But the point isn’t about just one number.  There are a set of numbers that need to be on your practice dashboard – that’ll tell you the whole story.  Not only that, there need to be productivity numbers that visually indicate what’s happening at any given point of time.  If you have special projects going on, there needs to visual demonstration of the progress of these projects.

I can’t stress enough the importance of visual indicators.  It serves the following purposes:

• helps you monitor what’s going on at a quick glance
• helps you take corrective action as close to the time of occurrence of the problem as possible
• helps everyone on the team get on the same page without room for ambiguity

What might be those indicators that are relevant to the health of your practice?  A thermometer would tell you in a minute if your patient has fever – it tells it visually and numerically and that helps.  If your practice has the flu, how would you know?

Do this exercise for fun.  Take about 5-6 post-it notes and write a step of your process on each of them.  Stick these post-its at different points on a string.  Tie one end of the string somewhere.  Now, pull the other end.  What happens?  Nothing dramatic but each of the post-its jiggle up and down.  More slowly now…a small tug at the end of the string triggers all the post-its (processes) one after the other.  That small tug is the patient call – that’s when John Smith calls your practice to schedule an appointment.  The post-its are your several processes – from checking John’s insurance eligibility, doing prior authorization for services, keeping all options to collect copays and pending balance ready, medical assistants pulling up reminders, checking on drug interactions, physician preparing for his visit based on historical information, insurance callers marking the precise day to follow-up with John’s insurance company (because they know the average payment cycle from the date of service), the clinical quality check process and so on.  Every one and every process is ready to focus on one John Smith at a time.

If it’s sounding overwhelming, it’s because we are seeing everything in action at once.  Fix one step at a time.  For example, start with verifying eligibility for all patients 3 days prior to the date of service.  Then fix the next one and the next.  Soon, you’ll have your string ready.  Your patients will notice the difference in your practice.

In order to pre-build quality into every step of the process, the team must be trained at a minimum on the before and after steps.  If I’m posting payments, I need to know how to submit charges and how to follow up with insurance companies on pending balances.  In smaller practices where one individual does everything, this may be a given.  You must therefore prepare this individual for the process before billing (e.g. front desk management, clinical support) and after billing (e.g. patient follow-up, quality surveys) – considering billing itself as a complete process.

Cross training has the underlying key benefit of the getting process beyond specific individuals.  I hear this all the time (especially in small practices): Mary knows this, Mary does that, that and that, Mary talks to insurances, Mary also talks to my patients, Mary manages my EOBs…you get the idea.  My question often is: what happens when Mary goes on an extended vacation?  I usually don’t get an answer back.

The situation is a little different but as common among larger practices.  People tend to operate in silos.  What I hear there is: Mary does that, Jane does this, Tracy sits here and it’s been that way for 15 years.  My question here is not when someone goes on vacation (they have that figured) but how is quality controlled and how the group manages employee attrition if it were to occur?

The answer lies in cross-training.  It makes the process independent of individuals and their specific skills.  It also makes what is normally assumed to be specialized skills not so specialized.  This allows the practice to make correct decisions without being held ransom by individuals (if such a situation were to arise).  It also brings focus to the process.  If a new member joins the team, she’s trained on different aspects of the process and her specific process.  Cross-training becomes the norm.  More important, it encourages the organization to constantly learn and motivates staff to strive for self development and growth.

I play a game every time I visit a medical practice for the first time.  I observe the front desk, patients, staff, medical assistants, signs, paperwork, medical charts – anything that catches my eye for a full 5 minutes.  Then I make a random  judgment on how lean or fat the practice is.  It’s funny – 9 times on 10, I’m right.  Practices that desperately need help, leave those traces all around.  Patients wait longer than normal, look more agitated than they must, there’s an undercurrent of lets-get-done-with-you, pharma reps get more love than patients do, there are little piles of paper here and there, several redundant notices, staff is always busy on the phone and everyone is searching for something…oh you’ll get enough clues.  Underlying all this, you get the sense that the practice has more than what it needs.

Let’s go to your practice and do some cleanup.  All you have to do is answer the following questions:

1. What information is collected from our sample patient John Smith at the front desk that is not required or has been provided before or could’ve been provided before?
2. What information does staff look for?  Where is this information located? (psst careful readers, I’m not hinting an EMR here.  I’ve seen practices manage information beautifully even without an EMR).
3. How far are the fax machine, scanner, photocopier from where they are needed?  Why are they printing so much? (Have you ever wondered why a front desk scans the patient’s insurance card, then photocopies it twice, attaching one to the medical chart and saving one for some other reason?)
4. Is the inside wall of the front desk looking like a post-it notes hall of fame? (how do they ever find the info they need quickly?)
5. Is any staff member doing two patient activities at the same time? (e.g. puts the patient on phone on hold, talks to the patient at the window, asks her to wait and reverts back to the one on phone)

Read your answers above (have you written them?) and finally list 5 things that you can unclutter immediately with no negative impact to your workflow.  C’mon, you know these.  Here’s one idea (“Folders”) to help you get started:

1. Make two columns: clinical and practice management (PM).
2. Under each column list down all the types of information that people seek from time to time.  For e.g. under the PM column you might list Patient Eligibility, Insurances, Denials, Accounts Receivables.

Using the information above, create a common folder on your computer network (anyone with basic IT skills should be able to help).  A sample folder is provided below.  There’s no one right way – do what’s right for your practice situation with the objective of finding any information that’s needed within 5 minutes or less.

The whole idea is to access information quickly.  Say, your front desk person Jane left abruptly and you requested your part-time staff Sarah to come on board full time.  Without too much help from anyone, Sarah will be able to figure out on her own to get all types of basic information.  For example, Sarah is trying to check if a particular Cigna plan requires prior authorization for the colonoscopy that you are about to do.  She doesn’t need to search too hard to get the Cigna information she needs; it’s in the Cigna folder under Insurances.

Are you thinking, I’m a physician am not supposed to be doing this stuff and let me forward this to my office manager? It’s a good idea to remind yourself that you are a business owner too.  Also that you would like to build a Lean practice that will give you the freedom to get back to patients without worrying about practice stuff.  If you are an office manager or a practice administrator, this should be easy.

What else might you unclutter?  Revisit your list.

What Lean forces you to do is clean up at a fundamental level.  In a medical practice that basically means taking care of patients and getting paid for it.  Lean forces you to be disciplined about things that are critical to the health of the practice.  This discipline offers you freedom.  It offers you time.  If you are constantly worrying about say getting paid correctly for your video capsule endoscopy from BlueCross, you are not going to have the time to focus on hiring that partner you’ve wanted to or going and speaking to more referral doctors.  If you are constantly worrying about which staff member is pocketing cash from your practice, you won’t have time to play with your kids.

Pause for a moment and list down all the elements of your practice that bother you – your Bothers-Me list.  Hopefully, it isn’t long.  Wave the Lean magic wand and I assure you that your list will shrink.  Why won’t it?  Say, you are bothered about lost claims due to missing timely filing limits of insurances.  After Lean, say your claims are submitted like clockwork and that would be one less thing off your list.

Lean isn’t about quick short term fixes.  It takes time but it gives you long-term, continuing benefits.  More than anything it offers you the freedom of time.

1. Imagine a patient that you are familiar with.  Let’s say, John Smith.
2. Map out your entire process from John’s point of view. (this in Lean jargon is called value stream mapping and you really don’t need to read it). Hint: your process must start with John scheduling an appointment and end with getting paid completely for his service.
3. Ask yourself at which points in the process things are likely to get stuck or delayed.
4. Estimate time-taken at several points in the process (in minutes, hours, days or even months!).

We can’t move forward unless you have a clear visual picture of the above.  So, please take a moment to do this – it doesn’t have to be precise and accurate.

Start with a small step in the process that gives you a lot of pain.  Ask yourself, if it’s possible to standardize this element of the process?  If your answer is no, ask what might be another small step that gives you pain.  Keep it small so it’s easy to complete.  For example, patient “no shows” might give you pain.  Ask why this occurs.  Once you get an answer, ask why again.  After you get that answer, ask why one more time.  What do you see?

Imagine for a moment what this process might look like when it’s standardized.  In the above example, the process might be patient scheduling.  The benefit this gives rise to is a certain amount of predictability in the whole process.  It’s just like ordering a cap at Starbucks – there is a certain amount of predictability.  They ask me the same questions, I fumble through the same responses (quickly adding “skim please”), the green and black uniforms are familiar (hey, even the staff looks familiar), the cups are the same, I find sugar in familiar spots, the furniture is the familiar, and finally, the coffee – it tastes the same (almost).  Predictability.  It’s less important whether we prefer this kind of predictability or not at a coffee shop.  What’s important is that it’s one less thing to worry about.

No aspect of Lean is fully possible until key processes are standardized and achieve a certain predictability in performance.  The square block in the square hole and the triangular block in the triangular hole.  No confusion.

Lean thinking is new to services.  Its origins are in manufacturing of cars, toys and other widgets.  But if you think about it, Lean essentially means cutting fat and it must be as relevant to a medical practice as it is to any physical product.  A practice can benefit tremendously by focusing on one patient at a time and by reducing their “batch sizes” to improve workflow.  You can stop patient flow and fix problems at source to avoid huge problems later.  You can trigger insurance processes when a patient first calls to setup an appointment.  Cross-train staff to check on quality before and after each aspect of your workflow.  Think about it, Lean perhaps applies in full to a medical practice.

At my company, we have been “experimenting” with Lean since the past year and have realized jumps in productivity and surprisingly (or not) increases in client collections.  I’d like to share some of these findings and ideas to help medical practices discover and implement Lean and achieve better flow.  Cost savings and faster cash flow cycle would be a bonus.  With Medicare cuts looming large, heck we need this.  Welcome to The Lean Practice!