Make Yours a “LEAN” Practice

Yes, you can apply manufacturing efficiencies to medicine without compromising quality. Here's how.

By F.W. Fraunfelder, MD

Healthcare delivery in the United States can provide excellent quality, but its long-term viability is jeopardized by potentially unsustainable costs.¹ Currently 16-17% of our GDP is consumed by healthcare, and this is expected to grow to 19.5% by 2017.² In other words, healthcare costs are growing faster than the US economy. America is also at the bottom of the list of industrialized countries in life expectancy, infant mortality and the number of uninsured (approximately 50 million).³

This is not to say that excellent outcomes do not occur, nor that US healthcare professionals are not well-trained. Our skills and technologies are among the best in the world; the fact of the matter is that the process of delivering care in the US is flawed. Consumers are not getting the quality that they pay for relative to other developed countries.

Take for instance the most commonly performed ophthalmology procedure in the US — cataract surgery. A recent study comparing the US to the Netherlands and the United Kingdom found the Netherlands and the UK were more cost effective by far than the US, primarily due to our fee-for-service system. This system encourages physicians to treat more patients and to execute redundant activities, such as preoperative internist consultations, photographs and ancillary diagnostics in most patients as opposed to just the few patients who may need these extra steps.⁴

Presented in this two-part article are tools drawn from the manufacturing industry that can be applied to ophthalmology. The aim of any operational process change within ophthalmology and all of health care is to improve quality of the service provided while also decreasing and controlling the costs of delivering it. Frequently, there is a trade off. The goal is to maintain quality whilst still decreasing costs.

Six Principles of Quality

Before embarking on a discussion of manufacturing process tools that might be applied to medical care, one must first consider how quality is defined. The definition of quality is dependent upon many factors; however, some medical absolutes do exist from widely accepted publications from the world's experts on quality of medical care. These parameters can and should be applied to specific clinics, procedures, surgeries and health systems whenever possible.

According to the Institute for Health Care Research and Improvement, healthcare quality can be defined by the following characteristics:⁵

► Safety — Patients should not be harmed by the care that is intended to help them.
► Timeliness — Unnecessary waits and harmful delays should be reduced.
► Effectiveness — Care should be based on a sound scientific knowledge base
► Efficiency — Care should not be wasteful.
► Equitable treatment — Quality of care should not vary even though patients' characteristics may vary.
► Patient-centered — Care should be responsive to individual preferences, needs and values.

Based on the initiative for Health Care Research and Improvement's healthcare definition of quality, a more efficient methodology that focuses on reducing healthcare process wastes will lead to improvements in cost-efficiencies and reduce wait times, improving the overall effectiveness and efficiency of healthcare delivery to ensure patient safety, and overall patient access to high-quality care.⁶ Translating these goals to ophthalmology can be straightforward for many types of disease management practices and surgeries. Improving vision, decreasing wait times, lowering complication rates, unbiased care, efficient care and not harming our patients should be paramount.

Manufacturing Processes as Applied To Medicine and Ophthalmology

Now that we have a better grasp of what “quality of care” is in medicine and in ophthalmology, the next step is to consider strategies from the manufacturing industry, as they could potentially lower the cost of delivery of healthcare and maintain quality as defined above. Three common and applicable strategies are described in the literature and appear the most amenable to application to the healthcare system, ophthalmic institutes and ophthalmology group practices. These are (1) lean manufacturing techniques, (2) benchmarking and (3) Six Sigma.

Other manufacturing techniques include balanced scorecard, focused factories, kaizen, 5S and just-in-time techniques; however, these strategies either are difficult to apply to ophthalmology and medicine or there is overlap, and the techniques are part of the aforementioned business practices. For instance, lean manufacturing, 5S and just-in-time practices are all part of the Toyota Production System.

Lean Manufacturing Within Healthcare

In healthcare terms, “lean” can be defined with the following five characteristics:

1. Provide the value to patients they actually desire.
2. Identify with the value stream and eliminate waste.
3. Line up the remaining steps to create continuous flow.
4. Pull production based on patient consumption.
5. Start over in the pursuit of perfection: “The happy situation of perfect value provided with zero waste.”⁷

Lean process implementation in healthcare seeks improvement within the framework of an organization's existing processes and does not rely on substantial reorganization requiring large-scale investments.

The obvious application of lean thinking in healthcare lies in eliminating waiting times, repeat visits, eliminating error, eliminating inappropriate procedures and, ideally, it will empower employees by providing them with the necessary tools to improve processes in their area of work. This means all healthcare staff become focused, not only on taking care of the patient, but also on finding better ways to take care of patients.

Customer value and waste reduction is at the center of lean thinking. There are many examples of improved financials, better quality and better patient satisfaction as a consequence of instituting lean principles within a hospital or clinic. Lean tools explicitly focus on removing non-value-added activities (waste); however, most evidence from positive results on lean thinking is anecdotal and speculative.⁸

Within ophthalmology, there are a number of lean process implementation examples with seemingly positive results. The retina clinic at the University of Iowa used lean tools to decrease the procedure of Avastin injections for macular degeneration from 16 steps to just six steps, and decreased the amount of time from beginning to end of the process from two hours to 45 minutes per patient. Clinical outcomes were the same and patients reported greater satisfaction with the lean process. The morale of the faculty and staff was not described.⁹

There have been a number of studies looking at cataract surgery and implementing lean processes. Lean concepts in cataract surgery attempt to improve lead times, decrease hospital visits and reduce costs. Measuring improvements in these areas look at operational focus, autonomous work cells, physical layout of the resources, multi-skilled teams, pull planning and elimination of waste. Using these tools, most hospitals and ambulatory surgery centers could probably decrease the frequency of hospital visits, reduce lead times and lower costs.⁴

Numerous principles from lean process thinking can be instituted in an ophthalmology operating room or eye clinic, principles which most eye institutes and large group practices do not yet employ. These include the following:

■ Eliminating the pre-assessment of a patient by the ophthalmologist and relying on the referring provider. Preoperative visits may only be necessary in three of every four cataract surgery patients, especially if the referring service has already obtained data on intraocular lens implant power.¹⁰
■ Elimination of the internist or general physical exam prior to cataract surgery. This practice has proven to be of no value in preventing morbidity and mortality associated with cataract surgery.⁴
■ Eliminating the postoperative day one visit. The vast majority of patients do well with a simple phone call the next day from allied health professionals.¹¹
■ Automating inventory. This is a simple step to ensure that correct lens implants can be available exactly when needed, eliminating the need to stockpile multiple IOLs and therefore freeing up capital for the hospital.¹²

The above measures can be instituted in addition to decreasing the number of staff assisting with the surgery. Have the physician wheel the patient into the OR, thereby freeing the nursing and anesthesia staff to be able to prepare the room. The ophthalmologist or the room turnover time are frequently the rate-limiting steps of the cataract surgery procedure. Ensuring the surgeon is constantly active and busy can improve workflow and decrease turnover time between cataract surgery cases.

Using some of or all of these lean principles can decrease lead times, decrease the number of hospital visits and reduce overall costs of cataract surgery. Also, there is very little to no capital investment to institute these changes in an eye clinic or eye operating room.

Benchmarking

The management tool of benchmarking has been around for many years in both the manufacturing industry and within medicine. Healthcare systems are developing ways to compare their practices, processes and resulting outcomes with other organizations to discover “best practices.” Comparative (also called competitive) benchmarking measures an organization's performance against that of competing organizations by focusing on key measures and indicators. There are five phases of benchmarking: (1) Planning, (2) Analysis, (3) Discovery, (4) Implementation and (5) Monitoring.¹³

The first step of benchmarking is identifying what to benchmark. After this, benchmarking should be a continuous, systematic process for evaluating the products, services and work practices of organizations that are recognized as representing best practice for the purpose of organization improvement. Benchmarking may be internal, external or functional. Compare performance to a particular function or process with the best performer regardless of the industry.¹³

One of the leaders in benchmarking experience is the National Health Service in the UK. Surveys in England have questioned the contribution of benchmarking to achieving improvement. An industry survey revealed most respondents in hospital systems claimed to be undertaking benchmarking initiatives, but few had progressed to comparisons of process and real improvements had been limited.¹⁴

It appears benchmarking in healthcare can still largely be used only to assess competitive position, with most services having great difficulty in finding suitable measures for comparison. Even when these are available, staff may be inclined to be complacent, preferring to emphasize differences rather than deficiencies when performance is shown to be poor. Benchmarking can become just part of the usual management-speak and be recognized as a “good” thing; however, it is possible that few health systems have truly adopted a formal benchmarking approach, which includes identification of gaps between current and best performance and analysis of the reasons for quality gaps.¹⁵ Based on published research, buy-in to benchmarking consists of the following four principles:

► A commitment to continuous improvement.
► A need to know your own organization before seeking to change it.
► A desire to learn from the best.
► A commitment to achieve measurable improvement.¹⁴

Using these principles, the field of ophthalmology has attempted to identify numerous benchmarks that physicians can refer to for determining areas for improvement. Improved quality of care for their patients as well as improved financial performance of eye departments are the main goals. The benchmarks can be financial or related to clinical results. Table 1 lists 15 useful financial benchmarks for an ophthalmology practice.

Clinical benchmarks within ophthalmology are numerous. These selected summary benchmarks contain the most relevant information in the AAO's preferred practice patterns. Guidelines and assessments are developed by the Quality of Care Secretariat, Hoskins Center, and approved by the Academy without any external financial support. Authors and reviewers of summary benchmarks are volunteers and do not receive any financial compensation for their contributions to the documents.

Benchmark data in PDF form is provided at the AAO Web site on primary angle-closure glaucoma, posterior vitreous detachment, retinal breaks, lattice degeneration, bacterial keratitis, diabetic retinopathy, dry eye syndrome, conjunctivitis, age-related macular degeneration, primary open-angle glaucoma, cataract in the adult eye, esotropia, primary open-angle glaucoma suspect, refractive errors and refractive surgery, blepharitis, exotropia, amblyopia, and idiopathic macular hole. For examples, visit http://one.aao.org/CE/PracticeGuidelines/SummaryBenchmarks.aspx?p=0.

Benchmarking in ophthalmology and within all of medicine highlights one key theme: the onus is on healthcare providers to embrace the benchmarking process for improving the quality of health care service locally, nationally and internationally. At the same time, containing costs and improving efficiency and effectiveness of the service can only be achieved through striving for best practices.

This means that all healthcare organizations should probably benchmark. It calls for rigorous performance targets, streamlined care practices, a focus on customer experiences and an emphasis on the costs of healthcare services. There will need to be strong leadership from management in order to realize these goals. A mandate for the maintenance of quality health care, the reduction of costs and improved efficiency and effectiveness flows from benchmarking practices.^16,17

Active physician involvement is vital; benchmarking processes can be successfully implemented in hospital systems if the lead administrators are significantly involved, timely information is provided to clinicians, application of benchmarking is timely and efficient, and trained facilitators are available who have clinical knowledge. Benchmarking as a management process can improve quality of care as a means to measure quality and search for better practices, implementing changes where necessary. Benchmarking is likely to be one of the most significant management tools to be used by healthcare systems during the coming years as healthcare reform is implemented.

Six Sigma

The Six Sigma process, developed in 1986 by Motorola, has been used successfully to reduce defects, redundancy and waste in operational processes.¹⁸ Using Six Sigma, companies have improved quality, customer satisfaction and operational and financial performance. Six Sigma can and has been adopted by health systems to develop efficient and effective processes that improve workflow, customer satisfaction and overall quality.^18,19

Both “lean” and Six Sigma are quality-improvement methodologies; however, there are major differences. Basically, lean business process is a philosophy and Six Sigma is an effectiveness approach that uses mathematical techniques to understand, measure and reduce process variation. Six Sigma helps to quantify problems, enable evidence-based decisions, helps to understand and reduce variation, and identifies root causes of variation to find sustainable solutions. Further, it quantifies the financial benefits and savings. This helps to focus organizational efforts in the areas that offer the most potential for quality improvement. Where lean serves to eliminate waste, Six Sigma reduces process variability in striving for perfection. Lean is qualityoriented and Six Sigma is quantity-oriented.⁶

Instituting Six Sigma methodologies into a healthcare system requires experts trained in Six Sigma doctrine. Socalled black belts and green belts are hired, and this would require some capital outlay and significant time and buy-in from administration and employees.

The steps of Six Sigma consist of the following: (1) define the problem, (2) measure key aspects, (3) analyze data to verify cause-and-effect relationships, (4) improve the process and (5) control future processes to avoid deviation. All Six Sigma projects begin with a problem, usually one that is systemic or chronic, affecting the success of a given process. The problem undergoes a metamorphosis during the Six Sigma project, changing from a practical hospital business problem into a statistical problem, then into a statistical solution and finally into a practical solution.⁶

Operating-room throughput has been significantly improved using Six Sigma methodology.¹⁸ Also, there are examples of improved efficiency, timeliness of care and improved quality of care in an internal medicine residency clinic²⁰ and also in a post-anesthesia care unit. Within ophthalmology, Six Sigma tools have been used to minimize the length of stay for ophthalmology day case surgeries.²¹

Six Sigma is more complicated than the aforementioned manufacturing processes described earlier in improving quality of care for patients in healthcare systems and eye hospitals. In addition, hiring expertise and outside consultants will be part of the overhead cost of change as well as the need for significant buy-in from top administrators. There would also need to be a significant amount of time devoted to learning Six Sigma techniques. Nevertheless, this manufacturing process model has proven to work within healthcare and ophthalmology, and can be used as a tool when needed, especially when controlling variation is of paramount importance.

Discussion

Lean techniques, benchmarking and Six Sigma are the most applicable manufacturing processes that can be applied to ophthalmology because so much of ophthalmology is process oriented, be it clinic workflow or specific eye surgeries that are commonly performed. Also, adoption of sweeping changes is easier in compartmentalized divisions as opposed to an entire health system. Many eye centers are now physically separate from the rest of the parent hospital. Instituting change within a single eye institute, while not completely autonomous from the university but still independent enough to make changes relatively unencumbered by influence from other hospital entities, is easier than trying to change an entire university system.

Also, ophthalmic procedures are particularly amenable to operational process changes, as there are many procedures that could be streamlined to improve quality of care, decrease lead times and reduce costs at the same time. Examples are intravitreal injections for macular degeneration, cataract surgery, corneal transplants, refractive surgery, blepharoplasties, strabismus surgery and the daily clinics that are run for the many subspecialties that exist within any large eye department.

From the manufacturing process tools presented here, the following benefits can be realized: improved quality, decreased costs, reduced wait times, quicker operating room turnover and improved clinic work flow. These changes, if instituted even for just one procedure, such as cataract surgery, could save the hospital thousands of dollars a year, increase patient satisfaction, and improve quality all at the same time. The question is, will ophthalmic surgeons buyin to process changes? The different processes may be counterintuitive to physician training, they may differ from past standard practices, the changes will require collaboration and teamwork, and surgeon choice may be limited.

Next month, part two of this article will apply the concepts described here to ophthalmology practice and will offer 10 good ideas that would benefit any practice. For a preview of what's to come, Table 2 lists the concepts that will be elaborated upon in the conclusion of this article. OM

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