Who needs a waiting room? (Part 3)

In a post below, I report on Dr. Sami Bahri's use of Lean principles to improve patient flow in his clinic.  In their comments, Sami and others explain more about how this is done.  Upon reflection, I need to issue a caveat:

You cannot just extract Sami's recipe for scheduling appointments and expect it to work  The cultural and thinking shift that he led for his staff is really central. Having now watched a lot of medical people in hospitals and outpatient settings, I have seen a tendency to try to take shortcuts, not knowing the depth of what is involved.   As I have said before, you don't "do" Lean:

Lean is not a program.  It is a long-term philosophy of corporate leadership and organization that is based, above all, on respect shown to front-line staff.  There are two essential aspects, training front-line workers to be empowered and encouraged to call out problems on the "factory floor," and training managers to understand that their job is to serve those front-line workers by knowing what is going on on the front lines and responding in real time (when problems are fresh) to the call-outs.   Yes, there are all kinds of methods and tools and terminology, and as Virginia Mason Medical Center's Sarah Patterson notes, "Lean provides a common language for process improvement." She also reminded us, though, that it is a focus on process, not on the outcomes.  The idea is to "build key features into processes that are waste free, continuous flow."  To do this we need to "grow leaders-- to respect, develop, and challenge your people."

This may scare some of you away, but it's important to know there is no silver bullet.  This is hard work and needs a strong and steady commitment from senior clinical and administrative leaders.

Who needs a waiting room? (Part 2)

In a post below, I give a short summary of Dr. Sami Bahri's dental clinic in Jacksonville, FL, and how he has employed Lean principles to make things better for patients and staff.  That elicited some good questions.  Answers have now been provided by some real experts, including Sami himself. 

If you are at all interested in applying Lean to clinical settings, these comments are worth a look.  Click here.

Who needs a waiting room?

Passing through Jacksonville, FL, I took the opportunity to catch up with "the Lean dentist," Sami Bahri, about whom I have written before.  Walking into his office, I was struck by this view of his waiting room.  This is a more or less typical situation.  Patients entering the clinic are immediately escorted into a treatment room.  Organizing a clinic's work flow to produce an efficient treatment of patient flows is a direct result of Lean process improvements.  I joked with Sami that he should find some other use for this space, like starting a book store or something!

One of the things I like about this clinic is the practice of treating a patient for all of his or her needs during one visit.  Most of us go to dentists who require us to come back for a second visit if we have a cavity that needs filling or some other procedure that emerges from the cleaning and examination.  Not here.  If they find a cavity, they fill it on the spot.  The result has been a 24% reduction in the number of appointments at the clinic (for the same number of patients.)  Besides making life more convenient for the patients, the office has eliminated the make-work associated with second or third visits: scheduling, confirmation, extra cleaning of each exam room, billing and collection.

Sami and his staff are very proud of customers' reviews on Angie's List--all "A" grades.  Comments reflect the perspectives of patients.  They don't know that this is a Lean clinic, but they do notice the aspects of customer service that result from the Lean philosophy:

This group is wonderful. Personnel are all low key.  I had a crown pop off.  No pain but they offered me a same day appointment if I wanted it.  Fixed tooth with the same crown.  None of this high-priced push for work you don't need.  I can really get intimidated at dental office and I didn't here.  My old dentist had retired and the new one was sell sell sell.

Thorough, professional and kind.  I was seen today and will be taking my children to this office also.

They are kind and compassionate.  They are all encompassing.  They will squeeze you in if you need them even if it is night.  You never seem to have to wait more than 10 minutes.  The staff is great and knows you by name.

There is not a single person there that I would not trust to provide 100% excellent service with skills, knowledge and compassion.

"What" before "Why"

As the Lean Coaching Summit drew to a close, John Shook, head of the Lean Enterprise Institute, offered a summation that included the slide above.  Although I have been practicing and/or coaching Lean for many years, it made a big impression on me.  Let me explain.

One of the techniques used in Lean and other process improvement approaches like Six Sigma is to employ the "5 Whys."  Wikipedia explains:

The 5 Whys is a question-asking technique used to explore the cause-and-effect relationships underlying a particular problem. The primary goal of the technique is to determine the root cause of a defect or problem.

The premise is that the root cause is often hidden and requires inquiry beyond the simple first answer.  Wikipedia goes on to give an example:

• The vehicle will not start. (the problem).

1. Why? - The battery is dead. (first why)
2. Why? - The alternator is not functioning. (second why)
3. Why? - The alternator belt has broken. (third why)
4. Why? - The alternator belt was well beyond its useful service life and not replaced. (fourth why)
5. Why? - The vehicle was not maintained according to the recommended service schedule. (fifth why, a root cause)

Lean practitioners spend a lot of time on the 5 Whys, and John's slide properly incorporates the "why" portion of a problem solving.  But he also reemphasizes the need to understand "what" happened.  As he said to me before the talk, we often do not spend enough time at the site of the problem to comprehend fully its characteristics and nature.  Failing to know what happened means that the root cause analysis can be off track, and the designed solutions therefore will not offer a complete or sustainable solution.

As in many things related to Lean, this kind of advice can either appear to be self-evident and simple, or too nerdy or techy for real-world situations.  But it is neither.  It represents a codification of an essential aspect of process improvement, an aspect often observed in the breach.

How often have you been in an organization where a supervisor learns of a problem, does a cursory review, and then decides what has happened without a full understanding of important factors and details?  I know I have been guilty of this flawed approach in every leadership position I have had.  It occurs because we are creatures of habit, and the framework we use in viewing problems or defects has developed over the years based on experience, anecdote, and impressions.  It takes real insight to overcome our habitual view of the world and have the clear vision to see a problem and fully comprehend its characteristics.

It also takes a lot of practice to learn how to see a problem and to fully comprehend its characteristics.  An essential aspect of leadership training should be to create comfort in spending time on the front lines, where the work is done and value is delivered to customers.  Beyond physical presence, leaders have to be taught to quietly observe the work patterns of the front-line staff, and especially to see how the staff people create work-arounds to overcome obstacles to the tasks they are trying to carry out.  Excellent coaching is required to teach leaders the observational skills they need to answer the question, "What happened here?" 

Double-Lean focus on coaching

The Lean Enterprise Institute and Lean Frontiers joined together to create the Inaugural Lean Coaching Summit, a collaborative and hands-on learning environment to address coaching in companies and institutions that have adopted the Lean process improvement philosophy.  As noted by the hosts:

“Most lean practitioners have heard the principle ‘Before we make product, we make people.’ This embodies respect for people and describes the two responsibilities of every leader: Get work done and develop people. To accomplish these as separate activities is difficult, if not impossible. So the lean leader’s solution is to develop people through getting the work done. Easy to say, but what does it take? It takes coaching.” 

I was pleased to be invited to deliver the keynote address, based on the coaching themes and stories from my book Goal Play! But as usual in these sessions, I learned a lot of new things.  There was one bit of history from the original Toyota Lean work several decades ago.  They employed a four-part mantra that could apply to any organization today that hopes to become a learning organization:

Build people before cars;
Establish mutual trust;
Lead as if you have no power;
No problem is problem.

We shouldn't need a waiting room.

Our Lean workshops at Jeroen Bosch Ziekenhuis ended today with a session about the differences between batch and flow processing.  It turns out that many hospital settings are based on batches of patients or tests or procedures.  This is often less efficient than a flow-based process.  It is also a lot less customer-centric.

Frederieke Berendsen (above) started talking about this with regard to out-patient clinics, noting that the waiting rooms are often full of people who arrive in batches (or near-batches) and then often wait to be seen.  She noted that in an efficient system, "We shouldn't need a waiting room."

I immediately awarded her with the astute-observation-of-the-week prize, as she had codified one of the Lean principles in a simple declarative sentence.  I then related the story of Dr. Sami Bahri, the Lean dentist in Jacksonville, Florida, whose "clinic prides itself on minimizing the amount of time patients spend waiting -- whether for an appointment, sitting in the front area, sitting in the procedure chair, or whatever."

Brava to Frederieke--and also to the other people in our workshops--for their attentive participation and excellent observations during our sessions!

Coffee breaks demonstrate Lean essentials

The essence of Lean is to have a focus on the needs of the customer and, when problems become evident in the workplace, to think about the obstacles and apply the scientific method to invent incremental improvements.  Such change originates with the front-line staff, but it is the job of leaders to encourage an environment in which this is encouraged.

An example arose recently at Jeroen Bosch hospital in the Netherlands.  It was the brainchild of Jeanne Smith, whose job includes serving coffee to patients on the wards.  You see her here. 

Jeanne was hearing complaints from patients about the temperature of the coffee.  It was highly variable, ranging from properly hot to less so to just warm.  She conducted a root cause analysis as she walked through the wards and noticed that coffee stored in the larger thermos containers stayed hot longer than the coffee served from the smaller containers.  (The greater thermal mass of the larger container held the temperature better.)  So, the solution was simply to use the larger containers.

Immediately, the complaints disappeared, as the coffee was served at a uniform temperature throughout the wards.

Now, admittedly, this is not an item of high clinical importance, but it is an indication of patient satisfaction.  After all, if you are going to offer coffee, why not make sure it is the correct temperature?

Jeanne's improvement won first prize in the poster portion of the hospital's Quality and Safety Day last week. Her poster title was "Dit is andere koffie!"  ("This is different coffee!")  CEO Willy Spaan said, "This is just the kind of sense of initiative and constant improvement that we are trying to encourage."