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Make Your Physician Practice a Lean, Mean Healing Machine

John Commins, for HealthLeaders Media, May 6, 2010

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.' "

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