While the term LEAN Six Sigma (LSS) may sound like complicated business school jargon, the principles behind it are relatively straightforward. And when applied to eye care, LSS can have a significant effect on patient care.
The use of LSS as a management philosophy originated in companies such as Motorola, Toyota and General Electric. It was born out of a combination of the Six Sigma approach to quality control in manufacturing, which relied on the recording of data to identify potential flaws in the process, and the LEAN principles of increasing operational efficiency and ensuring that limited resources are used only for purposes that add true value.
The underlying principles of the philosophy, therefore, become a powerful tool that any business, including ophthalmology clinics, can use to improve performance. Anyone with the right data and insight into a clinic’s workflow can use that information to put scarce resources — providers, staff, space — to more effective use. This, in turn, translates into measurable improvement in the area of greatest value to patients: percentage of time devoted to direct care.
APPLYING LEAN SIX SIGMA PRINCIPLES
The essence of a LSS initiative in eye care starts with identifying sources of inefficiency throughout the patient journey and reducing or eliminating them. This frees up existing resources and capacity to serve more patients and increase revenue.
On the surface, this appears to be a rather simple exercise. As we look closer, however, this hyper focus on patient-provider interaction can uncover underlying inefficiencies and significant opportunities for improvement.
The first step to unlocking the hidden value in any clinic or eye-care practice is understanding current resources and how they are used. Only by capturing and analyzing real-time data can we gain insights into the efficiency of our day-to-day operations. When performing this exercise, it is not uncommon to find that more than 50% of eye-care resources are expended on non-value-add activities.
REDUCING WASTE IN A CLINIC SETTING
The purpose of any eye-care practice is to bring together three key resources: a patient with a need, a provider to fill that need, and the staff, space and equipment needed to successfully complete the visit. The percentage of time each of these resources are actually used in a direct point-of-care encounter is an important measure of how effectively they are being utilized.
- Patients. The percentage of time spent in direct care (vs waiting) is a key factor in overall experience. It is important to stay above 50% direct care, with a target of 70% or greater.
- Providers. The percentage of time spent in direct care (vs other activities) is a key factor in clinic capacity (patient access) and efficiency (cost). Providers should aim for between 60% and 80% direct care, depending on the provider specialty and the care model deployed within the practice (in a delegated care model with care extenders, for example, it is difficult to achieve a provider direct care efficiency above 80%).
- Staff, space and equipment. The effective allocation of rooms and equipment avoids bottlenecks and is an important factor in capacity and utilization. An empty room, or idle or harried staff, could point to a need for change.
Accurately measuring this data can uncover the potential to increase clinic capacity, lower clinic costs and improve the patient experience. Any improvement in the length of time required to secure an appointment (ie, the sooner the better) and/or in-clinic wait times will contribute significantly to a positive patient experience.
KEY AREAS TO EVALUATE
The arrival rate of patients is the key starting point for addressing any patient flow issues that could be negatively affecting patient experience or provider efficiency. By understanding the provider work patterns and length of time required for examinations and procedures, practices can adjust and maintain the rate of patient arrivals to match the flow pattern of the provider. For example, if the patient flow tracking data shows that a doctor has a median exam time of 7 minutes and he would like to achieve 70% direct care time efficiency, then the arrival rate for patients should be one patient every 10 minutes. Done correctly, this provides the doctor with a time allocation of 30% for indirect care, administrative tasks and breaks.
Workflow time balance
The next step is to organize all the activities upstream of the provider such that they can be accomplished within the same pace and rhythm. While there can be many different factors that come into play, accurate insights into patient flow means that practice managers can effectively balance activities — such as patient check-in, rooming, technician workup, diagnostic testing and dilation (where appropriate) — to stay on pace while maintaining the highest level of care. In the above example, the room allocations and staff resourcing for the upstream processes must be balanced to consistently deliver a “ready” patient to the doctor every 10 minutes.
Does the practice have enough rooms to operate at the full pace of the provider? Delays in rooming patients because there are none available causes stress — to both staff and patients — and inefficiencies. Sometimes misinterpreted as a scheduling problem, space constraints are usually revealed during a thorough wait-time analysis. If clinics react too hastily by pulling back on the number of patients to address perceived space constraints, capacity is compromised, direct care is reduced and revenue is left on the table. If true space constraints are identified, the number of rooms must be increased to meet demand.
A REAL-WORLD SUCCESS STORY
A large eye-care practice outside of Boston was experiencing delays and waste in their workflow and knew that they had to identify what was causing these inefficiencies.
First, they mapped out the patient journey to pinpoint where the delays were occurring. When they did this, they discovered that delays often occurred when rooming patients. A provider working multiple exam rooms would all too frequently enter the next room to find it empty: the patient had not yet been roomed and prepped. Both patient and doctor were needlessly made to wait, reducing direct care time. It was evident that something needed to change in the workflow pattern.
In this clinic, each doctor was assigned a scribe, who was also responsible for picking up patients from the waiting area to room and prep them for the doctor. As often happens, however, the scribe stayed with a patient for a period of time after the doctor had completed the exam to finish up documentation and relay instructions. This meant that the doctor was ready to proceed with the next exam but the scribe had not picked up the next patient.
There were three possible options to improve the situation: add a second scribe, which meant added cost; add a non-clinical staff member who would be responsible for rooming patients to keep the pace going, which would also add cost; or use existing resources more efficiently. Using a Plan-Do-Study-Act approach, the practice experimented with all three options.
Looking closely at the data, they discovered that workup technicians often cycled through the waiting room when performing their duties. This clinic determined that their technicians could change their workflow patterns to room waiting patients without impacting their own productivity, thereby closing the gap in the flow.
As a result, productivity increased and wait times decreased. In fact, this new workflow reduced this particular wait time condition by 90%. The solution added no cost, improved team continuity and improved direct care time by 5%.
The same can be said for staff resources. As with room constraints, when we do not have enough staff to stay on pace with the provider, or if existing staff are not performing optimally, we should acknowledge this and make adjustments to keep the practice operating at the optimal pace.
No constraints, just waiting
We tend to place blame for wait times on the lack of resources — rooms, staff or equipment — but we can all recognize this scenario: A patient is waiting, a room is available, and a staff member is available, yet no direct care is happening. Here, there are no constraints — just a slow response. This is the worst and most expensive waste in the system.
The good news is that this problem is also the easiest to solve and does not require any great investment. With better workflow communications, team-based problem solving and management engagement, this type of “controllable” wait can be minimized and throughput enhanced.
WHERE TO START
Track and measure the patient journey
The first step in implementing LSS is to identify each value-added care step in patient flow, such as workups, diagnostic testing and provider exam. Once this ideal journey is mapped, add where patients are likely to experience wait times along this journey. Focus on the handoffs between care steps, since this is where much of the opportunity for improvement lies. Calculate the average direct care time for each step and the average wait time by area. Once you have this data, it becomes easier to figure out how to reduce any non-value-add time to increase efficiency.
Make it visual
One of the key tenets of LSS is Visual Management, which has the goal of creating a self-directed team. When every team member has full visibility into immediate patient needs and treatment room and equipment availability, they are able to react quickly and contribute to team success by keeping patient flow moving forward. There are software solutions available that provide a HIPAA-compliant flow screen that displays the status of all patients, rooms and resources in the clinic as they change in real-time. This “at-a-glance” visibility for everyone in the clinic also adds staff accountability, recognition and oversight.
Use a Plan-Do-Study-Act approach to test different ways to reduce wait times and optimize resource allocation. This iterative approach allows you to identify and implement changes you’d like to see, evaluate the outcomes of those changes using data, improve upon them as necessary, and test again until you get it right.
Long wait times can have a disastrous effect on an eye-care practice. Not only do longer wait times severely impact patient satisfaction, but the longer a patient waits, the lower their overall perception of their provider and quality of care. This can go on to impact how patients perceive important instructions and information given by their provider as well as how likely they are to return to your practice or refer you to others.1
The impact of waiting goes far beyond the patient experience, however, and exposes performance gaps. Through a careful analysis of patient flow and resource allocation, every eye-care provider can use the basic principles of LSS in their own clinic. The result? More efficient use of resources leads to less waste and a more responsive care team resulting in happier patients, more satisfied staff, lower operating costs and increased profitability. OM
- Bleustein C, Rothschild DB, Valen A, Valatis E, Schweitzer L, Jones R. Wait times, patient satisfaction scores, and the perception of care. Am J Manag Care. 2014;20(5):393-400.