August 16, 2003 my wife and I welcomed our fifth child into the world. Two weeks later on August 29th I visited a local urology group for an out-patient procedure to mistake-pro0f our process and ensure we didn’t have to make room in the house for a sixth child.
I arrived at my scheduled appointment time of 11 A.M. and began filling out several forms provided me by the smiling receptionist. I remember commenting under my breath that it would be nice if the forms were integrated into a single document and eliminated my having to waste my time providing the same information multiple times. After returning the forms to the receptionist I sat down to read my copy of USA Today. Little did I know in the ninety minutes that would elapse before I was called for my appointment I’d have time to read the paper front to back and complete the cross-word puzzle.
When I was finally called the nurse got my weight and then led me to a common treatment area where multiple procedures could be carried out at the same time. She drew the curtains around my table, handed me one of those embarassing hospital gowns and instructed me to change and then left so I’d have some privacy to do so. When she returned I was told to lie back on the table where she prepped me for the procedure, then she covered me with a warm sheet and left to attend to other duties including pulling the procedure tray from the pack room. My Physician arrived about twenty minutes later, greeted me with a little small talk, briefly explained the procedure, administered the local anesthetic and left while it took effect. It would be another ten minutes or so until I saw him again which in that predicament can seem like an eternity. All in all, my mistake-proofing procedure actually began slightly more than two hours after my scheduled appointment time.
As my physician busied himself with the procedure he made small-talk much as my barber would do when giving me a haircut. “So, what do you do for a living” he asked. “I’m a lean consultant” I said. “And what does a lean consultant do” he asked.
Resisting the urge to provide one of the punch-lines from any number of lean consultant jokes I knew I explained that “I help organizations improve their operating performance through the application of various lean tools and problem solving techniques to eliminate waste from their value streams”.
“Oh, manufacturing stuff” says the physician. “No, not just manufacturing. It can be applied anywhere” I said. “We don’t have much waste around here” he said. As I eyed the scalpel he was wielding I took a deep breath and said “Not from my perspective”. “Huh, what do you mean” he asked. So, I leapt, figuratively speaking of course.
“Well, I’m your customer. I was here at my appointed time nearly two and a half hours ago now, and the first thing I had to do was fill out several forms providing the same or similar information on each form. From my perspective as your customer those forms could have been integrated to eliminate the need for me to provide the same information more than once.” “Front office stuff” he said, “I don’t get involved in how they do their work”.
“OK” I said, “how about the two hours or so of my time wasted because this procedure didn’t start on-time”. The doc raised his scalpel, looked me in the eye and said “I had some unavoidable complications on rounds this morning, sorry but it couldn’t be avoided”. I guess he didn’t see any value in having someone at least let me know it was going to be a long wait. It certainly would have reduced my anxiety a little. I must have had a determined expression on my face because the nurse, standing slightly behind the physician, was shaking her head and giving me a don’t push it look. But I couldn’t help myself.
“OK doc, how many physicians in your group perform this procedure” I asked. “What, a vasectomy” he asked. Struggling to keep my sarcasm in check I said “yes, a vasectomy”. “All six of us” he said. “Do you all do it the same way” I asked. “Very similar” he replied.
“That wasn’t my question” I said. “Do you all perform the procedure exactly the same way. Do you get the same results? Do you take the same amount of time? ” I asked. My nurse now had a “you must be out of your mind” look on her face. “I’m sure we have a few differences based on personal experience and preferences” the doc said. “Then by admission you’re all different” I asserted, “and because you’re different I’m certain there’s differences in performance and waste in your process” I said, “waste that negatively impacts quality, patient care, cost, and morale”. He paused, obviously reflecting on our conversation.
“Look” I said, “because you’re all different one of you is probably faster than the other five, one of you is slower. One of you probably has more post treatment complications than the other five, one of you less. Do you know which one that is” I asked. Though I was particularly interested in the answer to that question he simply stated “We don’t keep track of those kinds of things”. It was pretty obvious he wasn’t buying into anything I was saying, yet. I would have to find another way in.
“I’m betting you all use different surgical trays” I said. He looked over at the nurse who nodded. “So the cost of performing the procedure is probably different for each of you.”
“We have a standard charge for the procedure” he said.
“I’m talking about the actual cost of the procedure not what you charge” I said. “If the instruments and supplies on each tray is different for each physician then the the actual cost of the tray is different for each physician which affects your groups bottom line”.
Looking at the nurse I went on “and someone has to know which tray to prepare or pull for each physician”. She nodded. “Do you keep multiple trays ready for each physician back in the pack room”? She nodded again. “How many are back there” I asked. “Not sure” she replied. “Does the wrong tray ever get pulled” I asked. “Not as far as they know” she said tilting her head toward the physician.
When my procedure was complete (and I could walk again) we visited the pack room and observed there were 3-4 vasectomy trays ready for use for each physician in the group, about 22 trays total. “Is this typical” I asked the nurse. “Most days” she said. “Again, an impact to the bottom line of the organization because you maintain excess inventory here because six very intelligent people can’t agree on a single configuration of tray to use” I said. “Inventory” said the doc, “a single way. You need to understand we’re not a factory here. Though it sounds like you’d like us to be more like one”.
“Continuous improvement is a fundamental concept in my line of work, doc. What I’d like is for your group to continuously improve its operating performance by eliminating the waste we’ve talked about through the application of lean tools and techniques. Remember, that’s what I do. When I say operating performance I’m including the timeliness, quality and cost of patient care, and patient throughput as well as patient and employee satisfaction.” I paused to give him time to digest that statement.
“Are you concerned about improving the quality of patient care within your group” I asked. “We certainly are” he said. “How can you do that if you don’t measure or know what the current level of quality is?” I asked.
“You should also understand the importance of something we call standard work. Your group doesn’t have standard work for performing a vasectomy. You’re all different. So, improving the process of performing a vasectomy would be difficult at best. Taichi Ohno, the father of the Toyota Production System once said “where there is no standard there can be no improvement“.”
“More manufacturing stuff” he said. “But universally applicable” I countered. “I suppose so” he said, then said his goodbyes and went on to his next patient.
I left his office that day with mixed feelings. Literally! I knew I had planted a few seeds with a very intelligent and thoughtful decision maker in the group. But whether or not the seeds would sprout and grow was yet to be seen. Remember, it was 2003 and there wasn’t a lot of successful lean applications in healthcare to point to at that time.
If the encounter above were to happen today I could draw from my own experience applying lean in healthcare, or better yet refer the physician to Mark Grabans groundbreaking book “Lean Hospitals: Improving Quality, Patient Safety, and Employee Satisfaction” which is available in the RadioLean Lean Book Store. The book makes a much better case for lean in healthcare in a language the care provider would both understand and appreciate. I’ve read the book myself several times now, and highly recommend it to anyone endeavoring to apply lean in the healthcare field. The book builds a strong case for lean in hospitals, and more importantly contains numerous case studies detailing how hospitals are successfully applying lean to improve many aspects of healthcare.
I’ve recently had the opportunity to interview Mark about Lean Hospitals and look forward to adding his session to the RadioLean Interview Vault in the near future.