh and Carolyn Suneja

ASQ Quality Press Milwaukee, Wisconsin

American Society for Quality, Quality Press, Milwaukee, WI 53203 © 2011 by ASQ All rights reserved. Published 2011. Printed in the United States of America.

17 16 15 14 13 12 11 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data Suneja, Aneesh, 1968- The lean doctors workbook: an application guide for transforming outpatient clinic systems with Lean/by Aneesh and Carolyn Suneja. p. cm. Includes bibliographical references and index. ISBN 978-0-87389-813-3 (alk. paper) 1. Medical offices–Planning–Handbooks, manuals, etc. 2. Lean manufacturing–Handbooks, manuals, etc. I. Suneja, Carolyn, 1968–II. Title. R728.S94 2010 610.68–dc22 2010046239

No part of this book may be reproduced in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher.

Publisher: William A. Tony Acquisitions Editor: Matt T. Meinholz Project Editor: Paul O’Mara Production Administrator: Randall Benson

ASQ Mission: The American Society for Quality advances individual, organizational, and community excellence worldwide through learning, quality improvement, and knowledge exchange.

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Printed on acid-free paper

Contents

List of Figures and Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Learning Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

How.to.Use.This.Book. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

The Six Success Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Lean Mapping Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Application Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Your Turn Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Case.Study.Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Main Street Orthopedics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Minimize.Patient.Wait.Times. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Low Patient Wait Times Indicate a Healthy System . . . . . . . . . . . . . . . . . . . . . . . . . 8 Application Exercise: Minimize Patient Wait Times . . . . . . . . . . . . . . . . . . . . . . . . . 11

Begin.One.Doctor.at.a.Time. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13.

Application Exercise: Begin One Doctor at a Time . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Success.Step.1:.Create.Physician.Flow. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Shared Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Changeover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Lean Process Mapping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Application Exercise: Create Physician Flow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

v

vi Contents

Success.Step.2:.Support.Physician.Value-Added.Time. . . . . . . . . . . . . . . . . . . . . . . . . . 29.

Team Leader Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Benefits of the Team Leader Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Developing Team Leaders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Application Exercise: Support Physician Value-Added Time . . . . . . . . . . . . . . . . . 40

Success.Step.3:.Communicate.Patient.Stages.Visually. . . . . . . . . . . . . . . . . . . . . . . . . . 41

Visual Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Patient Status Boards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Application Exercise: Communicate Patient Stages Visually . . . . . . . . . . . . . . . . . 48

Success.Step.4:.Standardize.Everyone’s.Work. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Definition of Standard Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Benefits of Standard Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Application Exercise: Standardize Everyone’s Work . . . . . . . . . . . . . . . . . . . . . . . . 61

Success.Step.5:..Lay.Out.the.Clinic.for.Minimal.Motion. . . . . . . . . . . . . . . . . . . . . . . . 65

Spaghetti Mapping and 5S for Individual Workstations . . . . . . . . . . . . . . . . . . . . . 67 Communication Flow Considerations Across the Clinic . . . . . . . . . . . . . . . . . . . . . 72 Application Exercise: Lay Out the Clinic for Minimal Motion . . . . . . . . . . . . . . . . 78

Success.Step.6:.Change.the.Care.Delivery.Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Application Exercise: Change the Care Delivery Model . . . . . . . . . . . . . . . . . . . . . 88

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

List of Figures and Tables

Figure 1 Current state at Main Street Orthopedics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Figure 2 Main Street Orthopedics without physician flow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Figure 3 FIFO lane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Figure 4 Physician Lean process map . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Figure 5 Physician Lean process map with communication flow. . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Figure 6 Physician Lean process map (one patient flow) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Figure 7 Main Street Orthopedics with physician flow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Figure 8 Main Street process with bottlenecks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Figure 9 Main Street Orthopedics process with changeover and a team leader . . . . . . . . . . . . . . . 39

Figure 10 Main Street Orthopedics without visual communication . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Figure 11 A patient status board from an orthopedic clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Figure 12 Main Street Orthopedics with visual communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Figure 13 Physician assistant–to–physician handoff without standard work . . . . . . . . . . . . . . . . . . 52

Figure 14 Standard work improvement process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Figure 15 Standard work chart example in a fractures clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Figure 16 Standard work chart example for day surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Figure 17 Physician assistant–to–physician handoff with standard work . . . . . . . . . . . . . . . . . . . . . 61

Figure 18 Inefficient Main Street Orthopedics front desk layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Figure 19 Spaghetti diagram of the front desk of a busy clinic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Figure 20 Commonly used forms moved to point of use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Figure 21 Cleaned and organized supply closet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Figure 22 Forms pull system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Figure 23 Efficient Main Street Orthopedics front desk layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Figure 24 Spaghetti diagram of Main Street Orthopedics layout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Figure 25 Hand-offs, delays, and communication barriers caused by inefficient layout . . . . . . . . . 75

vii

viii List of Figures and Tables

Figure 26 Common staff area redesign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Figure 27 Improved Main Street Orthopedics layout spaghetti diagram . . . . . . . . . . . . . . . . . . . . . . 77

Figure 28 Main Street Orthopedics casting process spaghetti diagram . . . . . . . . . . . . . . . . . . . . . . . 82

Figure 29 Departmental separation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Figure 30 A cell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Figure 31 Main Street Orthopedics in-room casting process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Introduction

LearnIng goaLs

What do you hope to learn by working through The Lean Doctors Workbook?

1

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How To Use This Book

THe sIx sUccess sTeps

The content of this workbook is based on our book, Lean Doctors: A Bold and Practical Guide to Transforming Healthcare Systems, One Doctor at a Time, and on our years of transforming care delivery systems with Lean. The Six Success Steps discussed in the book are presented here with a focus on implementing them to achieve dramatic and sustainable change. The Success Steps are building blocks; the order in which you apply them matters. They are presented here in an order that has worked for us and our clients; working through them logically will help you on the path to successful implementation.

Lean MappIng TooLs

Each Success Step includes a practical explanation of the theory and maps that illustrate how that particular step impacts the care process in the context of a detailed case study. We have used several Lean mapping tools, including:

• Lean Process Map: This is a tool we developed for our work in healthcare. It combines a classic step-by-step process map with the metrics typically found on a value stream map to provide a detailed process overview and performance analysis.

• Spaghetti Diagram: This classic mapping tool creates a visual depiction of the motion involved in the performance of a particular task. Spaghetti diagrams highlight where people walk or move while working; the goal is to reduce that motion and increase efficiency.

• Swim Lane Diagram: A swim lane diagram is a process map that highlights handoffs between different functions or job titles within a process. Each function involved in the task has its own “lane”; handoffs occur when the process moves from one lane to another.

In addition to illustrating Lean concepts and their application in the context of our case study, these maps provide instructive examples that can help you create similar maps for the processes you operate.

3

4 How To Use This Book

appLIcaTIon exercIses

Each section of this workbook includes application exercises designed to help you translate the concepts and tools to your particular setting and processes. These exercises can be completed individually or as part of a team training session or Lean project team meeting.

If you are responsible for a Lean implementation, consider using the exercises provided with your project team to facilitate group problem solving and idea generation. Regardless of your participation in a Lean implementation, however, we encourage you to take the time to complete the exercises. Doing so will help you shift your focus from theory to application and ensure that you get the most from Lean Doctors.

YoUr TUrn exercIses

The concepts and tools discussed in this workbook are illustrated through a case study. For each Success Step, you will be presented with the case study “Before” scenario and asked to record your thoughts about the process described. Then, in the Your Turn exercises, you will have the chance to quickly sketch out a new process using the content presented. Finally, the case study “After” scenario gives you one possible process improvement based on the Lean principles described in Lean Doctors.

case study Introduction

MaIn sTreeT orTHopedIcs

We will be using a high-volume orthopedic clinic as our case study. The clinic, called Main Street Orthopedics, has the following provider team:

• Tracy Smith, the program manager

• Dr. Bruce Plainfield, Main Street’s orthopedic surgeon

• Ann, the nurse who works closely with Dr. Plainfield

• One physician’s assistant

• One resident

• Two casting technicians

• One clinic assistant

• One receptionist

Dr. Plainfield’s team runs a four-hour fractures clinic three days of the week and sees approximately 50 patients in those four hours during the busy summer months.

There are four exam rooms for Dr. Plainfield’s fractures clinic, and no room for physical expansion. However, because of increased marketing and public relations work on the part of the larger hospital system, demand is growing and building capacity in Main Street Orthopedics is critical to the organization’s long term goals.

Dr. Plainfield and his staff have hectic days—there are emergency hallway meetings, the nurse and PA spend time chasing down missing information (such as radiology films) and misplaced files, the cast techs complain that they work in a “feast or famine” environment in which they have either nothing to do or a line of patients waiting for casts. Staff satisfaction is low, they never get to go home on time, and the unpredictability of the schedule is taking a toll on both their personal and professional lives.

5

6 Case Study Introduction

Dr. Plainfield does not feel as though he has the information he needs to accurately diagnose and treat patients at the moment he walks into the exam room. Often, radiology films are missing, or information from ERs is not passed along properly. He is uncomfortable with the amount of information that is passed informally in the hallways, and he worries that those exchanges are not thorough enough. He’s frustrated that he has no time to dictate files, and often stays much later than the clinic runs in order to catch up on dictations. He’d like the clinic to be calmer and allow him to focus more comfortably on patient care.

The nurse, Ann, is also frustrated. She feels underutilized in the clinic even though her days are hectic and she and the other nurses often work through lunch trying to keep the clinic moving. She’s uncomfortable giving Dr. Plainfield feedback about the work environment, but is tired of staying late and missing time with her family when the clinic runs over.

Patients wait in the waiting rooms and in the exam rooms, are often lost in the system as they move to radiology or physical therapy, and feel as though they’ve “lost their place in line.” The hectic environment of the clinic erodes their confidence in the care they receive. They hear comments from the exam rooms such as “Did you find Mr. Johnson’s file? I set it down somewhere.”

At the beginning of their Lean transformation, they had the following performance metrics:

• Patient satisfaction surveys show current patient satisfaction at 51%

• Most recent staff satisfaction survey shows staff satisfied 65% of the time

• Average patient consultation time with Dr. Plainfield is 3 minutes

• Average patient time in the clinic is 70 minutes

• Average wait time in the waiting room is 18 minutes

• Average wait time in the exam room is 24 minutes

• Average clinic end time is 5:45 pm (last appointment scheduled for 4:30 pm); clinic occasionally runs even later if patients are scheduled for the wrong clinic

We will explore different aspects of this case study as we discuss the Six Success Steps. However, before we begin the orthopedic clinic’s Lean transformation we must discuss two critical issues: focusing on patient wait times as the key metric and beginning with one doctor at a time.

Minimize patientWait Times

How closely are patient wait times tracked in your clinic or unit? How would the system change if patient wait times were the ultimate measure of success in your department?

7

LoW paTIenT WaIT TIMes IndIcaTe a HeaLTHY sYsTeM

Lean is about keeping the value and removing wastes in the patient care process. We define value from the customer’s point of view: what does the customer—the patient—care about? When we answer that question, we think of time spent with the provider, good communication with the physician, and outcomes. We do not think of waiting.

And yet patients do wait. Typically they wait at every step of the process: they wait to check in, they wait to be roomed, they wait to see the physician or another provider, and they wait to schedule follow-up appointments and check out. How long they wait tells us a lot about the process itself.

Shorter patient wait times are an indicator that the rest of the system is performing efficiently. We have found patient wait times to be the critical metric in a Lean trans-formation. No other metric—or combination of metrics—brings underlying sources of frustration, redundancy, and waste so clearly into view. Focusing on reducing wait times gives the project team a powerful common goal that can be clearly measured and tracked.

Our vision of Lean in healthcare is to create a calm clinic environment in which each patient experiences the highest quality provider interaction and seamless delivery of care from the beginning to the end of the visit. The principles we will discuss work together to create that system and allow patients flow through the clinic without unnecessary delays, confusion, or frustration.

Flow

In order to minimize patient wait times, we must understand the Lean concept of flow.

Flow in the Lean sense is a manufacturing term. It refers to the ideal state of product moving through a manufacturing process without stopping. When a system achieves flow, the thing (or person) going through the process does not stop from beginning to end; instead, it flows continuously as a river flows. Imagine a car being built using the principle of flow. The manufacturing process would start at one end and stop at the other end of the factory with a completed vehicle (and a customer to buy it!). Along the way, the product would not stop moving for any such reason as defects, lack of parts, absent workers, or broken equipment. At the end, ideally, the product would not be stored in a huge, wasteful warehouse.

8 Minimize Patient Wait Times

KeY poInT

Short patient wait times are an indicator that the care delivery system is functioning

well from beginning to end.

Learn the Lingo

FLOWThe ideal state of Lean in

which the thing (or person)

going through the process

does not stop from beginning

to end, but instead flows

continuously like a river.

Minimize Patient Wait Times 9

Paperwork

0 min.

Hi: 3 min. Lo: 1 min. Avg: 2 min.




Room andvitals

18 min.

PA/Resexam

10 min. 24 min.

Patient Flow Observations: 2 Hours

Check in W W W W


Check out

3 min.

W


Cast

3 min.

W


Physicianexam

12 min.

W


Radiology

• Patient satisfaction: 51%• Staff satisfaction: 65%• Average patient consultation with Dr. Plainfield: 3 minutes• Average patient time in the clinic: 70 minutes• Average wait time in the waiting room: 18 minutes• Average wait time in the exam room: 24 minutes

Wherever the product stops, it piles up, gets stacked in aisles, gets lost or damaged, and hides system-level problems in a sea of inventory. The goal is to keep the product moving, which requires focusing the system completely on the product, making that product to the rate of customer demand, and resolving problems immediately as they occur. Every step in the journey of meeting that goal has huge implications—and often requires huge changes—for the manufacturing system.

In healthcare, and specifically for the clinic, that product is the patient. In an ideal state, the patient would enter the clinic and move continuously from check-in to check-out without stopping. Each time the patient stops, the wait time is indicative of a larger issue with the system. A wait at radiology, for example, may indicate that the department is short of staff, that equipment is not working, or that the radiology resources are mismatched with patient schedules or needs. A wait for the physician once the patient is in the exam room may indicate that the physician is overloaded with other demands that do not fit into the schedule or that the clinic is chronically overbooked. A wait at a supporting department may mean that the workload is not balanced, which causes the department to experience work in waves that cause delays.

Patients at Main Street Orthopedics experience wait times at nearly every step of the process. The initial mapping session in the clinic observed patients for two hours, and resulted in the map illustrated in Figure 1.

Figure 1 Current state at Main Street Orthopedics.


What problems do you see with this process?

Where are patients waiting? How does the total wait time compare to the time spent with the provider?

What do the wait times indicate about this process?

Minimize Patient Wait Times 11

Who benefits if wait times are reduced?

appLIcaTIon exercIse: MInIMIze paTIenT WaIT TIMes

What are the most visible problems in your clinic or area? What makes your area fall behind schedule?


How would your patients describe the workings of your unit? What issues do patients raise in your satisfaction surveys?

What stakeholders and decision makers must be on board with Lean changes? How would Lean benefit each of these stakeholders?

Begin one doctor at a Time

Before you create your first map or hold your first workshop, you must decide on a strategy for your Lean implementation. Selecting a strategy is a critical decision—one that will largely determine the success of your Lean efforts. Will you begin with training sessions for all employees? Will you hire outside consultants to lead the effort? Will you raise awareness of the Lean effort first and then select some projects as experiments?

There are as many strategies for implementing Lean as there are organizations involved in Lean initiatives. One of the most common is the mass training approach, in which a consultant or internal quality group introduces Lean concepts to the organization by training everyone and then sponsoring some projects or simply encouraging areas to select projects to manage with their new skills.

This is not an effective strategy for several reasons. First, if people are not given an immediate opportunity to use what they have learned in training, they will quickly forget the content and the money spent on the training will have been wasted. Second, such introductory training is not sufficient to equip a physician or team to apply Lean in a meaningful way, so changes made as a result of the training are seldom sustainable. The resulting lack of progress often makes it even more difficult to get buy-in on the front lines for the next improvement initiative.

Another common approach is to train a group of internal resources to lead multiple projects within the organization. These resources are typically pulled from their regular duties part time to participate in training sessions and manage a Lean project. The more resources are trained, the more projects are launched within the organization. This strategy does away with the wasted training dollars by making the trainees immediately accountable for managing a project using their new skills. However, because of the number of projects organizations using this strategy tend to launch, these new Lean practitioners seldom have enough support to successfully effect change while they themselves are still learning the concepts and tools. Without intensive and knowledgeable coaching, taking on a Lean project becomes a stressful, high-risk assignment that too often ends in failure.

The problem with both of these approaches is the scope. A healthcare organization that decides to take on Lean must learn it thoroughly before launching it broadly. The mass training strategy and the multiple project strategy involve too many people and garner too much organizational attention to make good starting points.

13

14 Begin One Doctor at a Time

We recommend approaching Lean with a much smaller scope: one doctor at a time. This approach lets the organization learn what a Lean system looks like and creates a model that can be replicated in other areas. It is a lower risk opportunity to apply the tools to a specific set of circumstances and focus the available resources on making that one area work. Once it is successful—and it will be successful—it’s possible to move on to other areas using what was learned in the first.

To begin, select an area. This may be an area in great need of process improvement or one in which building capacity is critical. Whatever the need, the area that becomes the starting point for Lean must have a strong manager—one who is knowledgeable about the day-to-day operations and challenges, and who has the trust and respect of the care delivery team.

Once you’ve selected the area, work with the manager to identify one physician with whom to begin the Lean work. That physician should have the potential to become a champion for Lean within the organization. Select a physician who is open to direction and feedback, who has good working relationships with his or her team, and who will make a good spokesperson for the Lean work once you have achieved some success. Above all, the physician you select should be willing to participate; do not spend time trying to convince an unwilling doctor to be part of your Lean efforts.

The next step in the process is to map out the current processes and capture the amount of time patients spent at each step, including time spent in consultation with the physician, and present that information to the physician to build a case for change. If, for example, that physician is able to see 40 patients in a four-hour clinic, but the average consultation time was three minutes, where did the other two hours go? That kind of objective data makes a powerful argument for analyzing the process and looking for the sources of waste.

From there, the team has everything it needs to begin a Lean transformation: strong management, a willing and informed physician champion, and the initial data that highlights where the process stops flowing and causes patients to wait.

The strategy of working with one doctor at a time and laying the groundwork for change will allow your Lean efforts to result in sustainable and positive change. The Success Steps that follow build on these two strategic decisions—focusing on wait times and working with one doctor at a time—to create a logical structure for working with the provider team to achieve those changes.

In our case study, program manager Tracy Smith is a strong leader with a long history of working with quality improvement initiatives in the hospital system. She has detailed knowledge of the orthopedic clinic’s workings and has built a culture of continuous improvement within her area. She is the ideal manager with whom to kick off a Lean initiative.

In the past, the hospital has experienced difficulty in trying to change processes. Even small changes can consume a lot of a manager’s time, especially when one or more physicians or staff members do not fully agree on the best way to perform

Begin One Doctor at a Time 15

a process. This is true no matter where the change is to be introduced, whether in clinics, in the hospital, or in the emergency department. Knowing this history, Tracy decided to start small, with just one physician and his team. That way, she would have the ability to trial changes quickly and learn the Lean tools without involving so many people as to make the process time consuming and unwieldy.

Dr. Plainfield was selected to be the physician champion. He is an energetic doctor who is willing to try new ideas if he sees their value in enhancing his ability to care for patients. He is open with his team, is well liked and respected, and handles feedback well. Since he runs one of the orthopedic program’s busiest clinics, he was a natural fit for physician champion. He was thoroughly on board after seeing the data collected about average patient time in the clinic versus time spent with him in the exam room.

appLIcaTIon exercIse: BegIn one docTor aT a TIMe

What strategy does your organization typically use to launch quality initiatives? How successful has that strategy been in the past? Have changes been sustained?

16 Begin One Doctor at a Time

Which area or department or clinic within your organization provides the best starting point for Lean? Why?

Who are your candidates for physician champion? What qualities make those physicians good candidates?

Success Step 1: Create Physician Flow

The physician consultation and diagnosis is the value added service: the physician is the driver of the patient care process. A quality interaction with the physician—combined with a minimal wait time—is one of the primary determiners of patient satisfaction. When that physician is behind schedule and late in seeing patients, or does not have the information he needs in order to interact with that patient effectively, patient outcomes and satisfaction can suffer. In addition, the physician’s ability to stay on schedule impacts the end time of the clinic as well as the work environment for all staff members.

At the beginning of the Lean transformation, we must analyze how the physician operates as part of the larger process of providing patient care. This analysis sometimes strikes teams as uncomfortable. After all, physicians are highly educated and practice what can be viewed as an art as much as a science. However, the analysis focuses not on the consultation between patient and physician in the exam room, but on everything that happens between exam rooms. When the focus is on the process of getting the physician into the exam room with all the necessary information and without wasted time, everyone wins. The doctor’s job becomes easier because problems and hassles are taken out of her way. The clinic staff members reduce “fire fighting” and frustration and stay on schedule. And most important, the patient receives the care he needs without unnecessary delays or confusion.

Main Street Orthopedics: “Before”

Dr. Plainfield’s clinic was certainly suffering from delays and confusion. When he exited an exam room, he often took time to dictate a file, return a phone call, or take care of other tasks in his office—regardless of whether another patient was ready to be seen. (See Figure 2.) The rest of the staff knew his pattern and adjusted to his pace, often prepping the next patient and gathering the necessary information only when he was out of the previous exam room. As a result, there were frequent lulls in the day and the clinic was chronically behind schedule. The staff felt as though they were harried all day long trying to catch up, and Dr. Plainfield certainly felt as though he was busy all day.

17

18 Success Step 1: Create Physician Flow

Figure 2 Main Street Orthopedics without physician flow.

From the patient’s point of view, the busy-ness between exams appears more like unexplained wait time.

What problems do you see with the current process?

Patient #1history and

exam

4 min. 6 min.

Dictate,paperwork/data entry

on Patient #1

3 min.


exam

4 min. 4 min.

No Physician Flow

W

Waits or delays

W


exam

4 min.

Phys

icia

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tien

t

3 min.


exam

18 min.

W

W

4 min.

W

Exit and fetchstaff for #1follow up

Search forcharts/last note/

films

See if thenext patient is

roomed

Success Step 1: Create Physician Flow 19

Why is the physician unable to flow from exam room to exam room?

What do you think the rest of the staff is doing during the 18-minute wait time?

What would you do differently?


To achieve physician flow and remove the sources of waste that keep the physician and the rest of the care team from focusing on their value-added work of providing patient care, we must step into our steel-toed boots and borrow some concepts from manufacturing: shared resources and changeover.

SHARED RESOURCES

A shared resource is typically one specialized machine through which products from many different lines must flow. For example, an automotive plant that sends all painted parts through a central oven would consider that oven a shared resource. Shared resources are potential bottlenecks in the process; if that shared resource is behind schedule or unavailable, everything else waits.

In the clinic, the physician sees all types of patients. There is typically one doctor in the clinic, not one for each exam room. Since all patients must flow “through” the physician, we treat the physician as a shared resource. That requires paying special attention to how the physician’s time is scheduled.

The schedule of products going to that shared resource must be level: one product cannot monopolize its time and make all others wait. That automotive plant would not (or at least should not) cure only rear-view mirrors in its oven and let the painted doors and fenders stack up. Nor can the physician see back-to-back new or complex cases while quick follow-up appointments are made to wait. Because scheduling templates often reflect the personal preferences of the physician, clinic end times are a good way to verify that a provider’s scheduling template is working effectively. If the clinic consistently ends late, evaluate the template to ensure that the physician can work effectively with the interval between appointments and with the mix of patient types.

While the scheduling template dictates the interval at which patients arrive at the clinic, the concept of a FIFO lane determines in what order patients are seen in the exam rooms. FIFO stands for “First In First Out,” a concept frequently used to schedule shared resources in manufacturing (see Figure 3). Products that must flow through a shared resource queue up in a FIFO lane and are processed in that order, rather than being picked randomly or by some other priority.

In the clinic, a FIFO lane mentality would dictate that the next patient who is ready in the exam room is clearly identified for the physician. Ideally, the “next ready patient” is the one the physician sees next. Using a FIFO lane means there is a clear system in place to identify the next ready patient. The physician need not decide whom to see next or choose an exam room to enter at random. Leveling the schedule and seeing patients on a first in/first out basis will help ensure that wait times are minimal.

Learn the Lingo

SHARED RESOURCEA specialized resource

through which all products

must flow; a bottleneck.


Figure 3 FIFO lane.

CHANGEOVER

Treating the physician as a shared resource means making sure that the physician’s time is used for value-added activity. In the clinic setting, that means the physician should be seeing patients. To make sure that the physician’s time is used for value-added activity, the rest of the provider team must manage the changeover process.

Changeover refers to the time between value-added activities. In our automotive plant, changeover would refer to elapsed time between producing the last driver’s side rear-view mirror, retooling the machines, and producing the first passenger side rear-view mirror. In the airline industry, changeover would refer to the time it takes to clean the cabin of an aircraft, refuel, restock, and load baggage in preparation for the next group of passengers.

In the clinic, changeover takes place between patients being seen by the physician. Changeover begins when the physician finishes with one patient’s consultation. Changeover ends when the physician walks into the exam room to see the next patient. While the physician is with the first patient, the next patient must be prepared for the physician’s consultation: he or she must be ready in an exam room, complete with paperwork, radiology films, and all necessary information. Viewed this way, most of the activity of the non-provider staff can be seen as changeover.

Exam room #1

PhysicianExam room #2

Exam room #3

Exam room #4

Ready for exam“First In First Out”

Learn the Lingo

CHANGEOVERThe elapsed time from the

end of one value-added

process to the beginning

of another.

INTERNAL CHANGEOVERParts of the changeover

process that occur when the

“machine” is not running.

EXTERNAL CHANGEOVERParts of the changeover

process that occur in parallel

to the value-added process to

minimize downtime.


Changeover time is called “internal” if it happens while no value-added work is going on. It’s called “external” if it happens in parallel to the value-added activity. Internal changeover causes delays in the system because the machine is not producing and the product has stopped flowing. The goal is to move the changeover tasks from internal to external so they happen in parallel, causing the machine to be idle for as little time as possible. A racing pit crew is a great visual example of internal changeover. In order to keep the racecar off the track for only seconds, rather than minutes, the crew has everything ready before the driver makes the pit stop. When the driver pulls in, all of the equipment needed for the changeover is right where it is needed and the crew is focused on a single goal.

In the clinic, the goal is to make as much of the changeover external as possible. This means taking a critical look at all of the tasks that must be accomplished in the process of patient care both before and after the physician consultation, and performing them in parallel. While the physician is with one patient, the next patient should be prepped and all necessary information gathered. In addition to the patient preparation, a timely and standard hand-off is an important part of the changeover process. A focus on changeover can result in time savings of minutes per patient; multiply those minutes by forty patients a day and it can mean hours in terms of clinic end times.

It is important to note that the reduced wait times and other time savings do not come from shorter patient–doctor visits or from imposing target consultation times on the physicians. When we view the physician as the operator of a machine performing a value-added process, Lean tells us to look at changeovers and non value-added times instead of at the physician–patient interaction. Since the physician–patient interaction is a small percentage of the total time the patient spends in the clinic, Lean efforts provide more dramatic results when focused on the non-physician’s patient-facing time.

A pit crew is a great example of efficient changeover: each member of the crew has a specific task, and the goal is to accomplish the tasks as quickly and effectively as possible.


LEAN PROCESS MAPPING

Putting the concepts of shared resources and changeover into action takes a bit of analysis and planning. We need to take a closer look at the current process in which the physician is operating in order to discover sources of waste.

To do so, we create a Lean process map. The Lean process map shows us the detailed steps of the process and critical metrics about the time each step takes and how often that step is done right the first time. In addition, the Lean process map provides a picture of the communication among different roles in the clinic at each step.

A Lean process map (Figures 4 and 5) can only be created through direct observation. To create the map, define the beginning and ending points of the process in question and then observe it in action and capture the following information:

• Main steps of the process

• P/T: Process time for each step (the time required for the step; how quickly it can be done)

• E/T: Elapsed time for each step (how long the step actually takes)

• FTQ: First time quality (written as the percentage of time the step goes right the first time)

Once the basic process information is captured, add the communication that occurs for each step. From whom must the physician receive information in order to advance to the next step in the process? For example, perhaps a nurse has the patient history or the radiology tech has needed films.

Figure 4 Physician Lean process map.

II

P/T: 2 min.E/T: 5 min.FTQ: 30%




III IVWalk intothe next

exam room

Walk outof an

exam room

I

Total P/T = 2 + 3 + 5 + 2 = 12 min.Total E/T = 5 + 5 + 10 + 7 = 27 min.FTQ = .3* .6* .5* .9 = .081 = 8.1%*

*8.1% of the time the process goes in an ideal manner


Figure 5 Physician Lean process map with communication flow.

Finally, capture the reasons for any FTQ metric less than 100%. These are evidence of the seven wastes in the process and they provide a strong starting place for problem solving and change. Summarize the reasons on the map.

The Lean process map has the added benefit of being able to communicate problems with the current system with visual impact. Creating the map with the team responsible for making changes helps to dramatically increase understanding of the current state and commitment to the change process. (See Figure 6.)

Figure 6 Physician Lean process map (one patient flow).

II





III IVWalk intothe next

exam room

Walk outof an

exam room

I

CA PA RES Cast RAD

IT system

RN

• Walk out of an exam room• Determine the next patient to see

P/T: 2 min.E/T: 2-7 min.FTQ: 33%

FTQ opportunities• Interrupted with a question, phone call, issue, etc.• Number of patients waiting – how do you decide ‘who’s next’?• Quick or longer patient?

• Go to the exam room and review charts• Greetings / introductions


FTQ opportunities• Seen before but forgotten• Forget if a follow-up or new patient• Parent might be on their cell phone

• History


FTQ opportunities• Don’t have info from another provider or facility• Got misinformation on the diagnosis• Poorly scheduled patient (can’t help in this clinic)

FTQ opportunities• Patient not prepped• Difficult to find paperwork / 8 million sheets on the chart• Don’t have info in an easy fashion: medication, diagnosis, other medical info

• Physical exam


FTQ opportunities• Already been done – PA or RES (info missing)• Child anxious or in pain

RN CA PA RES Cast RAD


Main Street Orthopedics: Your Turn

Based on the content presented in this section, what changes would you make to the processes Dr. Plainfield’s team is operating?

Draw the revised process map to incorporate those changes.


exam

4 min. 6 min.


on Patient #1

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Waits or delays

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Main Street Orthopedics: “After”

Dr. Plainfield’s team analyzed the tasks needed to complete a successful changeover between patients and began to perform those tasks in parallel to the doctor–patient consultations. Dr. Plainfield knew that the average patient consultation time during his fractures clinic was three minutes; even seeing 50 patients per day left 90 minutes for returning phone calls and dictating files. The new process achieved physician flow (see Figure 7).

Figure 7 Main Street Orthopedics with physician flow.


exam

4 min. 4 min.


on Patient #1

3 min.


exam

• Room and ensure readiness of the next patient• Organize charts, films, last

note for the physician• Anticipate timing/need for

patient #1 follow up




Phys

icia

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aff

Goa

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ange

over


APPLICATION EXERCISE: CREATE PHYSICIAN FLOW

List the steps the clinic staff performs between the physician’s consultation with one patient in an exam room and the next consultation in the same exam room. Then decide whether each step is an internal changeover step (happens while the physician is waiting to see another patient) or an external changeover step (happens while the physician is seeing another patient).

Changeover Step Internal or External Changeover Step?


Creating physician flow means making as much of the changeover process external as possible. Which internal steps from the previous page could be made external? How?

Internal Changeover Step Tactic for Making it External

Success Step 2: Support Physician Value-Added Time

Physicians want to see patients. Patients want to see their doctors. Everything else can be considered a distraction or a source of waste in the process.

If it were only that easy! The physician could devote all of her energy to that day’s patients and stay completely focused on the task at hand—seeing patients as they become ready in exam rooms and achieving flow through the clinic. However, we know that the work we do to achieve physician flow will not magically make all of the other interrup- tions and wastes disappear.


In Dr. Plainfield’s fractures clinic, redesigning the changeover process and achieving physician flow brought to light other sources of waste in the care process. Now, even though Dr. Plainfield was ready to see the next patient, other issues were interrupting flow. Occasionally patients were scheduled in the wrong clinic, for example, and could not be accommodated in a 10-minute fractures follow-up appointment time. The quicker pacing caused frequent bottlenecks in the casting area and highlighted instances when needed information such as radiology films were missing. (See Figure 8.)

29

30 Success Step 2: Support Physician Value-Added Time

Figure 8 Main Street process with bottlenecks.

What problems do you see with this map?


exam

15 min. 4 min.


on Patient #1

10 min.


exam

4 min. 5 min.

W

Waits or delays

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Phys

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Missing supplies

Missing x-ray filmsPatient inthe wrong

clinic

Physicianreturning

non-urgent calls

Bottleneckin casting







Staf

f G

oal:

Chan

geov

er

Success Step 2: Support Physician Value-Added Time 31

Why didn’t focusing on changeover eliminate these problems?

Someone in the clinic must be “driving the bus.” Someone must maintain the tempo of the clinic flow, monitor patient progress through the clinic, and ensure resources are allocated properly. That someone is not the physician; in fact, in most cases physicians do not want that role. Nor is it the clinic director or administrator, whose accountabilities are often externally facing, rather than the day-to-day details for patients moving in and out of the clinic.

Instead, we create team leader positions to help patients, staff, and physicians in the clinic. A team leader is not an addition to headcount; it is a role assigned to a member of the clinic staff (usually a nurse). Creating the team leader position is the single most powerful way to establish and maintain physician flow and remove the everyday roadblocks to reducing patient wait times.

The concept of team leaders comes from the principles of Lean. In a Lean organizational structure, a team leader guides the work of three to nine team members in an organization called a mini-company or a mini-business. Just as in any business, each mini-business has a clear management structure, reporting system, roles and responsibilities, and accountabilities.

KEY POINT

The team leader orchestrates activity in the clinic to ensure that the sources of waste

are removed from the physician’s job and that the clinic can run smoothly.


The mini-business aims to:

• Ensure high-quality flow of product through the area

• Ensure internal and external customer satisfaction

• Capture data and trends for continuous improvement opportunities

• Identify and solve problems to improve products

• Allocate resources according to needs

• Create a dynamic and lively organization by engaging everyone

TEAM LEAdEr rESPONSIBILITIES

Clinic preparation

Team leaders ensure that the schedule is level (and therefore that the FIFO lanes will result in short wait times) by reviewing the patient schedule in advance of each clinic. First, she reviews it to be sure the correct type of patient is scheduled in each appointment slot. For example, in a busy fractures clinic with 10-minute appointment intervals, a complicated non-fracture case would severely compromise patient flow. The team leader would reschedule that patient into the correct clinic.

After ensuring that all patients for the clinic are correctly scheduled, the team leader checks to be sure that all necessary information is on hand for each patient.

Asking these and other questions with enough time to reschedule patients into appropriate clinics, call patients with reminders, and gather missing information takes those problems and sources of waste out of the schedule on the day of the clinic.

TOOLS IN ACTION: TEAM LEAdErS

In one of our clients’ clinics, there is only one exam room with radiology equipment

capable of producing long films needed for scoliosis patients. However, too many

people—from a central scheduling function to the physician’s secretaries—had

input into the schedule, resulting one day in eight patients being scheduled for that

machine at 10:00 am. The team leader took responsibility for reviewing the schedule

a few days in advance and working with the physicians to change the scheduling

template and prevent overbooking of that shared resource.


As part of the preparation for the clinic, the team leader also notes the resources available in radiology and ensures that the correct number and types of equipment are functional. The number of radiology technicians available is important because techs often need help holding a patient in the correct position and ensuring patient comfort and safety as x-rays are taken. Obviously, too few resources in radiology will interrupt flow in the clinic. The team leader can influence decision making in support departments such as radiology by leading process improvement projects or other coordination efforts.

On the day of the clinic, then, the team leader uses a checklist to ensure that everything is prepared for optimal patient flow. Checklist items include:

• Patient load and schedule are appropriate to clinic type

• Charts are complete, reports and x-rays are accessible on chart

• Support staff is sufficient (nurses, cast techs, radiology techs, physician’s assistants, nurse practitioners, secretaries, and clinic assistants)

• Exam rooms are stocked with clinic necessities

• Team is aware of clinic end-time goal

• Call-back issues are handled after the clinic ends

The result of all of this preparation is that preventable problems and sources of waste are taken out of the system. The team in a busy fractures clinic with 10-minute appointment slots is not surprised by a scoliosis patient who requires a 30-minute consultation. Bottle-necks at casting or radiology do not develop because there are enough people to handle that day’s patient load. The physician does not waste time looking for information that should be included in the charts. In short, the team leader’s preparation ensures that the clinic can achieve flow.

Clinic monitoring

During the clinic day, the team leader’s goal is to ensure that every time the physician enters an exam room, the patient is ready for him.

To do this, the team leader must stay up to the moment on the status of each patient in the clinic and direct staff and resources to the specific needs of the individual patient. For example, if the team leader in a busy fractures clinic sees that five of eight patients in the clinic are in x-ray, she can direct other resources to radiology to alleviate the bottleneck.

When the physician enters the exam room, all of the changeover tasks must be successfully completed. If the patient must have a cast removed or x-rays taken prior to an exam, those steps must be completed. Since seeing patients is the value-added task for the physician, she must never walk into an exam room to find a patient who is not yet ready to be seen. Through clinic preparation and continual monitoring, the team leader supports that value-added time.


Clinic measurement

The team leader maintains a “glass wall” of metrics that are important to the physician, the clinic staff, and the patient. The graphs for performance metrics are posted and updated by the team leader, making the clinic’s performance transparent to all those who view the graphs. She uses the data to identify problems that surface repeatedly in the clinic and set goals for continuous improvement.

The best metrics for the glass wall are the ones the care team owns. Ownership means that the team should care about that metric and be invested in improving it. Ownership also means that the team is empowered to collect the data firsthand, rather than relying on an external department or function to provide it. Finally, ownership means that team members can directly impact the metric or solve the problems that trends in the data illuminate. When the team owns the metrics, data collection and analysis becomes a meaningful step in process improvement, rather than a perfunctory exercise.

For example, a team leader may learn from a physician that the most critical metrics are clinic end times, clinic errors such as missing radiology films, and patient volume by injury type or complexity. The team leader would collect ongoing data to see trends of issues, set joint goals with the working team, and coordinate improvement activities. For example, the data may indicate a problem—perhaps the clinic consistently runs over— for which the team leader is able to set an improvement goal and begin a problem-solving process.

The old adage, “what gets measured gets managed,” is certainly true. The simple act of tracking key performance indicators focuses the staff’s attention on them and leads to improvement.

Patient advocacy

The team leader maintains the Lean system by using and developing processes that are patient focused. She is the point person for continuing to drive out waste to reduce patient wait times and improve patient satisfaction. As such, she has the responsibility to keep the patient’s point of view in mind whenever processes are changed or improved.

For example, a team leader may help develop a short survey to collect data from a given set of patients at the end of their visits to monitor trends and opportunities in patient satisfaction. A team leader may also look ahead to upcoming clinic schedules to ensure patients are correctly scheduled and make additional phone calls to patients to remind them of needed information for the clinic visit. Or, she may help manage patient needs within the clinic, coordinating appointments with other departments, for example.

Learn the Lingo

GLASS WALL

A bulletin board in the clinic

where graphs of key metrics

are posted for all clinic staff

to see. The term “glass wall”

refers to the transparency of

the data.


Cross training of the clinic team

Cross training is a great way to build added capacity into the clinic staff, so that in busy times team members who are not overbooked can help those who are. Team leaders work with their managers or supervisors to manage cross training programs, maintain training records, and ensure that those who are cross trained can proficiently perform the new tasks. When team leaders choose personnel for cross training who can handle added responsibility, additional training becomes an earned reward and job enrichment.

BENEFITS OF ThE TEAM LEAdEr POSITION

• Problem Resolution for the Physician With a team leader in place, the physician has an ally who will help to solve

problems that get in the way of flow in the clinic. For example, if a particular physician’s clinic consistently runs late because of scheduling errors, the team leader would collect data on the types of errors occurring and work with the scheduling function to improve the process and prevent future errors.

• Team Development The team leader position brings the staff together as a team. Without a Lean

system in place, clinics often operate as a series of separate departments—nurses, casting, radiology, and physicians—with little communication or cooperation. The power of assigning someone responsibility for maintaining the Lean system and aligning work around common goals is that departmental barriers are broken down and the staff becomes a team.

TOOLS IN ACTION: TEAM LEAdErS

Many team leaders we have worked with say that their philosophy is to make it

easier for the physician to know what to do next. Since the physicians’ jobs are

almost exclusively medical decision making, the team leaders remove the need for

decision making about the schedule and flow of tasks. They use their knowledge

of the patient mix and schedule for the day to decide which patient the physician

sees next and when in the day the physician can review billing documents or return

phone calls. Rather than resent the time management, most physicians appreciate

the clarity of direction. Some even want to cancel the clinics when the team leader

takes a day off!


The team leader position can help clarify the roles and responsibilities of the clinic staff. Without a team leader focused on maintaining the Lean system and collecting critical data, each member of the clinic comes to work with different—and often competing—priorities. When roles are not clear, problems that surface within the clinic’s operations quite often result in staff dissatisfaction. Once a team leader is in place, however, he or she becomes the go-to person for problem solving and quality improvement. The data that the team leader collects reduces opinions and perceptions and lays bare the facts of the problem. The data provides an objective look at the clinic’s operations, without personalities and history getting in the way.

• Lean Sustainability Finally, creating a team leader position builds sustainability into your Lean

transformation. The team leader is first and foremost responsible for driving waste out of the clinic operations and keeping the Lean system in place. Organizations that do not assign this responsibility to a specific person in the clinic lose the Lean focus as soon as the consultant walks out the door.

dEVELOPINg TEAM LEAdErS

In most cases, the team leader is a nurse. Once a nurse has been given the team leader position, he or she will need additional skills development to be successful. Four main areas for development include:

1. Problem Solving: Team leaders have problem solving as a primary accountability, and so need a strong foundation in basic problem-solving tools and techniques. Tools include run charts, control charts, and Pareto charts for data gathering and analysis. Team-based problem-solving techniques include problem identification, root cause analysis, and A3 (the Lean process for problem solving).

KEY POINT

Problem solving is a key skill for team leaders, and tools for data analysis and

collection are indispensable. Nancy Tague’s The Quality Toolbox (ASQ Quality Press)

is an easy-to-use, comprehensive book of problem-solving and data-analysis tools.

It’s a great place to start if your team leader is new to quality improvement.


2. Lean Systems Principles: Team leaders are responsible for managing the Lean system and continuing to drive waste out of clinic processes. They need training in the seven wastes, flow (see Success Step 1), value stream mapping, standard work (see Success Step 4), 5S (see Success Step 6), and other principles. Introducing a principle and working projects to put that principle into practice most effectively accomplishes this training. For example, a team leader may attend a short training session on the principle of 5S and then lead a 5S project in the clinic.

3. Interpersonal Skills: Team leaders impact everyone else in the clinic. They will be much more successful if they are equipped with an understanding of interpersonal dynamics, consensus building, and conflict management.

4. Glass Wall Creation: Team leaders must help in thinking through what metrics may be important to their staff and patients and how to collect data in a meaningful way. Once the metrics have been identified and the data collection is underway, team leaders often need help determining the best process for reviewing the data with managers.

Of course, team leaders do not develop in a vacuum. Their supervisors and managers must play an active role in their development and on-the-job growth. Managers should review the data on the glass wall at regular intervals, help point out trends, and provide opportunities for team leaders to lead problem-solving efforts. Managers have the chance to become coaches, rather than taking care of each issue personally as it arises. Managers can also use the data to identify and work on projects with the physicians and the hospital system.

Learn the Lingo

SEVEN WASTES

Lean breaks non value-added

activity into seven categories:

Overproduction, Inven tory,

De fects, Motion, Waiting, Over-

processing, and Transportation.

VALUE STREAM MAPPING

A 40,000-foot view of the

steps and processes needed to

fulfill patient needs.






exam

4 min. 6 min.


on Patient #1

3 min.


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4 min. 4 min.

No Physician Flow

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Waits or delays

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roomed



Tracy Smith, the program manager, looked at the process maps and discussed the clinic’s operations with Dr. Plainfield. As a result, she created the team leader position for the orthopedic clinic and asked Ann, the nurse, to fill the role.

Ann quickly found that her top priority was to review the schedule for the fractures clinic a day or two in advance to make sure all patients were scheduled appropriately. When she found patients who were scheduled in the incorrect clinic, she called them to make another appointment. A few weeks of analyzing the schedule led to a cross-functional improvement project to clarify scheduling protocols with the central scheduling function.

Ann also began to review resources in the clinic to alleviate the bottlenecks that had caused delays and waits. By cross training clinic staff to help with simple tasks in other areas, she was able to create “on demand” casting help when she saw a backup there and a more flexible staff to help with changeover tasks.

In addition, Ann tracked the team’s performance in these three areas—scheduling errors, wait times at the casting bays, and changeover times—to help the team understand the problem and track its progress toward solutions. Combining visible metrics that were relevant and meaningful with opportunities to work on solutions to pressing problems kept the team motivated and engaged with the Lean project work. (See Figure 9.)

Figure 9 Main Street Orthopedics process with changeover and a team leader.


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• Ensure exam roomsare stocked

• Review schedules priorto patient visits

• Ensure charts/filmsavailability

• Focus on minimizingpatient wait times

• Assist the team withtasks, as necessary

• Keep the team engagedand updated

• Call to attention tobottlenecks and createlive game plans

• Direct physician to phonecalls/other requests asappropriateTe

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APPLICATION ExErCISE: SuPPOrT PhYSICIAN VALuE-AddEd TIME

Who in your area is currently responsible for physician flow? Who is the most logical person to fill the role of team leader?

What process changes must occur before your department would be ready for a team leader?

What metrics are currently tracked in your area or department? Who is the keeper of that information?

If those metrics are not currently visible, what impact do you think a glass wall would have on the physician and the rest of the team?

Success Step 3: Communicate Patient

Stages Visually

The team leader position truly enables success in a Lean transformation. The team leader is able to proactively root out waste in the clinic or practice and then monitor progress and address problems that arise.

There is much for the team leader to keep track of to ensure that patients are flowing. This section describes a pivotal tool the team leader will use to enable success: the patient status board.


The team leader role has provided Ann with opportunities for professional growth and job enrichment, and she is happy that she can make such a positive difference in how the clinic operates. But even she admits that being a team leader means coordinating many different tasks in the clinic. She needs a way to share the responsibility with others on the provider team and to communicate at a glance what must happen next to keep the clinic flowing. (See Figure 10.)

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42 Success Step 3: Communicate Patient Stages Visually

Figure 10 Main Street Orthopedics without visual communication.




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• Ensure exam roomsare stocked

• Review schedules priorto patient visits

• Ensure charts/filmsavailability

• Focus on minimizingpatient wait times

• Assist the team withtasks, as necessary

• Keep the team engagedand updated

• Call to attention tobottlenecks and createlive game plans

• Direct physician to phonecalls/other requests asappropriateTe

am L

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Who’s nextfor me?

How do Iknow theyare ready?

Which patientroom should

I go to?

How do Icommunicate

“who’s ready?”

Patient ison their way

from radiology

Next patienton schedule or a

quick patient?

Next patientis late – now

what?

Success Step 3: Communicate Patient Stages Visually 43

ViSual COMMuniCatiOn

Visual communication is the Lean concept of using visible markers, signals, and signs to communicate the status of a given process so that anyone walking into a work environment can tell what’s in progress, what’s working, and where there are problems.

People working in an environment with visual communication can easily make decisions about what actions to take. Visual communication tells us when our cars need maintenance, when to stop for a school bus, and whether a check-out lane at the grocery store is open.

Visual communication in the clinic essentially answers the question, “How do I know what to do next?” Imagine the physician’s job without visual control. (See Figure 10.) He comes out of an exam room and does not have a clear picture of who is next in line to be seen. Sometimes a clinic assistant acts as a traffic director and tells the physician which room is next. Sometimes he goes into a room because he sees charts outside the exam room indicating that a patient is waiting. Sometimes the patient comes out of an exam room to question the wait time and check his own status. In all of those scenarios, the physician is guessing what the next priority is, can be easily taken off course by unscheduled activities, and is dependent on verbal updates about patient status—updates that may or may not be current.

The same confusion impacts the rest of the clinic staff as well. If the nurses, residents, and physician’s assistants do not know the status of each patient in the clinic, there is unnecessary checking, delay, and frustration in the process. These are the wastes that increase patient wait times, lower patient satisfaction, and create stress for staff as well.

For the project team, communicating patient stages visually has several powerful benefits:

• It gives real-time information to people who can impact the outcome.

• It flattens the hierarchy by providing the same information to everyone.

• It clearly communicates priorities.

• It illustrates how each role fits into the overall process.

• It reduces waste of motion for the staff because it is visible over long distances.


Patient StatuS BOardS

Making patient status visible to the entire clinic team is a simple process with very powerful results. The clinic creates a patient status board that tells the staff where in the clinic each patient is located. This is a low-tech solution: a whiteboard with taped columns for each process step (see Figure 11).

Figure 11 A patient status board from an orthopedic clinic.

A visual board also reduces waste of motion. Just as we can see a stoplight from 500 feet away and decide whether to stop or go, a visual board can communicate the status of the entire clinic from anywhere within the clinic area, helping team members prioritize their tasks to support patient and provider flow.

As a fracture patient progresses in time through the fracture clinic, a magnet with the patient’s name written on it represents that patient on the clinic status board. Some of our clients add the appointment time and a color code for new or follow-up patients to the magnet as well.

Any member of the clinic team can move the patient’s name along the status board, but it is the team leader’s special responsibility to know the status of each patient and know where the physician is at all times during the clinic. Using the status board as a visual guide, the team leader tells the physician, for example, that exam room 2 is next, followed by exam room 4. The physician does not have to decide where to go next, leaving it to the team leader to direct flow through the clinic.

Room

7

8

9

10

11

12

Cast A

Cast B

Cast C

Cast D

Cast E

Cast F

Ready tobe seen inCast Room

Res/NP/PA X-RaysNeeded

Ready forPhysician

CastRequested inExam Room

Wrap Up

Exam Hallway

Patient Name

Name/Apt.

Name/Apt.

Patientin X-Ray

KeY POint

A low-tech, low-cost patient status board communicates the clinic’s priorities and

potential problems at a glance, allowing the clinic staff to allocate resources where

they are most needed.


Key to achieving this flow is ensuring that the patient is not moved to the “Ready for Physician” column of the status board unless all other changeover steps have been completed. The physician’s value-added time is increased when she presents only to those patients’ rooms that are ready. The status board is constantly monitored and updated by the team leader: it is the tool the team leader uses to provide direction and increase the physician’s available time for patient interaction. When both the status board and the team leader are in place, the physician is like a pilot, free to focus 100% on the task at hand, while the air traffic controller (the team leader) uses the radar (the status board) to oversee the larger picture.

Although the team leader is primarily responsible for directing clinic activity using the patient status board, the board itself triggers the next work in the process to begin. When a patient moves to each status column, the person doing the work can automatically assume duties without being told. If the patient is ready to be seen for casting, the cast technicians are aware that a patient is waiting. If the physician finishes with a patient and moves her to the wrap-up column, the nurse can be available to answer final questions or the clinic assistant can be ready to quickly turn over the room for the next patient.

The status board also creates the FIFO lanes we discussed earlier and ensures that patients are seen in the order in which they are ready. Visually communicating patient status removes the possibility that some wait longer than others simply because no one knows where they are.

Finally, the status board also provides a powerful visual image of the clinic operations. If the team leader sees a cluster of patient magnets in the casting column, for example, she can reallocate resources and alleviate the bottleneck. The visual summary of clinic activity is invaluable; in fact, one clinic thinks of the status board as a “clinic crystal ball.”

tOOlS in aCtiOn: Patient StatuS BOardS

One orthopedic client has taken whiteboards to new levels in the fractures clinic,

adding color coding and brief summaries of patient needs to the simple system of

columns. New patients, who take more time in the exam room, are represented by

red magnets. Follow-up patients are represented by yellow magnets. This gives the

physician a quick visual cue about the time requirements for the day. Further, the clinic

assistant created laminated magnetic cards with short descriptions such as “Pins Out”

or “Suture Removal” to summarize for the team what each patient’s visit requires.

Finally, the clinic assistant records the number of patients booked in the clinic for

the day at the top of the status board and numbers each patient throughout the

day. This has proven to be a powerful visual metric for the physicians, who are often

not fully aware of the number of patients they have booked for a particular clinic.

That awareness can lead to an adjustment of scheduling templates or protocols to

prevent chronic overbooking and late-ending clinics. The physician can also use the

“countdown” number to prioritize patients: if there are two or more in the “MD”

column, he knows to see the patient with the higher number first, assuring that the

FIFO lane works.


The principle of visual communication can be used in other areas of the clinic. For example, a basket for patient intake paperwork placed at the front desk acts as a visual queue for the clinic assistant, indicating that the next patient is ready to come back to an exam room. Making this kind of communication visual (rather than verbal) takes the possibility for errors of miscommunication out of the system.

Main Street Orthopedics: Your turn




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Main Street Orthopedics: “after”

Ann worked with the rest of the provider team to create a patient status board for the orthopedic clinic. Installing the board and using it consistently was a turning point in the Lean implementation: suddenly, all members of the provider team knew where patients were in the process, who was next in the FIFO lane, and when their own particular tasks needed to be done. The team leader was still responsible for ensuring patient flow, but with the patient status board as a tool, the rest of the staff began to perform their parts of the process automatically as patient magnets were moved across the columns. Ann began to feel more supported in her role as team leader, and the work environment began to improve as the rest of the staff became more engaged with the process. (See Figure 12.)

Figure 12 Main Street Orthopedics with visual communication.


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Phys

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Role

Look at the MDcolumn on the board

Changeover Update the board Changeover

Plan ahead Prioritize patients Alleviate bottleneck


aPPliCatiOn exerCiSe: COMMuniCate Patient StageS ViSuallY

Use the following questions to begin developing a patient status board for your area or clinic.

What are the stages patients in your clinic or practice go through? How do you know which patient is in what stage? Is the information available at a glance?

How does a patient move from stage to stage? How will that movement be represented on the board?

What common patient conditions can be easily indicated on the board (provided that the board is outside patients’ view)?


Who will be responsible for updating the board?

What benefits can you anticipate if you and the staff know the status of each patient at a glance, consistently and accurately?

Success Step 4: Standardize Everyone’s Work

At this point in a Lean implementation, the main obstacles to patient flow on a macro level have been addressed and the examination of individual roles and processes used to keep the clinic operating can begin. Problems arise when roles and tasks are ambiguous, especially in processes in which team members interact. In this section, we will address role and task clarity through the Lean tool of standard work.


In the Main Street Orthopedic Clinic, the team experiences problems handing off patient information from the physician assistant’s examination to the physician. Although the file is now complete and radiology films are ready to be viewed thanks to a well-defined changeover process, the verbal hand-off of information between members of the provider team is a big opportunity for omission and error.

The physician assistant conducts the first examination with the patient; if the physician is unavailable after that exam, she makes some notes and moves on to the next patient. When the physician is ready to see the first patient, he has to decipher the PA’s notes and often ends up repeating the history and exam. This repetition is a waste of the PA’s talent and time and gives the patient a poor impression of the provider team. (See Figure 13.) As a result, this process has a first time quality metric of less than 65%.

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52 Success Step 4: Standardize Everyone’s Work

Figure 13 Physician assistant–to–physician handoff without standard work.



PAhistory and

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MDhistory and

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timing betweenPA & MD

Too muchirrelevant

informationshared

PA/MD workflowtiming not well

coordinated

Forgotten details/incomplete

information

Success Step 4: Standardize Everyone’s Work 53

DEFinitiOn OF StanDarD WOrk

Standard work is a document that defines one person’s role in a particular task. It lists the main process steps, details for each step where needed, the time it takes to complete each step, and a layout diagram of where each step is completed. Standard work captures the current best way of performing a particular job and gives an organization a method for communicating process improvements systematically to the workforce.

Standard work is sometimes confused with other documents that provide information

about a job. Standard work is not a job description, which defines a job’s main account-abilities and how that job fits into the larger organization; nor is it an overall process description, which would include more than one person and the handoffs between functions. It is also not a standard operating procedure, which shows work in great detail and often includes safety and regulatory information.

Standard work can take many different forms depending on the organization, but all have the same elements: main process steps, work elements, time, and layout.

BEnEFitS OF StanDarD WOrk

1. Standard work provides a way to improve the process. Process improvement starts with workers analyzing what they do to complete required tasks. (See Figure 14.) The process of looking critically at your own work and writing the steps starts the wheels turning and makes you think. If you have had training in the seven wastes and principles of Lean before starting to create standard work, you can immediately start to see the wastes in your own job. Standard work analysis for wastes is the responsibility of the individual team member with coaching and guidance from a team leader or a manager.

kEY POint

Standard Work = One Person + One Job

kEY POint

A standard work document should always include the main process steps of the task,

the work elements, the time it takes to complete the steps, and the physical layout

of the workspace.


Figure 14 Standard work improvement process.

Additionally, the standard work document becomes the place to capture improvements. If there is nothing that defines the work method, then there is no way to improve it on a systemic level. One person—one nurse or PA, for example—might come up with a more efficient way to do his or her job, but without standard work documents that define how the job is done, there is no place to capture a change. Although it sometimes appears counterintuitive, it is precisely standardization that allows for easier improvement.

2. Standard work exposes resource imbalances. In the process of capturing the time needed for each job in the clinic, it may become apparent that a resource has time on his or her hands. Once that resource imbalance is exposed, tasks can be reassigned to correct the imbalance or that time can be put to good use in cross training.

In the Orthopedic Clinic, casting technicians are a good example. Some patients need casts and others do not, so the process of assigning times to the cast tech’s standard work will reveal downtime during the course of the work day. Once that time is identified, cast techs can begin to add new skills through cross training and job enrichment. They essentially become resources for other positions in the clinic that experience fluctuating volumes; for example, they could help turn over exam rooms or take on specific administrative tasks during busy times.

Peer / teamleader/manager

observations

Identifyopportunities

Discuss opportunities

Create a plan


Standard work helps define what the tasks are that keep the clinic operating smoothly; knowing how long each task takes to complete helps managers ensure that no one resource is overloaded or underutilized. It can also help a manager determine how many resources are needed for a given schedule and answer such questions as: What’s the work content of a secretary on a busy afternoon? How many cast techs are needed for a clinic in July?

3. Standard work ensures that handoffs and interactions among staff are smooth. A busy clinic is made of five or six different roles that interact with the patient separately or together to provide care. In most cases, these people have not been trained together; they are at different levels in the organization and have different perspectives and varying expectations of each other. They are the secretaries at the front desk, clinic assistants who room the patients, nurses who prepare charts and care for patients, PAs who conduct initial assessments, physicians who are the target for everything, cast techs, and radiology techs. As the patient interfaces with each role, there are handoffs and the transfer of information. (See Figure 15.)

kEY POint

Use resource imbalances as opportunities to provide cross training or help in over

loaded areas.

tOOlS in actiOn: StanDarD WOrk

In one clinic, the team leader recognized that the clinic assistant was a good candidate

for cross training and sometimes had excess capacity. The clinic assistant underwent

training through the hospital for cast removal and later approached the team leader

during a particularly busy time to offer to take the cast off a patient who had been

waiting. Through a combination of standard work and team leaderfacilitated cross

training, these clinic members created an “all hands on deck” attitude in the clinic.


Figure 15 Standard work chart example in a fractures clinic.

In the absence of standardization, staff in the clinic will develop their own methods of working; the standard becomes that everyone does things his or her own way. This is not a willful attempt to cause problems; it is simply the result of having to get the job done and not having agreed-upon methods. Often workers don’t like the methods their coworkers are using. Perhaps one person prefers paperwork assembled in a particular way, or a particular level of detail in notes, or a particular method of casting. Unless open confrontation is part of the clinic’s culture, people who prefer to work together begin to form cliques. Some days, things run smoothly. Substitute someone else into the mix, and problems can arise.

This kind of underground conflict can lead to ongoing personality clashes and higher stress levels among team members. The process of simply creating standard work clarifies roles and expectations, provides a forum for discussions about methods and improvement, and removes the root causes of many kinds of workplace conflict.

4. Standard work makes training new employees easier. In many organizations, on-the-job training means following an experienced worker around for a couple of days to “learn the ropes.” The new employee is supposed to observe the experienced worker and then do things the same way. Problems occur, however, when that experienced worker has a different way of doing tasks than other people in the same position, passes along inaccurate or incomplete direction to the new employee, or does the job incorrectly.

Title: Team Leader Workflow – Fractures Clinic

Developed By: Lori Peterson

Version (Circle one): Draft or Final

Approved By: Pam Longo

Tips for Success Step Activity or Task (Ideas, Technique, Notes, Time Supplies, Information)

Before clinic starts, check charts. Be sure sticky note with plan is on every chart. Most recent note and flow sheet (if available) should be on chart. For new patients, go to exam room and assessreason why seeing Ortho.Ask if X-rays, labs, or otherstudies ever done.

1

2

For questions regarding X-rays or in OOP, ask the provider before the clinic starts and fill out X-ray slip, if X-ray needed.

If X-rays not brought along,discuss patient assessmentwith the provider to see ifX-rays should be orderedbefore they see the patient.

CA, Cast Techs, or Rad Asstscan enter X-ray orders in System.

If CTs, MRIs, labs done but not brought along, find out where

3-5 Min/Each


But if the job has been defined through standard work, new employees can read the standard work document and use it to observe the experienced worker. The trainer, in turn, can walk through the standard work as he or she demonstrates the task and can explain critical steps or outcomes to the new employee. Using standard work as a tool for new employee training ensures that valuable process knowledge will not be lost and that turnover in the clinic will not mean a return to chaotic work practices. (See Figure 16.)

Figure 16 Standard work chart example for day surgery.

What tasks require standard work?

For ease of discussion, let’s break the clinic process into two main parts: the time the patient spends with the physician and everything else. The physician’s time with the patient is patient dependent; it is not the first priority for standard work creation. However, everything leading up to the physician’s time with the patient—and everything after—should be standardized with the goal of setting up the most effective patient–physician interaction possible.

This includes functions performed by each of the roles in the clinic staff:

Clinic assistant:

• Greeting and rooming patients

• Questioning patients and writing answers on charts for the ease of the PA, resident, or physician

• Updating white board with patient status

Stock mobile supermarket cart from storage supply room.

Stock room carts from mobile supermarket cart.

Pod 3 will be stocked daily.

Pods 1, 4, 5, 6 will be stocked weekly.

TOTAL TIME

1

2

3

4

5

6

7

Some items are stocked directly from supply room (personal belonging bags, laundry bags).

Do not fill item bins in room cart past fill lines.

Determine schedule of which pods on which days.

Day Surgery: Standard Work ChartTitle: Room/Pod Supply Cart Stocking Protocol

Step Work Element Description Key Points Service Time


Physician’s assistant:

• Presenting desired information in the order the physician wants it

• Processing orders for support services, such as radiology

Nurse:

• Knowing what to watch for when the clinic is behind

• Setting up schedules for the team

• Performing the team leader role

Physician:

• Finding information for the next patient

• Receiving hand-off information before walking into an exam room

• Updating the white board before and after seeing a patient

Secretaries:

• Working with scheduling systems

• Greeting patients

• Dealing with late arrivals

Clinic set up:

• Computers and other equipment turned on

• Exam room supplies replenished

• Supply carts replenished

• White board prepared

• Referral forms read

• Charts and patient paperwork prepared for next day’s clinic


Process for creating standard work

Standard work begins with individuals writing the steps they go through to perform their required tasks in the left-hand column of the standard work form. At first, there is no need to include work elements or to indicate whether the step is value added or even how long it takes to complete. There is also no need for special computer programs or complicated formats: simply capture the steps using a copy of the form and a pencil.

Because clinics have more than one person completing each job, the next step is to compare first drafts, look for obvious areas for improvement, and agree on a basic process among all those who perform that job. This step often involves some negotiation and compromise and can best be done with a “let’s try it and see” attitude. Nothing is set permanently on paper, and changes and improvements can be easily made. Once a draft process is determined, the team can jointly decide to revise it.

Once the main steps are agreed upon, it is time to gather the additional detail that the form captures. The people doing the jobs are the ones who should gather the information about work elements, times, and layouts. Further, that information should be gleaned through direct observation and measurement as the job is being done, rather than through estimation in a conference room. Clinic team members can carry a stopwatch and a note pad throughout their workday to get the most accurate process steps and times.

As the initial standard work documents are completed, they should be reviewed at two levels: first by all staff members in the clinic who complete that particular task (all nurses, for example, or all physician’s assistants). Then the people who perform the next task in the patient process should review the document to be sure the handoffs of information or patient interaction will be smooth. For example, if the physician’s assistants are writing standard work for handling x-ray orders, they would logically ask the radiology technicians and the physicians to review the document to ensure that everyone involved knows what information is needed and where that information belongs.

Reviewing and updating standard work documents is a continual process. Each time a new situation, improvement, or problem results in a process change, the standard work must be updated. The standard work document is the definition of the process—as long as those who use it keep it up to date.






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Dr. Plainfield worked with the physician assistant to jointly develop standard work for the handoff process. They wrote the steps that the physician assistant would take in conducting the exam and obtaining the patient history to avoid redundant questions, as well as the sequence, content, and method of communication between the PA and the physician. In addition, they mapped the physical location of the handoff and agreed on when the handoff discussion would take place for each patient consultation.

As a result, the PA’s expertise is more fully utilized, Dr. Plainfield has exactly the information he needs, and the patient is left with the impression that these two care providers communicate well. (See Figure 17.)

Figure 17 Physician assistant–to–physician handoff with standard work.

aPPlicatiOn ExErciSE: StanDarD EVErYOnES’ WOrk

What process definition documents exist in your department? How thoroughly are they used? To what degree is the format user friendly?

PAhistory and

exam

Plannedhand-off

between PAand the MD

MDhistory and

examPhys

icia

n


Where in your area does a lack of standardization cause problems? For example, are roles well defined? Do errors occur because of misunderstandings or partial hand-offs?

How are new employees trained? What process documentation is used? How are best practices captured? How is knowledge shared between senior and junior staff regarding a task?


What “low hanging fruit” can you identify as a possible starting place for standard work? What process changes must be made before those standard work documents can be developed?

Success Step 5: Lay Out the Clinic for

Minimal Motion

We’ll discuss laying out the clinic at two levels. The first level looks at individual workstations and uses spaghetti mapping and 5S tools; the second looks at the flow of communication and care through the entire clinic.

We will start with 5S for the individual workstation. We come to this process step rather late in our Lean transformation, and intentionally so. We know that 5S is a tangible, visible, and popular tool and one upon which many Lean transformations get stuck. It is easy to start with 5S and never move beyond it.

By this stage in the process, we have achieved flow for the physician, created a Lean organizational structure with team leaders, and clarified and improved care processes through visual communication and standard work. Any 5S activity at this point will further support these patient-centered improvements.


At Main Street Orthopedics, the standard work activity revealed a resource imbalance between the receptionist at the front desk and the clinic assistant who was responsible for various administrative duties. The clinic assistant had an opportunity to play a more active role in the changeover process, but needed to share some administrative tasks with the receptionist in order to do so. The receptionist had felt underutilized in the past and was eager to take on additional responsibilities.

However, within the first few hours of performing her expanded job, she realized that she was spending more time walking than working. She and the clinic assistant made a spaghetti diagram, mapping her movement at the front desk. (See Figure 18.)

65

66 Success Step 5: Lay Out the Clinic for Minimal Motion

Figure 18 Inefficient Main Street Orthopedics front desk layout.

What problems do you see with this layout?

Computerprinter

Forms

Credit cardreader

Copier

Charts

Success Step 5: Lay Out the Clinic for Minimal Motion 67


Spaghetti Mapping and 5S FOr individuaL WOrkStatiOnS

The tool 5S is often the starting place for making changes in a clinic after the initial waste walks and value stream mapping have been completed. It is the Japanese methodology of sorting the useful material in the workplace from the unneeded, organizing the essential tools and materials so that the worker does not waste motion, and then maintaining a clean and visual workplace. The goal of 5S is the have “a place for everything, and everything in its place.”

The best way to figure out the optimal workspace organization is to observe the process in action and create a spaghetti diagram. A spaghetti diagram is a map that tracks movement in the course of one person’s job. To make a spaghetti diagram for nursing, for example, one nurse will observe another with a rough sketch of the room layout in hand. Whenever the nurse walks to get something (supplies or forms, for example), the person observing draws a line on the diagram from the beginning point to the end point. The more movement involved, the more lines on the diagram. The result is a visual representation of the time spent with patients versus time spent getting supplies and information. The goal is to maximize time spent with patients (value added) and minimize individual wastes such as walking, searching, looking for each other, and so on.

Figure 19 illustrates the traffic at the front desk of a busy clinic. Even in a job that seems to be contained in one area, a spaghetti diagram uncovers lots of wasted motion.

Learn the Lingo

5SThe Lean system of sorting,

cleaning, and organizing the

workspace.

SPAGHETTI DIAGRAMA picture of the workspace

layout used to observe the

motion involved with per

form ing a given task.

WASTE WALKAn organized walk through

the clinic to identify sources

of waste.


Figure 19 Spaghetti diagram of the front desk of a busy clinic.

As clinic team members are creating the diagrams they usually ask, “Who designed this place anyway?” The team realizes that supply rooms are located too far away from where supplies are used, or that exam rooms are not large enough to accommodate all of the equipment needed on a patient-by-patient basis. Of course, the clinic was not designed to be inefficient: how things are stored is often a product of years of busy operation without time taken to step back and analyze the system.

Once the spaghetti diagrams are created, the team uses their knowledge of Lean principles to organize workstations, clear out clutter, and make sure necessary supplies and materials are exactly where they are needed.

Examples of common solutions that arise from spaghetti diagramming and 5S organization include:

• Moving commonly used forms (education, excuse, prescription) to the exam room to prevent nurses from leaving the room to retrieve forms from a central filing cabinet.

• Creating carts with nursing supplies such as bandages, scissors, and suture removal kits that can be moved from room to room. Supplies should be brought to the patient, rather than making the patient wait while the nurse walks across the clinic to get something.

• Organizing paperwork at the front desk to minimize motion and searching for the right forms.

• Locating printers at the point of use to eliminate unnecessary staff motion.


The photos in Figure 20 illustrate the results of 5S efforts to eliminate wasted motion by placing commonly used forms at the point of use rather than in a cabinet several feet away. Figure 21 shows a supply closet that has been cleaned and organized so that available inventory is clearly visible, making inventory management and reordering easier.

Figure 20 Commonly used forms moved to point of use.

Figure 21 Cleaned and organized supply closet.

When supplies and materials are organized and placed so workers need not waste motion in the course of their jobs, the next logical step is to look at how those supplies are replenished. The clinic will not be able to sustain the system of organization if supplies run out or if an internal or external supplier delivers inappropriate quantities of forms or casting supplies that must be stored in hallways or in cluttered cabinets.

Before 5S: Forms located too far away.

Before 5S

after 5S: Forms organized at front desk.

after 5S


To prevent those scenarios, we apply the concept of material pull to the supplies that the clinic needs. Pull is established using a kanban card system, which creates a supermarket for high-volume forms and supplies. When the inventory of supplies in the supermarket reaches a predetermined minimum quantity (based on the amount of time it takes to replenish the material), the clinic orders more.

Let’s take the example of a supermarket of intake paperwork forms at the front desk. If the receptionist uses twenty forms per day and the internal supplier can deliver more forms with half a day’s notice, the replenishment order would be placed when only ten forms remain. (See Figure 22.)

Figure 22 Forms pull system.

A system of material pull in the clinic helps to maintain an orderly environment because what’s on hand is only what’s needed. Further, establishing a pull system with internal suppliers drives your Lean initiative across departmental boundaries, thus clarifying requirements and reducing the possibility for errors caused by supplying functions.

Depending on the reaction time of the external departments, it may make sense to have a central supermarket in the clinic as an intermediate step to reduce space requirements around each staff member for forms storage.

Form A Form A Form A

WithdrawalKanban

ClinicTrigger orKanbanLevel Desk Trigger or

Kanban Level

DeskRefill

Kanban

Clinic

Internal Supplier






exam

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on Patient #1

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films


roomed



After the clinic assistant and the receptionist created a spaghetti diagram of the receptionist performing her new and expanded duties, they decided to relocate the forms, charts, and equipment that were needed to do the job. (See Figure 23.) When they asked members of the team about moving supplies, they found that no one knew why the supplies were stored where they were. No one objected to moving them to a more convenient place.

The outcomes of this simple exercise were powerful. The clinic assistant had time freed to help with changeover that would keep the clinic flowing. The receptionist felt empowered by making her work environment match her needs and setting herself up for success on the job. Both team members saw positive outcomes from their problem-solving initiative and helped to keep the focus on continuous improvement in the clinic.

Figure 23 Efficient Main Street Orthopedics front desk layout.

COMMuniCatiOn FLOW COnSideratiOnS aCrOSS the CLiniC

The second phase of spaghetti diagramming goes beyond the individual worker to map the communication and movement of all clinic team members in the process of patient care. Individual spaghetti mapping asked the question, “Where should supplies and equipment be located to help this person do her job most efficiently?” Spaghetti diagramming for the entire clinic asks questions such as these: “How many times did the physician go to someone to ask a question? Where are supporting departments such as radiology or physical therapy? Where are the break room and the coffee machine? How far are the nurses from the rest of the team? How much information is passed along verbally in the hallways?”

Computerprinter

Forms

Credit cardreader

Copier

Charts



At Main Street Orthopedics, the patient status board greatly simplified and clarified team interaction, but the layout of the clinic impeded effective and efficient communication. Members of the care team worked in areas designated by job title: nurses in one area, physicians in another, and so on. Individual work areas, separated by long hallways of exam rooms, made it difficult to find a team member to request assistance or clarify an order. See a spaghetti diagram of the layout in Figure 24.

Figure 24 Spaghetti diagram of Main Street Orthopedics layout.


Exam#1

Exam#2

Exam#3

Exam#4

Clinicassistants

Providerswork room

Nursingstations


How would this layout affect communication?

The diagram captures interactions among staff members to highlight where questions, clarifications, or instructions add to patient wait times as physicians, nurses, and other staff cross and re-cross the clinic for needed information.

Such an analysis can result in:

• Reduced patient wait times

• Enhanced visual connections to facilitate information seeking and interaction

• Reduced staff fatigue

• Maximized time with patients

• Feeling of teamwork and an interactive environment

• Reduced stress and chaos for both patients and the staff

Once the diagram reveals the extent to which the team is dependent upon each other for information, the physical barriers to effective communication become clear. These barriers include long hallways of exam rooms that prevent staff from seeing each other or the patient status whiteboard; supporting “departments” that are located at the far end of the clinic—isolating staff members who need to interface with the clinic staff—and workstations set up by job title that prevent the clinic staff from acting like a coordinated team. (See Figure 25.) Even a break room designed to keep coffee-drinking staff out of the view of patients adds to the staff’s difficulty in finding people and information in the moment they are needed.

keY pOint

Spaghetti diagrams can be used to uncover wastes in individual workstations and

tasks and across the clinic as a whole.


Figure 25 Hand-offs, delays, and communication barriers caused by inefficient layout.

preconstruction considerations

Significant changes can be made to existing clinics to improve communication flow and reduce patient wait times. Perhaps nothing can be done about that long hallway of exam rooms, but it is possible to rethink how the exam rooms and workstations are used.

Obviously, building a new clinic or an addition to an existing clinic provides a great opportunity to rethink traditional clinic layouts and design facilities for minimal patient and staff motion. (See Figure 26.) When minimal patient wait times are the primary design consideration, clinic planners must ask themselves a new set of questions to break through old paradigms about what a clinic should look like:

• Should supporting departments have doors that open to a common workroom so the staff can easily access the physician (and vice versa)?

• Rather than a nursing station, should there be a team station instead to remove the physical barriers to communication?

• Should exam rooms be arranged in a semicircle so the physician has visual communication with the staff no matter what room he’s in?

• Would a high, communal work counter promote teamwork better than individual desks or offices? Are the exam rooms designed around the patient assessment process?

• Are exam room cabinets big enough for storage of supplies at the point of use?

Patient #1

Patient #2

Patient #3

Patient #4

Provider

Nursing

Clinic Assistant

Casting

Handoffs – Delays – Clarifications – Communication Barriers


Figure 26 Common staff area redesign.


Main Street Orthopedics had an opportunity to design a new clinic as part of the hospital system’s expansion. Using what they knew about Lean and layout for minimal motion, the team made two major design decisions.

First, they created a common work area for the entire care team, which facilitated open communication and the continual exchange of information about patient status. Second, they added another door to each exam room, allowing them to open directly into the common work area. Patients entered the exam room from a quiet hallway and were not exposed to the hustle and bustle of the common work area. Staff, however, could find each other quickly and easily to request help or clarification.

These two changes combine the best patient experience with the most efficient layout for staff communication, ensuring that both the care team and the patients have the environment they need. Figure 26 illustrates how a redesigned common staff area facilitates better communication and easier access to staff members. Figure 27 is an improved spaghetti diagram.

Patient #1

Patient #2

Patient #3

Patient #4

Visual Communication – Team Space – Accessibility – Less Motion

Nursing Casting

ClinicAssistant

Providers


Figure 27 Improved Main Street Orthopedics layout spaghetti diagram.

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appLiCatiOn exerCiSe: LaY Out the CLiniC FOr MiniMaL MOtiOn

How would a new employee coming into your unit describe the organization of the work stations? Are materials stored where they are needed? How are inventory levels managed? How much time do employees spend searching for forms or supplies?

Where in your unit would you begin a 5S workshop and why? Who should be involved? What would be the goals of the workshop?


What opportunities are there in your department to change the layout for more efficient patient flow? Could any departments be broken down or moved closer?

Based on your knowledge of the unit or clinic, what immediate opportunities do you have to move information and supplies closer to the point of use? Where would you begin spaghetti mapping to learn more about staff motion?


If you could rebuild, what would you change? Based on our discussion of this principle, what layout changes would you make?

Success Step 6: Change the Care Delivery Model

The steps outlined so far in this book describe a method for laying a stable foundation in care delivery processes upon which even more dramatic changes can be built. These steps—creating physician flow and a team leader organization and using visual communication, standard work, and 5S—are essential to uncovering the root causes of waste in healthcare systems and driving that waste out.

Once those steps have been taken and the process is running predictably and efficiently, many other possibilities emerge that would not have been feasible at the beginning of the Lean transformation. Innovations such as mobile services and new models of care simply bring chaos when they are implemented in an environment that is poorly defined and fraught with waste. When these steps are successfully implemented, the sky’s the limit.


Main Street Orthopedics has successfully completed the first five steps. The work environment is calm and paced, team communication has improved, and volumes are up 25% in the same physical space. Both staff and patient satisfaction are near 100%. The team has adopted a mentality of continuous improvement and continues to look for ways to become more efficient and achieve better outcomes.

One opportunity to do so is with the casting function, which has always been located in three small casting bays at the end of a clinic hallway. Patients are moved from the exam rooms to the casting bays to have casts taken off or put on. If the team leader notices a backup in casting on the patient status board, she sends cross-trained staff members to assist. Figure 28 illustrates a spaghetti diagram of staff motion related to casting.

81

82 Success Step 6: Change the Care Delivery Model

Figure 28 Main Street Orthopedics casting process spaghetti diagram.


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Cast A Cast B Cast C

Success Step 6: Change the Care Delivery Model 83


Changing the care delivery model means rethinking the clinic processes to focus relentlessly on patient flow. The idea of focusing on flow is central to Lean. If Lean has one counterintuitive principle, it is that organizing work in departments does not work. Breaking support departments such as radiology, physical therapy, labs, and pharmacy into decentralized mini-departments fundamentally shifts the focus of the care process from the provider to the patient.

For example, imagine a product that is processed on specialized machine A in Department A, then moved to another specialized machine B in Department B, and finally moved to machine C in Department C for completion. (See Figure 29.) This traditional department-based process leads to the wastes of overproduction, excess inventory, wasted motion, wasted transportation, and so on.

KEY POINT

Organizing the care delivery process into physically separated departments results in

longer wait times, more hand-offs, and more waste.


Figure 29 Departmental separation.

The way to eliminate these wastes is to bring machines A, B, and C together and allow the product to flow from A to B to C and out the door. Now, because the product is not being transported and someone is overseeing its entire process, it is produced with higher quality, lower costs, and better morale and safety. This is a fundamental change that results in dramatic efficiency gains.

A layout that brings all of the parts of the process into one physical space is called a cell. In a cell, all equipment, supplies, and personnel are arranged to ensure that product flowing through the cell (in this case, a patient) travels the smallest distance possible. (See Figure 30.) There are no departments separated by space and walls, everything needed to perform the process is centered around that product. If we apply that concept to the clinic, the result is a focused team of professionals who are co-located and in constant communication and a patient who receives coordinated care without delays or confusion.

Figure 30 A cell.

A B C

Learn the Lingo

CELLA workspace design that

brings the people and equip-

ment needed for a given

process into one space so

that the product travels the

smallest possible distance.

A B C


Creating cells means rethinking the location and purpose of support departments in the context of patient flow. Support functions such as radiology, casting, labs, and pharmacy must be evaluated for the possibility of bringing them directly to the patient or moving them closer to the provider–patient interaction.

To the extent possible, all care should be provided in the exam room—from check-in to exam to radiology to casting to scheduling the next visit. Simple, low-cost changes (with the exception of portable radiology equipment) enable this change: wireless laptop computers can be used for check-in, follow-up appointment scheduling, even billing. Cast carts equipped with all supplies needed for applying and removing casts are easily assembled.

Some changes to the care delivery model require no technology at all, just a different way of viewing who does what. Once resource imbalances have been exposed and corrected and a cross-training or job enrichment program is started under the auspices of the team leader, the clinic staff can be much more flexible in providing service to the patient. One of our clients, for example, trained most of the staff to teach patients how to use crutches—once the domain of the physical therapy department, which was located in a different part of the hospital. Now the patients are casted in the exam room; they have their crutches adjusted and are taught to use them without having to leave the orthopedic clinic.

Further, if the other six principles presented here have been applied to the clinic, the foundations are already laid to make these changes successful. For example, there is already a simple and clear method for communicating patient status, so cast techs and radiology know which exam rooms are next in the queue. There is a team leader who ensures that the physician is available to see each patient without delay. Clinic management knows how long the casting or check-in process takes from the standard work documents, so in-room services can be staffed appropriately. Without these fundamental changes in place, changing the care delivery model to focus on in-room services would add new chaos and stress to the clinic’s work environment.






exam

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on Patient #1

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Waits or delays

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ian

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roomed



Main Street Orthopedics decided to trial mobile cast carts, eliminating the need for the patient to leave the exam room or wait in the hallway outside of the casting bays. (See Figure 31.) Providing the casting service in the room also helped preserve patient privacy. This change had the further benefit of bringing the cast technicians into more constant contact with the rest of the clinic staff and making it easier to for them to request help or clarify orders.

Figure 31 Main Street Orthopedics in-room casting process.

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APPLICATION ExErCISE: ChANgE ThE CArE DELIvErY MODEL

What care does your clinic or unit already bring directly to the patient (in the exam room)?

What steps of the care process require the patient to leave the exam room?


Recognizing that many process changes must come before changing the care delivery model, what can you envision as a future state for you?

What foundational steps must you take before changing how care is delivered?

Index

Aairline industry, changeover in, 21automobile manufacturing changeover, 21 Lean and, 8 shared resources, 20

Bbottlenecks, 30

Ccare delivery model, changes in, 81–87casting process, changes in, 81, 82, 87cells, 84–85, 84changeover, 21–22, 26, 39, 51, 65clinic assistants and standard work, 57clinic layout, 65–77, 76clinic measurement, 33clinic monitoring, 33clinic preparation, 32–33clinic set up and standard work, 58coaching, importance of, 13common work areas, 76communication, process information and, 23communication barriers, 74, 75communication flow, 24, 72–75, 76cross training, 35, 39, 54, 55, 85

Ddata analysis and collection tools, 36department-based work processes, 83, 84direct observation, 23

EE/T (elapsed time), 23employee training, 35, 39, 54, 55, 56external changeover, 21, 22

FFIFO lane (first in, first out), 20, 21, 32, 45, 475S, 37, 65, 67–69, 69flow, 8–9. See also physician flowforms pull system, 70front desk layout, 65, 66, 67, 68, 72FTQ (first-time quality), 23, 24

gglass walls, 34, 37

hhandoff process, 22, 52, 55, 59, 61, 75

Iinternal changeover, 21, 22interpersonal skills, 37

91

Page numbers in italics refer to tables or illustrations.

92 Index

Jjob descriptions, 53

Kkanban card system, 70

LLean coaching, 13 definition of, 8 mapping tools, 3 sustainability, 36 systems principles, 37Lean implementation documentation of initial data, 14 project scope, 13 role and task clarity, 51–63 selection of project and physician, 14 strategy, 13Lean process maps, 3, 23–24, 23, 24, 39

MMain Street Orthopedics (case study) casting process, 81, 82, 87 changes in care delivery model, 81–82 clinic layout, 65, 73, 76, 77 clinic team, 5 front desk layout, 65, 66, 67, 68, 72 handoff process, 61 introduction, 5–6 patient wait times, 6, 9, 24 performance metrics, 6 physician flow, 17, 18, 26 process bottlenecks, 30 role and task clarity, 51 sources of waste, 29 with team leader and changeover, 39, 39 typical schedule, 5–6 and visual communication, 42, 47management, role of, 37mass-training approach to Lean, 13material pull system, 70mini-businesses, 30–31

mini-departments, decentralized, 83minimal motion, clinic layout and, 65–77mobile cast carts, 87multiple-projects approach to Lean, 13

Nnurses and standard work, 58

Oone-doctor-at-a-time approach to Lean, 13–16outside consultants, 13ownership of glass wall metrics, 34

PP/T (process time), 23patient advocacy, 34–35patient flow, 24, 44, 83patient satisfaction surveys, 6patient status boards, 44–46, 44, 47, 73patient wait times, 7–11 and clinic layout, 75 current state at Main Street Orthopedics, 6, 9 as indicator of a healthy system, 8performance metrics, 6, 8, 34, 39physician flow, 17–27, 18physician Lean process map, 23, 24physician–patient interaction, 22physician time management, 35physician value-added time, 29–39physicians and standard work, 58 willingness to participate, 14physician’s assistant–to–physician handoff

process, 52, 61physician’s assistant and standard work, 58pit crew example of changeover, 22problem resolution for physician, 35problem solving, 36process improvement, 53process maps. See Lean process mapsproject scope, 13, 14pull system, forms, 70

Index 93

QThe Quality Toolbox (Tague), 36

rresource imbalances, 54, 85resource scheduling, 33role and task clarity, 51–63

Sscheduling, 20, 39secretaries and standard work, 58seven wastes, 24, 37, 43, 53, 67, 83–84shared resources, 20, 32Six Success Steps care delivery model changes, 81–87 clinic layout for minimal motion, 65–80 implementation sequence, 3 physician flow, 17–26 physician value-added time, 29–37 standard work, 51–63 visual communication, 41–49spaghetti diagrams busy clinic, 68 casting process, 81, 82 and communication flow, 72–76, 72, 73, 77 Lean mapping tool, 3 and 5S, 67–68 solutions arising from, 68, 69staff satisfaction, 6standard operating procedure, 53standard work benefits of, 53–57 clinic roles, 57–58 creation process, 59 defined, 53 documents, 53, 54 improvement process, 54 need for, 51–52 physician assistant—physician handoff, 52 sample chart, 56, 57status boards. See patient status boardssupplies, organization and replenishment of,

30, 68–70, 69, 84, 85support departments, 83

swim lane diagrams, 3system efficiency, 8system-level problems, flow and, 9

TTague, Nancy The Quality Toolbox, 36team development, 35team leader development, 36–37team leader responsibilities clinic measurement, 34 clinic monitoring, 33 clinic preparation, 32–33 essential nature of, 31 glass wall creation, 37 interpersonal skills, 37 Lean sustainability, 36 Lean systems principles, 37 patient advocacy, 34 patient status board, 45 physician time management, 34 problem resolution for physician, 35 problem solving, 36 team development, 35 training, 35technology changes, 85training, 35, 39, 54, 55, 56

Uunderground conflict, 56

vvalue stream mapping, 37visual communication, 41–49, 42, 76

W-x-Y-Zwait times. See patient wait timeswaste of motion, 44waste walk, 67wastes, 24, 37, 43, 53, 67, 83–84workspace organization, 67–68

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the lean doctors workbook : an application guide for transforming outpatient clinic systems

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