DailyKaizen

When you make an appointment with your own doctor, do you always try to get the first one of the day to stay on schedule?

The year of KaizenHappiness is not quite over yet, Lee!

As I have mentioned previously, I have been looking for a LEAN practice on this side of the U.S. since I arrived here. My visit to the Lean Enterprise Institute confirmed that it would be a bit of a hunt in the Mid-Atlantic area; however, it is here and it is helping patients (and if readers know of other examples in DC/Maryland/Virgina, let’s have them).

This particular practice is at our sister organization, Kaiser Permanente, who, independently of Group Health, have begun a Lean-Six Sigma program. I was invited to a training session, and learned that they had completed a very successful project in one of their clinical areas, involving first appointment starting times. This is really interesting to me because in my work at Group Health, we had not yet entered clinical operations in our LEAN transformation. Since physicians ultimately control spending of 84% of every health care dollar in our nation’s medical centers and hospitals, I think this is where LEAN ultimately needs to transform. This group is there.

The location where this happened is the Woodlawn Medical Center, in Baltimore, MD. My problem is that I am not facile with a car here in DC (because you don’t really need a car here, sorry Toyota). However, there’s no replacement for the Gemba, so I asked if I could go, and they said yes. So I rented a car and went.

When I arrived, I was asked what I wanted to see. I said I would like to stand where patients arrive as the medical center began its day and watch. So we did - no chalk circles, though!

The words in the title of the post came from the Medical Center Administrator, when she asked members to participate in time-motion studies to learn about starting medical appointments on time. She said the patients said yes, and when their contribution was complete for the day, she said they came back to her and said, “Wow, this is a different place.” It’s a reminder that involving your customers in your transformation only makes you look better, and a finding that I have discovered in my travels - observation by itself is a powerful intervention.

Images - click on any to see full size:

The MCA talked about what they learned when they did the studies. 91% of patients arrived at or at least 1 minute before their appointment start time, ending the erroneous belief that late start times was because of late patients. There was also a belief that patients with more complicated check-in processes (e.g. cash collection, demographic updates) took longer, ended by the data showing that each patient requires about 60 seconds. More data showed key root causes that were not going to be solved by simply adding more staff in pre-medical center prep. The impact: 8% of appointments started on time, with about 44 appointment times, or 10% of physician capacity lost to delays in meeting patients on time.

We watched the new process unfold as patients approached the desk for their first appointment. The check in desk was prepped and ready, with computers booted because of a slight shift in work hours ($0 net cost) for one clinical assistant. Check-in staff were trained with scripts in waiting room management to bring first appointments forward. A stop in a triage room was eliminated for first appointments - patients were taken directly to the exam room. This in and of itself was interesting to me - thinking about the impact of a patient with limited mobility needing to go from room to room to see their doctor. Nursing backup was readily available for clinical issues brought up - the patient-physician relationship was prioritized.

As we stood there, physicians walked in to the office before the first appointments started. It seemed that a virtuous circle was created. I did not see a queue in the check in area, as patients were brought back to rooms at the medical center start time.

I was able to ask the Physician Team Lead about the impact, and she reported it to be positive. I asked if this problem made it easier to focus on other problems now, and she said yes. She also did something that impressed me, which was to teach back what she had learned about process improvement through this work. Something that started at the Administrator level now involves medical leadership in clinic operations, which in primary care can be very busy. This is huge in my mind.

First appointment on time in Internal Medicine is now at 80%. Overtime costs are decreased. Referrals to Urgent Care are decreased. Physician capacity is increased, and members can feel confident that arriving on time means seeing a physician on time.

The Map, showing how they think

I am as interested in the thinking as I am in the doing, and the map is very instructive (see images). The patient is at the top. It’s easy to see what the value added steps are - the patient arriving, and the patient connecting with their doctor (this is a physician appointment, after all. If the patient is coming to see a nurse or other member of the team, that would be the value added step - I don’t want to imply that other members of the care team are not valuable!). From the physician perspective, it’s easy to understand how every member of the team supports this experience - from my own perspective we don’t often understand what it takes to get from point A to seeing me in the exam room - and visually how the impact of shortening the time between value added steps will make a difference. If you look at it, it is really a “patient workflow” which for me is the most important one. I have seen value stream maps at other orgs where the patient was nowhere to be seen - the “there are no cars on this diagram” problem described in “The Toyota Way.” This is not the case here. It’s clearly about the patient.

Finally, I received the toolkit and related collateral for the project. Each impact statement begins with member experience and member expectations. A member could read this and know that they are the primary customer. Two thumbs up for the thinking in my mind.

Setting the stage for improvement

I could tell when I was observing and walking around that this was a medical center that was happy to host me and demonstrate what they had done. The idea came from their MCA, who was asked to participate in Green Belt training, with the requirement that she create an improvement project in her medical center. It seemed to me that a person not working in the medical center might be hard pressed to find the right project by reviewing data. It also seemed that the impact of improving member satisfaction makes an impact in job satisfaction - because budgets are now easier to balance and physicians can do more for patients in the time they have.

A tale of two health systems

The day was a very interesting one for me, because after I left Woodlawn, I went to Baltimore Medical System (which I describe here). You can compare the two in terms of challenges. I wondered as I drove back to DC how improvement figures into different parts of the health care spectrum. Why doesn’t a system like Kaiser Permanente, which typically doesn’t worry about 30% turnover or running out of cash after 14 days, become complacent? The answer for me is that every health care professional wants to be the best for their patients, and the best will always look for ways to improve. The organizations I work in really see themselves as accountable for solving problems for society - we will never be satisfied. The organizations I am visiting are solving problems for entire communities with great creativity and resilience. The contrast was great for me to see - every health system has a contribution to make in helping people achieve their life goals. What better philosophy than LEAN to help us speak the same improvement language for our communities and society?

Of course, it was worth the rental, and the most fun thing in health care is watching people take great care of others. The Gemba is the best place to be for that. With great thanks to the members and staff at Kaiser Permanente Woodlawn Medical Center and the Mid-Atlantic LEAN Consultancy for their time. I hope their example encourages others to start something new. And if you do, maybe we’d like to have you post about it here….

Okay, Lee, now we can start the holidays. Happy New Year!

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