Eliminate waste and reduce variation in your medical practice

At the heart of healthcare operations are their processes – processes that must run correctly all the time to avoid unnecessary risk to patients’ lives and health.

Once the healthcare industry acknowledged the fact that we all make mistakes – even physicians – it began to look into methodologies used by other industries to structure more “perfect” organizations.

Two such process improvement methodologies — LEAN and Six Sigma — are now being applied across our industry to continually examine the functioning of health systems, hospitals, large provider groups, health information technology organizations, and health product manufacturing organizations.

I admit that I’ve always found these terms a bit confusing until I came across a straightforward, easy-to-understand chart comparing and contrasting these two concepts.

LEAN = Eliminating waste

In healthcare, things that can be classified as “waste” include excessive motion (e.g., incorrect layout of emergency department resulting in inefficient work flow), excessive wait times (e.g., waiting for approval or responses, searching for information), and unnecessary processing (e.g., unnecessary steps in the work flow).

By eliminating waste, the LEAN methodology seeks to add value to any procedure or activity that the patient receives.

In a healthcare context, LEAN is a patient-centric methodology focused on identifying opportunities for improvement by eliminating things that do not add value (i.e., wasteful activities) thereby creating value. For example, the physician and patients alike benefit from an improved turnaround time for results of critical laboratory and diagnostic tests.

SIX SIGMA = Reducing variation

While the normal variation found within a given process is considered truly random, special-cause variation emanating from sentinel or unusual events that are outside of everyday operations should be sought out, addressed, and prevented.

Six Sigma reduces variation by means of the DMAIIC Cycle (Define > Measure > Analyze > Improve/Implement > Control) and associated tools for analysis, such as histograms, fishbone diagrams, scatter graphs, and flow charts.

What it means for docs

So, what does this have to do with typical physicians and patients?

With the emergence of Accountable Care Organizations and the Patient-Centered Medical Home concept, all physicians are being challenged to assess their processes for providing healthcare (clinical, business, and communication) to make them both more valuable to patients and most effective for their clinical practices and bottom lines.

Not surprisingly, LEAN and Six Sigma are getting some traction in the medical literature.

LEAN Six Sigma (LSS) refers to the merging of these two methodologies to address the business side by enabling a physician or physician group to assess how the practice is functioning.

LSS facilitates a review of the practice’s processes and systems to identify improvement opportunities that ultimately help the physician, staff, and patients realize their common goal – better healthcare at a lower cost.

Two simple, handy LSS tools that are commonly used are checklists (or “cheat sheets”) and flow charts (also referred to as the Value Stream Maps or Process Maps).

Checklists can be used for any situation in which numerous tasks must be completed in a relatively short time – e.g., a follow-up visit for a patient with diabetes – and many electronic health records include versions of such tools.

Flow charts help to break down office processes into basic, sequential steps and are helpful in identifying opportunities to add value for both the physician (greater efficiency in medical charting, patient scheduling, routine task distribution) and the patient (less waiting time to schedule a visit, shorter waiting time during the visit).

Many of us cringe at the prospect of adding yet another thing to our growing “to-do” lists, but the time we spend understanding and improving upon how we do things in our practices will save us valuable time, improve the overall quality of the care we provide, and – importantly – make our patients very happy!

David B. Nash is Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University and blogs at Nash on Health Policy.

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  • southerndoc1

    Trying to keep a civil tongue in my mouth, all I can say is that this is 100% pure bullshit from someone who has never (thankfully) run a medical practice.

    Anyone who works on a daily basis with CMS and large insurers, and is familiar with the PCMH, knows that waste (of time, resources, and money) is what drives today’s health care. A physician who thinks they can change that by using check lists and flow charts needs to up their meds.

    • ninguem

      ^^^^ What southerndoc said ^^^^

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I am not sure how renaming something you do all day can have such enormous powers.Most practices I’ve seen have, and always have had, standing orders in place for staff to efficiently deal with repeatable processes. In a small practice, these may just be verbal, but they are still there. Now we’re supposed to refer to them as checklists and workflow optimization tools.

    Perhaps this is because so much unnecessary regulatory complexity has been injected into a very simple and straightforward process [I once saw a workflow diagram for an office visit that spread across several pages to accommodate insertion of all Meaningful Use activities at various points in the process].

    Also, how much shorter are we planning to make the actual encounter with a physician before it becomes completely useless? Is that really a good way to prevent “mistakes”?

  • azmd

    It seems a little harsh to accuse Dr. Nash of never having run a medical practice, although it is disturbing to see a piece which encourages those of us who work with actual patients to adopt “process improvement methodologies” which are well-known to have been originally developed to help factories workers function more efficiently on the assembly line.

    Philosophical concerns aside, a quick internet search reveals that Dr. Nash did indeed once practice medicine, albeit quite some time ago, and here is a very interesting quotation from an interview he gave in 1997:

    “Of course, it makes sense [that doctors will begin to treat patients following algorithms established by their HMO rather than looking at the patient's chart]. I think of my own practice in primary care. I don’t treat anybody differently. It would be too complicated, and there’s too much work to do, and I can’t remember which drug is on whose formulary. So you develop a generic practice, if you will.”

    The funny thing to me is that we are also told to expect that in the future we will be compensated based on our patient satisfaction surveys. However, patients are not stupid; they are quick to figure out when you are treating them generically, as though they were just another widget on an assembly line, And that realization is generally reflected in their patient satisfaction scores of the encounter.

    Catch-22 anyone? No wonder burnout continues to be such a significant problem in our profession.

  • Guest

    It’s not an acronym, not need to say “LEAN” in all caps. But, yes, the approach can help medical practices and hospitals.

  • http://www.markgraban.com/ Mark Graban

    It’s not an acronym, no need to say “LEAN” in all caps. But, yes, the approach can help medical practices and hospitals.

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