Healthcare providers are under ever-increasing pressure to increase efficiency and reduce waste. To reach that goal, some are turning to process improvement philosophies like Lean and Six Sigma that have their roots in manufacturing.
To find out more about how strategies like Lean Six Sigma can help healthcare organizations become more efficient and productive, I chatted with Frank Cohen, Director of Analytics and Business Intelligence for Doctors Management, a healthcare consulting firm based in Knoxville, Tenn. Frank is an expert in applied statistics, predictive analytics and process improvement strategies. He has a master black belt in Lean Six Sigma and is the author and co-author of several books, including Lean Six Sigma for the Medical Practice: Improving Profitability by Improving Processes.
Maureen: What are Lean and Six Sigma and how are they used to increase value?
Both Lean and Six Sigma are process improvement methodologies, but they’re each at opposite ends of a spectrum. Six Sigma has proven to be very useful in manufacturing because it’s aimed at reducing defects and variation, but it’s big and formal and oriented toward statistical control. Six Sigma projects are usually very large and take a lot of resources and time. Lean, on the other hand, is smaller and less formal and focuses on eliminating waste. Lean Six Sigma is a mix of the two, in which some projects will be more heavily reliant on analytics than others.
Lean and Lean Six Sigma are good for healthcare because they don’t take too many resources to get started. It’s fairly easy to create a process map and see how long it takes to check in a patient or clean a room or replace a used instrument. Once you identify which steps are wasteful and redundant, you can remove them and do more with the same resources.
Maureen: Why do you think healthcare has been slower to adopt Lean principles, especially given the evidence of their potential to drive success?
Frank: Healthcare is slower to adopt nearly everything, to be honest. Our industry tends to be short-sighted and I think that has a lot to do with the fact that physicians have so many competing priorities to manage. They are overwhelmed with so many different requirements and programs, and introducing process improvement feels like one more thing added to their plate.
I do feel like things are changing a little and some providers are expressing more interest in Lean Six Sigma, but across the industry it’s not a focus. I don’t think people in healthcare understand how powerful Lean can be. If you want your organization to be more efficient and profitable, you either have to increase revenue or cut costs. Increasing revenue is challenging because it often requires working with payers, and you can’t keep cutting costs and still provide good care. But by focusing on improving efficiency, you can reduce waste and do more without spending more.
Maureen: What are some of the ways that Lean Six Sigma can drive improvement in healthcare organizations?
Frank: Reduce visit cycle times, reduce wait times, improve check-in processes, decrease turnaround times for test results and imaging, have more productive staff meetings, communicate more effectively with patients—there are so many different ways to break these processes down and cut waste.
Here’s a good example. Years ago, I worked with a three-physician practice that saw about 80 patients a day. We process-mapped their whole organization. At check-in, they asked people their medical history and background, and then the physicians asked those exact same questions again at the start of the visit. We eliminated that redundant process and that saved 3 minutes per patient visit, which worked out to four hours of wasted time. They wouldn’t get four full hours back in practice, but even if they just get one hour per day, that’s four more patient visits.
In another practice I worked with that served an older patient population, the treatment rooms were located at the back of the building and the waiting room and physician offices were located at the front. Older people walk at a slower pace—on average, about 2.8 feet per second—and they were taking an extra 30 to 50 seconds to walk back to the rooms. We moved the physician offices to the back and the treatment rooms to the front and it made a big change in both efficiency and patient satisfaction.
Many times, I’ll start the process by just sitting in a practice’s waiting room and watching what happens. In one organization, I watched several patients take their clipboard of registration forms to their seat and then walk back up to the front desk a minute later with questions. I asked a staff member what the most common questions were. One was related to small, hard-to-read print on the forms and the other was about confusing language in the financial policy.
We made a few simple changes. We rewrote the financial policy in simple, layman’s terms. Then I went to Sam’s Club and bought 20 pairs of reading glasses and put them in a basket in the waiting room with a sign that said, “Help yourself to a pair of reading glasses.” We cut check-in time from 17 minutes to 9 minutes just because people didn’t have to keep walking up and asking questions. That’s what Lean can do.
Maureen: What does the process look like?
Frank: There is a basic model we use called PDSA: Plan, Do, Study, Act. During the “plan” cycle, you decide what the problem is that you would like to focus on and you make a plan. Let’s say we’re trying to shorten wait times. We decide to take the first patient of every hour and put a sticky note in their chart with the times they checked in, went in the room, got procedures done and checked out. The “do” part is when we put the plan into action and measure times for those patients. The “study” cycle is when we analyze the data and look for additional consequences. Then in “act,” we look for solutions, screen them, simulate them and implement them.
Maureen: For healthcare organizations that are new to Lean Six Sigma, what are some good places to start looking for waste?
Frank: I always start with check-in times. There’s so much low-hanging fruit there. From there, I go to revenue cycle and then to quality. Anything clinical is obviously much harder because it’s difficult to tell physicians what to do with their patients, so my advice is to start with the first two.