Does your physician practice have what it takes to be lean?
For decades now, we've heard about manufacturers and retailers running Lean or Six Sigma or whatever you want to call it—putting workplace processes from scheduling to supplies management under the scalpel to carve away excess overhead, inefficiencies, and redundancies.
In the past few years, larger hospitals and health systems have bought into the process, and now a growing number of physician practices have embraced Lean, including Kalamazoo, MI–based Borgess Ambulatory Care (BAC).
"It is an intense effort, and it works," says Ed Millermaier, MD, MBA, chief medical officer and COO at BAC. "Breaking down processes into individual steps is daunting work. We're learning that we need to focus on pieces of the process so we can measure improvement and track ourselves. This is a long-term process; there are no quick wins."
It's also a very time-consuming process that requires a lot of expert help, which may prove to be the biggest challenge for many physician practices that want to go Lean. BAC, with 58 physicians and 16 offices, didn't do it alone. It had help from Lean experts at the University of Michigan Health System and funding and guidance from Blue Cross Blue Shield (BCBS) of Michigan.
"It is very difficult to truly embrace the principles of Lean without help. I don't think you need a major institution, but you may need some outside consultation or education assistance," Millermaier says. "One could argue that, for the small physician practices, doing this on your own could be more challenging."
BAC used consultants identified through the BCBS physician group incentive program who all had a background in Lean. They were experts who brought their experience from Fortune 500 companies to the organization, Millermaier says. Those experts provided BAC physicians and staff with analytic principles and tools of the Lean process, which allowed them to strip down the typical office day into a series of individual steps. They mapped out the steps needed to complete everything from incoming calls to sick visit scheduling to filing paperwork—then they improved those processes.
At the end of the initial review, the wait time for pediatric well visits was reduced from 60 days to eight days, and mammography patients saw their wait times for follow-up testing after initial screening drop from 19 days to three days. The practices also created efficiencies in medical records filing, storage, and response time.
The value stream map
To identify process inefficiencies, BAC dissected an everyday event: a newly diagnosed diabetic patient scheduling a nonurgent return visit. Staff members walked through the process from start to finish, using everyone involved in the visit—from the receptionist to the physician—to create a value stream map that identified 13 steps needed for a successful encounter.
"The more steps you have, the more opportunities you have for the whole event to not be a complete and accurate event," Millermaier says. "By day two, we had it narrowed to nine steps. We got rid of a bunch of rework on the telephone because we realized the schedule wasn't out far enough to accommodate needs of the patients. We looked at all the silly stuff we do to accommodate the schedules and the physicians stepped up to say, 'This is crazy. We want the schedule out 13 months to account for annuals.' "
The process worked in part because BAC selected staff and providers who would not have problems leaving their titles at the door and focusing on flow, Millermaier says. "The physicians were willing to hear, 'Gee, Doc, when you do that with the chart, I can't find it. When I can't find it, I can't meet the need of the patient.' The medical records clerks were willing to hear that they had to reorganize their medical records. The insights that they got on how to fix flow problems were enough that they could clean up the medical records process. They figured it out on their own. Those were line associates, not the managers."
Tom Leyden, manager of clinical program development at BCBS Michigan, said the Lean program began in June 2008 and now includes approximately 8,000 physicians from about 100 large physician groups in the Lean Professional Collaborative Quality Initiative.
Not every physician group is ready for Lean, Leyden says.
"Once they express their interest, there is a readiness assessment where the coordinating center out of U-M Health System meets extensively with the physician group to determine if they're ready to embrace Lean," he says. For some organizations, it might be a three- to six-month process to determine whether there is strong organizational support for it and to start thinking about what they want to address.
Leyden says BCBS Michigan will fund any Lean program in the ambulatory setting that will improve quality of care and advance the practice "along the path to a fully functioning patient-centered medical home."
BCBS Michigan fully funds three value stream mappings for physicians' groups, which usually take more than 18 months to complete. Consultants' fees are paid by the insurer, which also provides the physicians' groups with about $15,000 to provide compensation for any temporary disruptions to practice work flow.
"The expectation is that each organization will have at least one person who will become the internal Lean coach. It's a 'see one, colead one, do one' approach," Leyden says.
In the first value stream mapping session, the internal Lean coaches observe. In the second value stream mapping, they colead the whole three-day session, the 30-day report out, and the 60- and 90-day reports, working closely with the consultants. In the third value stream mapping, the Lean consultants have it pretty easy. They watch and provide some pointers, but it is the physician organization that does the work.
Outside expertise
"Sometimes the best Lean coaches are the people who haven't had a background in quality improvement or process improvement previously," Leyden says. "It is based on their interest and desire and ability to effectively implement change." So far, Leyden says BCBS Michigan has spent about $2 million funding physician Lean programs in the past two years.
And what bang does the health insurer get for its buck.
"We get improved quality of care for our members, reduced readmissions," he says. "The better the physician organizations use their disease registries, the better care is delivered. Hopefully that results in less [emergency room] visits, in less patient stays, and things of that nature."
Despite its origins in the manufacturing sector, Millermaier believes Lean is a good fit in medicine.
"The principles of Lean can apply," he says. "None of the Lean consultants had a healthcare background when they started with us. They brought to us a perspective around business operations that is challenging for us in medicine, particularly for physician leaders. It is not an area that we are strongly trained in."
"Once you get past the notion of the widget manufacturers coming in to commoditize healthcare, it teaches us how to be more effective and efficient in what we are doing," Millermaier adds. "And it aligns very much with the Institute for Healthcare Improvement's Triple Aim when you look at optimizing the patient experience, improving the population's health, and keeping costs per capita under control."
John Commins is the news editor for HealthLeaders.