“Don’t Waste My Time”Healthcare Examples

James P. WomackPresident, Lean Enterprise Institute

Frontiers of Lean Summit October 31, 2005

Time Wastes in HealthcarePrimary care (the visit to your doctor):• The waits on hold and the call backs while trying to

schedule an appointment.• The wait for the appointment if you want to see your

own doctor.• The wait in urgent care if you can’t see your own

doctor.or

• The wait in the waiting room when you get an appointment to see your own doctor.

Why?• Belief that using minimally trained staff for “triage” – at the

point of first contact with the patient – will send the patient down a path that makes most efficient use of the healthcare provider’s assets.

• Belief that a queue will insure that the most expensive asset inthe healthcare system – the doctor or the monument diagnostic machine – is never idle.

• Belief that demand is highly erratic, so that queues are unavoidable in any case.

• Belief (fostered by insurance companies) that doctors must see/touch patients to provide appropriate care.

• Unstated belief that the patient’s time is worthless!

Lean Solution Number OneThe current-state at Kaiser Permanente (California) 1990s:

• Clerical staff triaged patients calling for appointments.

• Time consuming for patients and staff because of difficulty contacting busy doctors and nurses.

• Many call backs; lengthy “phone tag” to set appointment.

• Complex, computerized scheduling system introduced to solve problem, which actually got worse.

• Two-month wait to see patient’s own doctor, with stable queue length.

• Lengthy waits once at the doctor’s office, particularly later in the day.

Lean Solution Number OneOpen Access (pioneered by Dr. Mark Murray):

• Rather than triaging patients, have them come in to see their doctor that day. (Required some overtime to work down the two week backlog.)

• Lengthen scheduled appointments from the standard 15 minutes so doctors could complete paperwork after each patient and stay on time.

• Schedule longer daily hours for doctors and nurses but get them home immediately at the end of the last appointment rather than staying hours to catch up with paperwork.

Lean Solution Number OneResults:

• Patients wasted practically no time on scheduling.

• Practically all patients could see their doctor that day.

• Most appointments started on time.

• “Doctors were doing today’s work today and discovered there was a lot less work to do.” (The same for staff.)

• Outcomes improved: diabetics had lower blood sugar; heart patients had lower cholesterol; stroke risks had lower blood pressure.

• Costs of the practice fell substantially because less staff and investment was needed to manage the practice.

Lean Solution Number TwoCurrent state in most primary-care practices today:

• Doctors need to see/touch patients to bill for services. (90-95 percent of care takes the form of office visits.)

• Widespread belief that seeing/touching provides a higher level of patient care and better outcomes.

• To be seen/touched, patients must make time-consuming trips to the doctor’s office (which also costs the provider time and money.)

Lean Solution Number TwoDr. Charles Kilo, a primary care physician, noted

several trends:A rising fraction of care is for maintenance of patients with chronic conditions – diabetes, high blood pressure, high cholesterol.Chronic care will steadily increase in the advanced economies as baby boomers age.Rapid advances in personal healthcare technology for home use permits patients to do their own testing.

• Kilo then asked a simple question:Why do many patients need to go to doctor at all?

Lean Solution Number TwoGreenfield Health (Portland, Oregon, USA):• Kilo set up a new multi-doctor practice applying all

of the open-access principles pioneered by Mark Murray.

• Introduced new technology to create accurate, computerized history of each patient for instant retrieval.

• Arranged for patients to obtain appropriate personal technology at home.

• Made immediate access to each patient’s primary care doctor easy with e-mail and voice-mail.

Lean Solution Number TwoResults:

• All the benefits of open access, including a very high chance of seeing one’s personal physician the same day if needed.

• 50 percent reduction in the number of annual office visits per patient.

• Higher reported satisfaction with the practice than with Kilo’s previous HMO.

• Better outcomes on chronic care measures.

• Lower total cost of the practice.

Lean Solution Number Three

Current state in most primary-care practices today:

• Large, complex HMO facilities with large, expensive overheads to manage the complexity.

• Contributing to the time wastes already described.

Lean Solution Number Three

Dr. Gordon Moore asked several simple questions:

• Why does simple treatment of individual patients (who are relatively small) require massive facilities?

• Why is so much capital needed (along with space and complexity) for the amount of value actually being created?

• What would happen if a doctor tried to set up a practice with practically no capital investment or facilities?

Lean Solution Number ThreeDr. Gordon Moore primary care practice (Rochester,

NY):• A true “sole practitioner”: A small office (sharing a

waiting room with another doctor), no receptionist, no nurse, no record keeping staff.

• Practically no assets or overhead.• Except sophisticated (but now inexpensive) medical

records and communications technologies.• Open access plus reduced need to come in.• Patients all dealing directly with their doctor who

knows the details of their personal situation.

Lean Solution Number ThreeResults:

• 99 percent chance of seeing doctor same day.

• No waiting arranging appointment or upon arrival

• Large reduction in need to come in.

• Higher reported satisfaction than in previous HMO.

• Better patient outcomes than same patients in previous HMO.

• Dramatic reduction in the total cost of running a practice with a given patient population.

More Time Wastes in Healthcare

The complete diagnostic cycle:

• Consultation with the primary care physician.

• Referral to a specialist in the suspected problem.

• Lengthy travel by the patient through complex facilities, often far away.

Let’s take a walk and count the steps and time required to diagnose a simple problem (chronic hoarseness):

Lean Solution Number FourThe current state in a typical healthcare system:

• Massive facilities for diagnostic referral and treatment.

• Co-mingling many diagnostic and treatment paths.

• Managed by complex scheduling systems.

• Located considerable distances from patients.

• With low velocity through the system.

• With high costs of complexity.

Lean Solution Number FourDedicated Diagnostic Path:• Disaggregate co-mingled treatment paths.• Re-locate each path to smaller, closer, cheaper

facilities as appropriate/possible.• Line up steps in diagnostic path in adjacent

sequence.• Conduct the steps as nearly as possible in

continuous flow.Let’s take a second walk, through the dedicated

treatment path for the problem just discussed (hoarseness):

Lean Solution Number FourPotential results:• Patient time commitment reduced by 80%• Provider time expenditure reduced by 50%.• Lower cost due to smaller, simpler facilities and

elimination of complex methods for managing complexity.

• Higher quality as well?But…

• Highly threatening to existing investments and organizations.

• Harder to implement than Solutions 1, 2 & 3.