Thursday, July 05, 2012

An eye clinic helps us see Lean more clearly

One of the lovely aspects of Lean that we discussed during this week's training workshops at Ipswich Hospital was the concept of kaizen, process improvement accomplished by incremental change.  I often add another characteristic to the approach:  Can we achieve an improvement with no incremental cost?  Strictly speaking, that cost constraint is not part of Lean.  After all, sometimes you have to make an investment in personnel or equipment, and it often has an excellent return to consumers, the firm, or both.  But I have found that asking people to think about how to change things at no cost opens up floodgates of creativity.

Here's an example from our discussions.  Ipswich Hospital operates an eye clinic and has an open access policy, i.e., you do not need an appointment.  The open hours are from 9am to 1pm, and then from 2pm to 5pm.  The idea of open access is terrific: More and more organizations have employed it.

What happens here, though, is not quite terrific.  A patient goes to a GP and is told that s/he needs an eye exam or other treatment.  S/he shows up the next day at 9am, only to discover that the people referred by any number of the several dozen GPs have also decided to go first thing in the morning.  The staff cannot handle this huge batch of people, and many are left waiting for two or more hours to be seen.  These are often elderly people with vision problems, and so you can imagine the discomfort and, ultimately, the frustration and anger that result.  Also, as word has gotten out about this problem, people have started to show up even earlier, at 8:30, in the hope of getting to the head of the queue. It feels like a case of "no good deed going unpunished," but it is actually a classic case of batch processing when what is desired is a flow.

When this scenario was presented to our class, I asked them to invent an improvement with which we could experiment that might alleviate the problem.  How do we transform the batch to a flow, to match the consumers' needs with the resources available in the clinic?  People immediately started by adding steps to the process:  Perhaps GPs would have pre-printed chits, with different times of day, that would be handed to patients.  (But how would we coordinate the chits across all of the GPs, with changing numbers of patients every day?)  Perhaps the staff in the GPs' offices could call ahead and see how busy the clinic was.  (But then we would add to their work and would also be interrupting the people working in the clinic.)  Perhaps we could install a computer system that would post on a website the number of people waiting at the clinic and the expected delay in appointments.  (But then we have to pay for that system and have someone at the clinic enter the information throughout the day.)

I then asked the group to consider a process that would involve no new steps and add no costs.  The answer emerged:  Make it clear with a simple one-time message to GPs and a poster on the clinic entrance that the clinic would prefer (but not require) that people whose surnames began with "A" to "F" would be welcome at 9am; "G" to "M" at 10am; and so on.  "Ah!," said the person who had mentioned this problem, "So simple.  Let's try it."


Anonymous said...

If memory serves me, I believe it's Charles Kenney's book "Transforming Health Care" that offers a similar scenario whereby an office or clinic affiliated with Virginia Mason Hospital was able to eliminate appointments and offer walk-in medical services due to a Lean process redesign of their office. It was very impressive, but this sounds like a good beginning!


Anonymous said...

Correction to my previous comment: The Kirkland Clinic from Virginia Mason achieved same-day appointments, not walk-in's. Still pretty amazing for a primary care office, and their patient satisfaction scores went through the roof.


C.Ritchey said...

Have you ever thought that the “open access policy” is actually more of a hindrance than a help? I mean let’s examine some of the specifics. With a scheduled appointment, the patient knows what time to arrive and can expect to be seen within a half-hour of their appointment time. You (the office) know the patient is coming, so the office staff can be prepared visit documents and details (reason for patient visit, etc.). The office can also control the volume of patients at any given time, based on the schedule.
Now, don’t get me wrong. I think the idea of “open access” is great; the concept of patient freedom and the patient’s ability to make their own choice as to when they see the doctor is excellent. However, don’t you think this could be done through an effective scheduling process? Possibly by dividing the work day into sections; grouping patient appointments based on estimated time/severity of illness/whatever will most effectively keep the office on-schedule, eliminating long waits for service. What’s the point of having an “open access policy” if the patients are never sure how long they will have to wait to be seen. The idea behind the “open access policy” is that patients can visit the office/clinic whenever best fits their free-time. Are we actually fulfilling that idea when the patient shows up and finds it will be a two hour wait to be seen, because the entire community, with a last name close to theirs, has decided to visit that day? I think not.
I feel the problem here is not necessarily that the patient wants the choice to arrive freely, whenever s/he wants, but moreso that the patient wants the visit to be as effective as possible without excessive waiting time.
By determining and outlining effective scheduling practices, the office can also better manage its expenses. How? By having a schedule and consistently being aware of appointment volume, you can more effectively manage staffing; more staff for busier days, less staff for low appointment volume days, etc...
Please respond, as I am looking for an active discussion on this :)

Paul Levy said...

We found that a combination worked well. For example, in our neurology clinic, there were regular appointments, but a portion of each day was left open for last minute needs. I think those were "scheduled," too, with people calling in right beforehand; but there may also have been straight walk-ins, too. I forget.

C.Ritchey said...

I can agree. I feel a combination, as you mentioned, would work great!