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.

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