Lean Process Improvement (LPI) is a methodology used to reduce waste and thus increase efficiency in any process that requires multiple steps. It was initially developed by Toyota for manufacturing automobiles in the 1950s and has since been applied to the service industry sector.

Prior articles on LPI published elsewhere have focused on useful tools (such as value stream mapping, spaghetti mapping, bottleneck analysis and A3 problem-solving, among others) that can be applied to begin the process of waste reduction. This article, however, will focus on some key principles, useful lessons and unforeseen benefits of integrating LPI into your practice.

KEY CONCEPTS

1. Subsidiarity

In my experience, two key concepts that underpin LPI are subsidiarity and incrementalism. I will explain what these look like in action below.

Subsidiarity states the best solutions are determined by those closest to the problem.

The principle of subsidiarity is illustrated in my clinic, Austin Retina Associates, by the delegation of patient flow through the clinic (“throughput”) to the ancillary staff. We made this decision because ancillary staff better understand the details of the patient throughput process as they are the “foot soldiers” in the trenches. This gives the clinical staff keen insights into possible solutions for decongesting any bottlenecks and smoothing out any friction points. Those insights are translated into metrics-driven small-scale trials to determine if their solution is effective (more below).

During the past 4 years, the most impactful changes in our practice have been proposed by our technical staff. These include creating “doctor-teams” made up of personnel who consistently work with the same provider. The doctor, as the de facto leader of his team, encourages and empowers the staff to continuously identify bottlenecks and friction points so they can design and run new trials to resolve them. This “delegation downstream” (subsidiarity) not only generates better solutions to problems, but it also creates a more engaged staff because they have the opportunity to collaborate and problem solve. No matter a team member’s position, the principle of subsidiarity will improve the overall performance of everyone involved.

2. Incrementalism

This principle is illustrated by the introduction of small-scale trials after each change to tweak the processes for improvement. By making these changes and testing each one after implementation, incrementalism has the advantage of reducing the unintended negative consequences that often result from larger scale changes made by a management team or the doctors. For instance, prior to incorporating LPI at my practice, many operational initiatives that were imposed from above would never gain traction and would ultimately fail because there was no “buy-in” from staff. This was largely because the solution had not been fully vetted by those it would most impact — the staff.

TEST AND MEASURE

Small-scale trial for success

Over the past 6 years, more than 200 small-scale trials have been proposed, evaluated and integrated by our clinic team, thanks to the creative problem solving of our clinical staff. Those trials have led to a 50% reduction in patients’ cycle times (check-in to check-out) in the clinic. (See the Value Stream Map [Figure 1]). The trials range from the assignment of teams surrounding one doctor to smaller changes such as moving a chair out of the exam room to create more space.

Small-scale trials include:

• Placing a white board at the doctor’s review station so they can list any issues that arise during clinic with the intention of discussing them after clinic.
• Instead of the doctor taking their time to pull up medical records and images, the staff members pull them up so they are ready for review by the doctor.
• Review stations outside examination rooms prepare the doctors for the patient encounter and enable them to fully focus on the patient while in the exam room.
• Consistent injection set-ups and numbing techniques established to help reduce additional chatter and unnecessary procedural interactions with and by the staff.
• Documenting the patient’s name and the eye to be injected on the medicine box on the injection room countertop to create more effective communication and reduce errors.

Creating additional, small changes add up to significant time savings when seeing a high volume of patients in a retina clinic.

It’s all in the metrics

Another key element of LPI is its emphasis on metrics in measuring process improvements. When teams clearly understand the overarching and personal goals in the form of measurable results, they work more efficiently and effectively in achieving those results. Managing people becomes more about managing processes to achieve results. Discussions become more understandable and helpful when numbers define the problem and the goal.

For example, telling a scribe they “often” forget to close a chart is not as clear as telling them they did not close the chart five times when seeing 30 patients yesterday. The more metrics that are measured and integrated into communications and evaluations, the less time we need to clarify misinterpretations. This helps staff members remain focused on their jobs, because they more clearly understand what is expected and determine better ways to achieve it.

Another benefit of being laser-focused on metrics is its impact on creating healthy competitions within the practice. For example, we started displaying to our staff each doctor-team’s efficiency scores and patient satisfaction scores (Figure 2). Efficiency score is determined by the number of patients seen divided by the staff hours. For example, if 32 patients are seen in 4 hours with eight staff members (excluding the doctor), that gives an efficiency score of 1.0 (32/8 x 4). Patients satisfaction scores are the average of publically available online reviews. These averages are determined for each doctor and each location. When these scores are displayed for the staff to see, we observed that the teams took those scores much more seriously. The friendly rivalry between doctor-teams and clinic locations created added incentives.

MULTIPLE APPLICATIONS, MULTIPLE BENEFITS

Beyond throughput

Initially, we used LPI simply to reduce wait times. It worked so well that we have deployed it throughout our organization to better execute other functions. Our business and administrative offices constantly engage staff members (subsidiarity) to problem solve issues.

In fact, we have found LPI so impactful to our organization that we have created a new job title of “Process Improvement Analyst.” This position teaches the LPI tools and principles to all staff members and facilitates problem-solving on issues that involve multiple departments. As in any initiative, human nature tends to revert to the status quo. Keeping LPI at our core with our Process Improvement Analyst team member has helped our organization stay on the path of continuous improvement. We have also integrated LPI tools and principles into our onboarding process. Every new hire is introduced to LPI principles and encouraged to bring their own ideas into the office of how to improve our processes and patient experience. We have also created our own LPI certification program for our staff, with the expectation that all leadership positions must be credentialed.

SURPRISE BENEFITS

Our organizational culture has benefitted from LPI in ways we never initially anticipated. As patient wait times decrease, so do the number of complaints. This has a direct, positive impact on our staff’s overall attitude, with less employee burnout.

Relationships within the organization have been enriched, because everyone has a role in the solutions for their particular domain. Each team member is seen as the potential answer to any problem. This shifts the nature of relationships from one of subservience to one of co-collaboration. The doctor’s domain of expertise is medical decision-making, but the remainder of the organization’s operations is delegated to the staff. Consequently, as an organization, we have come to believe and behave as co-collaborators who are operationally intertwined for the good of our patients.

LPI is more than a set of tools to reduce waste. It is the door to a better work experience. OM

About the Author

Jose Agustin Martinez, MD, specializes in the surgical and medical management of all disease of the retina, vitreous and macula. He practices at Austin Retina Associates, Austin, Texas, and serves as an affiliate faculty member at University of Texas Dell Medical School.