Posted by: knightbird | September 9, 2015

Lean in Healthcare

Yesterday I said I would talk about how the healthcare system came on board with the idea of Lean Thinking. When I asked a healthcare executive for an opportunity to talk to the healthcare leadership, I was told that it probably would not be a good idea. 2 healthcare providers had been involuntarily terminated within the 6 months before I was hired. Increased productivity was demanded of staff, but no additional resources offered. As I told many around me, I would have loved to have either provider return and work for me.

One lesson that my Sensei taught me, and stuck immediately, was the concept of “Going to the Gemba.” Visit the workplace where the work happens, and spend time there. I have referred in the past to “The Ohno Circle,” a place where Taiichi Ohno would place a manager to observe a workplace, sometimes for an entire shift. Ohno had seen something he hoped the manager could identify, and if he could not, the manager would be told to look some more. Sensei Yoshiki Iwata would do a similar exercise, but would ask a multitude of questions that his managers were asked to answer. Going to the Gemba is necessary to learn how to see what is possible.

My visits to the Gemba were instructive. A visit to the emergency room let me see that there were very few emergencies there. Instead, patients who couldn’t get appointments were using the emergency room as a clinic. The exam area waiting room had a lot of people waiting, and further inquiry told me the length of appointments and the hours of patient care. Visiting late at night, I could see that our medical providers were working long hours, and regular patient hours could be followed by emergency room duty as well. The Providers had very little support, and Providers had to handle their own communication responsibilities. We had only one Medical Assistant for 5 Providers in the clinic on a daily basis. The clinic averaged 55 patients a day, or about 11 patients per provider. Appointments were 30 minutes in length and about 14 slots were allocated daily. Discussions with Providers revealed that negotiating the Electronic Health Record would take about 20 minutes of an appointment. And getting technical help with the EHR was difficult. I had a chance to listen in on a conversation about the EHR between a techie and a provider. I watched on a screen a problem the techie denied was possible.

There were many more problems. But with my experience, I knew that a possible future state would allow each provider to see 26 patients per day (or 130 patients daily). With 250 open days annually, this adds p to 18,750 additional patients annually. In the U.S., patients average 3.2 visits annually. The data I had for the 8,000 patients in our service area indicated 4.2 patient visits on average. 55 daily visits meant seeing 13,750 patients annually, or just enough visits to see about 3,300 patients. The total service population that could be served if Providers saw 26 patients per day was almost 7,400. I felt this was achievable, and could generate substantial additional revenue.

But this goal could not be achieved without considerable improvements, which I felt Lean could provide. We could not increase flow without improving EHR performance. The budget for all IT in this organization was about $5.3 million annually, far more than I believed was required. My first 3 months demonstrated that IT was overfunded and could be reduced substantially with a higher level of service through application of Lean. Unfortunately, I would meet heavy resistance from the IT executive.

It was also difficult to hire local medical assistants, LPN’s or nurses. The trained population did not exist, and I knew that working with the local training center was a requirement to develop the expertise we needed. Every provider would need a medical assistant before we could increase patient flow. And it would take about a year to train an MA using a combination of classroom, online and on the job training. But the investment is certainly worth it given the potential for an increase in patients of 18,750. The added revenue would more than cover the additional expense.

Medical records was another tremendous area of need, one that was also affected by the lack of an effective EHR. The EHR used by the organization was essentially free, but because of a lack of training to keep the EHR up to date, we experienced massive problems. One of the solutions I thought feasible was to outsource a server to a DOD/HIPPAA compliant server provider with the expertise to keep both operating software and EHR software up to date. Local effort could then be focused on a Helpdesk and training. Training has been proven to reduce Helpdesk need and is a mean to achieving substantial improvements once standard work has been identified and training is based on standard work.

Records management, including billing and coding, are Pull Systems, and if they are inefficient, reduce revenue potential. The systems were so inefficient that Billing and coding had been partially outsourced, and the system was full or defects, rework and multiple feedback loops. But if you think about Takt time (regular patient visits and emergency room visits), the daily requirement for processing bills is dependent on cycle time. My assessment is that we were overstaffed and again, our strategy had to start with making our EHR more efficient to use.

In my next post, I will continue to talk about the challenges for fixing this healthcare system without significant pull system improvements. I will also talk more about how better flow could be achieved.

Bear in mind that employees had to buy into the potential for improvement. Without their willingness to participate, the system would continue to operate ineffectively. Fortunately, there was great buy-in with the Medical Staff. Unfortunately, IT was not buying in. That lack of buy-in would prove to be the greatest hurdle to overcome because its inefficiency was the root cause of many of the defects among pull systems.


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