How ‘lean’ helps us serve our patients

Patient Cynthia Ernst, who works in Physicians Billing, meets with orthopedic surgeon Dr. Erin Greer for a follow-up on her recent hand surgery. The team at Ferrell-Duncan Orthopedics is successfully handling a high volume of patients thanks to a lean project that focused on streamlining the patient experience.

If you want to know how powerful lean thinking can be, just talk to someone who’s been involved in a lean project at CoxHealth. They’ll tell you lean has improved the way their department works, but they’ll also point out how the skill of mapping the steps in a process and eliminating the waste gets internalized. Once you’ve seen it applied, it colors the way you view everything. It becomes clear that lean projects don’t just make satisfied workers, they make lean evangelists.

“The lean process is so valuable, the whole system should go through it,” says Karen Miller, medical secretary in Ferrell-Duncan Clinic’s Orthopedics department at the Bone & Joint Center. Lean thinking has her looking at everything her department does and asking “is this the best way?” or “does this add value for our patients?” “Lean really teaches you to be open minded to change. Keep your ears and eyes open and don’t get stuck in a rut.”

Miller’s first exposure to her new way of thinking came during a lean project the department conducted last spring. The project was designed to help staff members handle an increasing volume of patients while streamlining the patient experience. The lean team broke down the process from a patient’s initial phone call to having an appointment scheduled – any step that didn’t add value for the patient was a candidate for adjustment or elimination. At the same time, clinic staffers identified waste in their own work processes, which they eliminated and made their own workdays more efficient.

The orthopedics project is one of several lean projects under way at CoxHealth and leaders say the lean approach to constant improvement is key to getting the most out of the resources we have and thriving in the future.

Ken Jennings, operations administrator at Ferrell-Duncan  and a lean team facilitator, spells out the need for lean in a simple equation: Volumes are up, but reimbursements are down. Quality must go up. How do we make up this difference? By improving our own processes and cutting waste and inefficiency.

“Lean projects are exactly what we need to be doing at Cox,” Jennings says. “We need all the people we have, so where do we find the resources to make it work? We have to look at and streamline every single process.”

Applying lean

At Ferrell-Duncan Orthopedics, physician turnover had left the department with fewer doctors, but the demand for orthopedic services continued to rise.

“The issue became how do we sort, separate and filter this volume, this huge need in the community for orthopedic services, in a more appropriate way,” Jennings says.

Like many people hearing the term “lean” for the first time, some staff members were leery of what applying lean thinking would mean for their work. Scott Rogers, CoxHealth’s administrative director of organizational development, says that one of the first steps to introducing a lean project is making it clear what lean is and what it is not.

Lean began as a process-improvement discipline developed by Toyota as the company sought to perfect its manufacturing processes. They created the Toyota Production System, which studies how people work and looks for ways to eliminate waste – wasted time, wasted effort and anything that doesn’t add value for the customer.

Departments like orthopedics that take on a lean project examine their own work, beginning by mapping out all the steps in a particular process, such as how patient calls are routed. The lean team will take a step back from the map and look for barriers, bottlenecks or frustrations in the system, what Jennings calls “boulders” or “stones” in the stream of daily work.

Karla Riley, certified medical assistant for Dr. Erin Greer, says mapping the scheduling process from the patient’s perspective opened the eyes of the clinical staff.

“From a clinical perspective, you think about your area, but not about the broader context,” she says. Riley says having lean team members from administration, clerical and surgical scheduling helped everyone to think beyond their individual areas of responsibility. “This puts the patient at the center and helps you see how to be more effective.”

The lean team developed what’s called a “current state map” of all the workflows in the clinic. After identifying areas for improvement, they created a “future state map” to work toward. Ideally, that future map will become their new current state map and they will develop a new future state to work toward in a cycle of constant improvement.

Chad Kuhlmann, orthopedic department supervisor, says just looking at those maps and being able to ask questions and propose solutions brought staff on board with the lean process.

“When you map everything like this, light bulbs come on,” Kuhlmann says. “The staff support was incredible. Now the team is engaged and they throw out ideas to help everybody. You see your co-workers as a resource, not as a barrier.” 

Key measurements

With the department’s processes mapped out, the lean team could see where improvements were needed to help patients access care efficiently.

They began by focusing on two priorities: streamlining the way phone calls are handled and making sure patients are scheduled with the most appropriate physician for their case. 

After identifying the issues, the team began working on ways to collect relevant data. Kuhlmann says having concrete data is key to making the lean process work. It removes perceptions and allows the team to work with measurable facts everyone can agree on. The lean team looked at two key measurements: the volume of calls coming into the clinic and the physician/surgery ratio, a measurement of how often a meeting with a surgeon results in a surgery.

Phone volume: The sheer volume of phone calls coming into the department was an obvious first target – simply hearing the way the phones rang constantly illustrated the need for a new process. 

Staff members estimated that the main line for the department was receiving 3,200 calls each month. With the previous screening method, patients were being transferred among staff before getting to the right person. It was a process that could be frustrating for patients and staffers and calls were sometimes dropped.

Kuhlmann says that as staff members scrambled to handle the phones, they were less able to handle their regular duties in the department, a fact that was beginning to show up in Press-Ganey patient satisfaction scores.

Seeking a solution, the lean team took a “gemba walk” at Adult Medicine & Endocrinology Specialists. The gemba walk is a lean tool that involves looking closely at another group’s processes to see what can be applied to the problem at hand. They discovered Adult Medicine & Endocrinology Specialists uses an automated phone system to route their incoming calls. After seeing the system in action, the team recommended adding a phone system called Agent to the Orthopedics department.

The new system includes menus and a queuing process that allows patients to answer questions and actively assist in triaging their own calls. In its first few months of use, the system has greatly improved the way patients are connected with the appropriate areas.

The Agent phone system also provides real-time tracking of call volumes, which offers hard data that quantifies a truth staff members already knew: they are busy. In the first month, the total calls added up to more than 6,000, almost double their estimate.

“We all knew we were busy, but we didn’t see the real volume until we went through this project,” Miller says.

Now, with the Agent system in place and more calls going to the right staff member the first time, the phones have become quieter.

“Well, we don’t like to say that,” Miller says with a laugh. “As soon as we say it, they’ll start going ballistic. Let’s just say they’re peachy.”

The automated phone system frees up staff members to take care of the patients who are in the office in person rather than juggling duties answering phones. Similarly, nurses in the clinic are freed up to work with their patients with minimal interruptions.

Jennings points out that the phone changes are a good example of how eliminating waste produces a synergy of benefits for everyone involved. The more efficient system speeds things up for patients and it improves both the way employees work and the overall culture.

“Transferring calls is waste, and if staff members can’t take lunch because of trying to keep up with call volumes, that’s bad for morale.”

Physician/surgery ratio: When the team began looking at the overall workflow in the clinic, it became clear that patients and physicians would benefit from a better triage system as patients first made contact with the clinic. It wasn’t just a matter of handling the volume of calls, there needed to be a standardized way to route patients into the correct path of care. Before the lean project, there were times when patients with surgical needs were placed with non-surgical doctors and vice-versa.

“Our goal is to get the patient in the right exam room at the right time,” Jennings says.

Meeting that goal is a key to providing the best patient access for the clinic – getting patients to the care they need with the most efficient use of their time and the physician’s time. The lean team began looking at how often a visit with a surgeon was resulting in a surgery. The team wanted to improve scheduling accuracy for patients and move that ratio toward 1:1, ensuring that only patients needing surgery met with a surgeon. The team found the original number to be 2.76 patients seen for every surgery a physician scheduled.

To correct the issue, the lean team designed a clerical triage process in which schedulers ask patients a series of questions and then use a decision tree to confirm the correct course of action. The team worked with doctors to develop “scope of practice” documents for each physician. Those documents, updated quarterly, detail what surgeries and treatments a physician is currently doing and they make that information available at a glance for schedulers.

“This makes everything visual for everyone to see and it keeps the physician in the driver’s seat in terms of how they want to structure their practice,” Jennings says.

A team culture

In the first few months following the lean project, numbers tracked by the department were already showing that their efforts were paying off.

Press-Ganey scores on “ease of access to the clinic” had started around 85. By the end of October, the department had gained 5 percentage points on that question. On the question about the ease of reaching the clinic by phone, the numbers rose from the 81-82 range to the 88-89 range.

“The data reflects a positive change,” Kuhlmann says. “The patient is more in control than before and that’s a satisfier.”

Equally important is the change the project has made for the culture of the staff. The project has engaged staffers from throughout the department and given them a voice in ongoing efforts to improve their workplace.

Miller says the regular meetings offered a positive setting for staff members to discuss issues and find solutions together. She says there’s a real fellowship among co-workers and with their leaders.

“If you’re invited to join a lean project, say ‘yes’ and get involved,” Miller says. “It’s amazing. Instead of being told ‘here’s how you’re going to do it,’ the people who do a job every day have real input on how it should be done.”

Jennings says that’s what makes lean so valuable, and so empowering for the front-line staff who help drive the improvements. 

“The people who actually touch the work being done know where the barriers are and they know what the solutions can be,” he says. “We just bring the tools so they can remove those barriers to providing better patient care.”

The team is currently focusing those tools on the clinical side of their practice. Remember those maps of the current state of processes the team developed at the beginning of the first lean project? They included what’s called a “parking lot” – a space for additional issues that fall outside the scope of the current project. The items noted there are now forming the basis of a second lean project that is tracking the entire process of care a patient goes through. 

Team members are excited about the possibilities lean thinking brings as they look at the entire scope of care from the patient’s perspective. They know they’ll find ways to make things better for the people we serve every day.

Riley says: “Everything you do is for the patient and increasing value for the customer.

“Satisfied customers improve the bottom line and we want to provide the best care we can provide. That’s why I went into health care, I want to take care of people.”

About lean

Lean thought has its roots in a process improvement discipline developed by Toyota. While it began in the world of manufacturing, the lean approach can be used to examine and improve a variety of work processes. Here are a few of the terms you’re likely to hear as lean projects are deployed at CoxHealth:

Muda: A Japanese term for an activity that is wasteful and doesn’t add value.

Gemba walk: When leaders examine first-hand how work is done on the front lines. They’re visiting “gemba,” or “the real place” in Japanese.

Value stream: All the steps in a process of producing or delivering a product or service. Value streams are mapped to show the flow of information and work in the process. How work is carried out at the beginning of a lean project is defined on a current state map while a goal for how processes could be improved is spelled out in a future state map.