Looking Lean through Muda glasses

buy Ventolin San DiegoHow much time do you spend in ‘the Red Zone’ with your patients? What is your average doorknob to doorknob time? How long since you mapped your process flows? When is your third available appointment slot?

I recently attended the Institute for Health Improvement’s 7th Annual Summit on Clinical Office Improvement, held this year in San Diego. (It happened to coincide with the baseball World Cup, so I went to my first ball game with hot dog, Millers and all!)

No one, including the Americans, would argue that the United States has a model primary care system. Family medicine is very much the poor cousin to specialist and hospital care – especially in funding. This contrasts with the UK where primary care is recognised as the key determinant in producing optimal population health outcomes. Nonetheless, many practices within the US system are providing excellent care – delivering equitable, timely, safe, systematic and evidence based care to their practice population – or ‘panel’, as they call it. There are many lessons to be learnt from practices that can achieve such demonstrably high levels of care within such a flawed system.

Many successful practices adopt a ‘lean’ model, drawing on lessons from industry, especially the production methods used in Japan. The lean model focuses on the needs of the customer. Waste at any level reflects poor resource allocation and produces a sub-optimal customer experience and company outcomes. In health care, our patients are the customers.

Consistently, interviews with patients indicate that they value access to their doctors when they need it, and they value the amount of time the doctor can devote to them. We also know that health outcomes in chronic disease can be improved by proactive, systematic care.

How long do patients wait on the phone? How long until they can get a routine appointment? Long waiting times decrease access to your services and contribute to less satisfactory clinical outcomes. How long do your patients spend in your practice, from the time that they arrive, to the time they leave? That’s the doorknob to doorknob time. How much of that total time is spent on clinically useful activity, and how much is just sitting around? Full waiting rooms create a sense of ‘churn’ within a practice and a sense of uneasiness for patients, staff and doctors.

In Japan, ‘muda’ is waste. Those trained in Toyota Production Systems wear metaphorical ‘muda goggles’ to distinguish value-added steps from non-value added steps. What can we learn from those who have looked at their surgeries through trained ‘muda glasses’?

These are some of the points I noted after listening to a number of presentations from exemplar practices.

1. Value the physician’s time
The value in a visit to the surgery is the time that the patient spends with the doctor, and that part of the time that the doctor is focused on the patient’s problems. This is the ‘red zone’ of a consultation. It is also the rate determining step in the whole patient process. The more time the doctor spends in the red zone each day, the more value the surgery delivers to its patients. Our ‘muda goggles’ will glow when a doctor is walking down the corridor to get the next patient, or performing an ECG, or out the back photocopying a handout, or struggling through his drawers looking for an X ray request, or looking in every room for the one Doppler that the surgery owns, or being interrupted by someone looking for the one Doppler that the surgery owns – in short, doing any job that could be done by someone else or could be avoided by better planning.

The doctors in the US were amazed that we had one room for each practitioner, and fetched our own patients from the waiting room. They each worked in a team with their own ‘physician’s assistant’, and had at least two examination rooms dedicated to the team. (In Australia, read perhaps ‘practice nurse’ for PA) The PA would call the next patient from the waiting room, record vital obs, and open the computer record in readiness. They can make sure that any required results will be available to the doctor. The doc would come in and be able to go straight into focused attention on that patient. After the consultation, the doc would go into the other room, where the next patient was ready. The PA would come back to the first patient, perform any tasks that the doctor had left (book an X ray, arrange a follow up, arrange a Webster pack etc), and escort the patient out. The PA would clean up the room, tidy the desk, and then bring the next patient in. Each room would be set up identically, with all necessary equipment readily accessible.

This process is called rooming, and you will note that dentists in Australia do that all the time. They are much more focused on efficiency than we are.

2. Systematic care
The most successful practices were systematic about developing registries of patients with particular conditions and proactive in managing those registries. The team work involved in rooming provides potential to improve systematic care. We all have particular skills – a principle of lean production is having the right person do each job. The practice nurse when rooming a patient can check that their medications are listed correctly, can ascertain their immunisation status, and can check their progress on their ‘diabetic flowchart’ against recommended best care. Nurses have been demonstrated to be significantly better at following guidelines than doctors (who have different talents one hopes).

purchase Sildenafil 3. Check all the ‘microsystems’ in a practice
You can gain valuable information by observing workflow practices. How often do the receptionists have to walk out the back to the photocopier. Would another centrally located photocopier be helpful? Is a phone line needed at another point near a computer terminal? How are X rays handled when they are delivered? The experts on inefficiencies in each part of your practice will be those who are working there. Train and encourage them to use ‘muda goggles’ to assist improvement.

4. Achieve ‘Advanced Access’
Timely access to a medical appointment is valued by patients and improves outcomes. Waiting days or weeks for an appointment is wasteful. And it is fixable. At many of the presentations I attended, clinics that previously had waiting times of 25 days had transformed their systems such that patients routinely arrange a ‘same day’ appointment, regardless of the clinical urgency. Previously, all the practices had considered this an impossibility.

There is a well described and tested set of principles to assist a practice to achieve ‘Advanced Access’. These were developed by Mark Murray, and are listed at http://www.ihi.org The UK NPDT team has spread ‘Advanced Access’ throughout primary care in the UK and their set of change principles is taught by the Australian collaborative team (www.npcc.com.au)

5. Use the improvement model Lasix online
Deming’s improvement model – measure what you do and make small, incremental changes – was a common factor of exemplar practices. Further information about this model is also available on the IHI website, and of course this model is taught to practices participating in the collaboratives program.

Maximising clinical efficiency has not been a focus of Australian primary care. The well described shortage of GPs and increasing chronic care demands are causing increased stress within our system. I think that we can learn much from the ‘lean production’ model proposed by the IHI. It might be time to put on your ‘muda glasses’.

PS. I wouldn’t recommend the hot dog or the Millers – but San Diego was fantastic.

www.emaildigest.com is the occasional blog of Tony Lembke, the division’s chair. You can subscribe to emaildigest and receive a fortnightly newsletter by email, or receive an RSS feed of its articles. Contributions welcome. Tony is also clinical chair of the National Primary Care Collaboratives, as well as enthusiastic coach of the Lismore Rubgy Club U12s, which he hopes will soon win a game.
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