I recently accompanied a patient to the orthopaedic clinic of one of Boston's eminent hospitals. When we checked in, I noted that the waiting room had about 50 seats. I was appalled.
If a hospital has designed an outpatient facility with the capacity to place that many patients in a holding pattern, it is a sure sign that the clinic's work processes are substandard. Note that I do not assert that the care patients receive in the exam room is deficient. But the pipeline through which they get their care is certainly so.
Almost 10 years ago, the staff of our orthopaedic clinic at Beth Israel Deaconess Medical Center collected data showing that an average person spent over three hours going through the process of a routine repeat visit after a repaired fracture or similar treatment. There were the usual steps: check in, see the doctor, get an X-ray, see the doctor again after the X-ray. The problem was that patients had to wait before every single step.
The result was that patients were disgruntled, and they often took out that frustration on the front-desk staff, making those workers feel cranky and put-upon. Meanwhile, the X-ray technicians were frustrated by a hurry-up-and-wait environment. And doctors couldn't understand why they couldn't see more patients every day.
With a little technical help from one of our process improvement experts, a group of clinic employees — from the front-desk workers through the doctors —spent a few days studying their workflow. They discovered dozens of steps that did not add value to the patients or the staff, and they experimented with changes to eliminate unnecessary actions.
They also set up self-guided routes through the clinic — with colored footprint stickers on the floor — so that the front desk staff and techs wouldn't have to escort people from step to step. They spent a few dollars on plastic holders to hang outside each office, so that patient records would be on hand for techs, nurses, and doctors.
When it was all done, the team had reduced the previous visit time of 187 minutes down to 60 minutes or less, an improvement of more than 66 percent.
Now, if I as CEO had gone to the chief of orthopaedics before all this happened and set a target of, say, a 10 percent improvement, I would have been told, “Mind your own business. We're already working to capacity here." But here, with strong support from the chief, the staff themselves analyzed the workflow and designed experiments for improving it. They set their own improvement target, rather than relying on one set by a detached senior executive.
Our orthopaedic team had been involved in applying the Lean approach to their workflow. Lean, based on the Toyota Production System, provides an environment and tools that empower front-line staff to improve their work environment. In a healthcare setting, Lean can also be used to improve the patient experience and the cost structure of the hospital.
Lean is not a program. You don't “do" Lean. It is a management philosophy. The approach is to find incremental improvements by designing experiments in the workplace. And the premise is that the staff in an organization are trustworthy and well intentioned, and will achieve substantial improvements if they are shown proper respect, along with the training to use a number of well-proven tools.
Lean sometimes get a bad rap from those who don't understand it. That is because it is often poorly taught and implemented. Indeed, some of the world's largest consulting firms charge lots of money in often-wasted training. I learned of one such training program in an National Health Service hospital in the United Kingdom, where management consultants charged several hundred thousand pounds to take the staff off-site for six weeks to train them in Lean in a classroom.
If only malpractice claims were permitted for this kind of consulting. Training people in the Lean philosophy off-site is like teaching gymnastics in a closet. Not surprisingly, the best Lean training firms are themselves quite efficient, and are more able to help organizations succeed in adopting this philosophy.
Research also shows that Lean tends to fail or erode in organizations that lack strong support from the senior executives. Why? Because it is based on conducting experiments, and experiments sometimes fail. Unless senior leadership supports learning through failure, the staff will quickly get the message that it's just not worth trying.
Our hospital and others around the world have shown that Lean offers a partial answer to the trend of higher costs. We'll know it's been more widely adopted when no one is sitting in those seats in the waiting room.
Paul F. Levy was CEO of Beth Israel Deaconess Medical Center in Boston from 2002 to 2011. He is the author of "Goal Play! Leadership Lessons from the Soccer Field."