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It’s Harder to Tolerate Waste “When You Know What Good Looks Like…”

I recently “fired” my primary care physician. I’m lucky to not have to go to the doctor very often, but the last few times I did, I had to wait more than an hour beyond my scheduled appointment time (in a tiny windowless room, as pictured at left).

I had talked to the office manager about this before and, in the last visit, I complained that they weren’t respecting my time. The office manager argued back (quite rudely) that they didn’t disrespect me and that I shouldn’t jump to that conclusion. But, to me, the repeated pattern was that they cared more about physician utilization than patient waiting time. It was an usual occurrence, it was a repeated habit. It’s not that something went wrong that day that messed up patient flow – it was a very systemic problem.

I left without seeing the doctor and asked that he call to talk to me about why I wasn’t coming back. I also called and left him a voice mail asking him to call if he was interested in why I left his practice. I never got a call back. That said way more about their lack of giving a crap than anything else. I guess their business is doing just fine without me.

So I hope to find a new PCP when I need one. I’m hoping to find a better method for choosing a physician other than 1) who takes my insurance and 2) who is close to my home. But who has public data on A) waiting times and B) effectiveness and population health? That’s part of the transparency problem in healthcare – that we often don’t have good data (or any data) for choosing a doctor, a hospital, or a surgeon.

Not to make it all about me in this blog post, but I have a congenital problem with some vertebrae and it’s flaring up and bothering me. I was referred to a spine specialist practice and was on the phone yesterday trying to book an appointment (more than a week after my chiropractor referred me to them and they didn’t me call to book an appointment without me following up twice).

I was on the phone for, no joke, 21 minutes and 37 seconds booking this appointment.

The woman on the phone was complaining to me that her office had a new computer system and it was hard for her since they hadn’t trained her very well and she was now using a laptop instead of a desktop and the keyboard was funny to her. “It’s like I have a handicap,” she said, which isn’t very politically correct or very sensitive. Lack of training is a short-term focused cost-cutting choice that people make. It’s not fair to people with real disabilities, people who don’t choose to have them.

So one reason it took so long is that she was collecting (slowly) tons of information – my personal info, my wife’s info, her insurance information, etc.

She then told me that I’d have to arrive 30 minutes before my appointment to fill out a new patient information form.

I asked, “What? Isn’t that what we’re doing right now, filling out the form over the phone with you?????”

She then asked for my wife’s social security number. I hesitated and then asked, “Am I going to give it to you over the phone and THEN have write it down again on that form that I’m arriving early for, along with all of the other information that I’ll likely duplicate?”

She wasn’t the right person to be asking such systemic questions to, as she was just trying to do her job, So I gave her the info without further fussing. I’ll suffer the “waste of overprocessing” by having to give the same information multiple times when I have my appointment on Friday.

Since I was at the offices of the ThedaCare Center for Healthcare Value when I was making his call, Dr. John Toussaint walked by right after I was done and I complained a bit about the waste in the system when he saw the frustration on my face.

He said, “When you know what good looks like…”

Yes, when you know what good looks like, it’s harder to tolerate the preventable waste that we face in the healthcare system as patients or providers.

When you know that some primary care clinics and “The Lean Dentist” Dr. Sami Bahri basically have “zero waiting room” practices, the idea of waiting 60 minutes because the physician overbooked (probably intentionally) is harder to take. When you know that some hospitals have a “zero wait E.D.” it’s harder to tolerate a long time in the waiting room.

An ideal patient care experience (or “what good looks like” from Dr. Toussaint’s perspective) might include:

  • less waiting (not waiting weeks for an appointment or not waiting many hours if you arrive at the emergency department)
  • less harm (fewer infections, fewer falls, fewer medication errors)
  • lower cost (as ThedaCare has demonstrated as a provider, with 20-30% lower inpatient care cost, or as an employee of the company Serigraph, where they get free on-site preventive care and have better outcomes at lower cost, as detailed in the book The Company That Solved Health Care Its Harder to Tolerate Waste When You Know What Good Looks Like... lean

If you’re familiar with Lean healthcare improvements, you know that “what good looks like” includes a 37-minute “door-to-balloon” time at ThedaCare for Code STEMI heart attack patients (far better than the 90-minute U.S. standard). You know good looks like more patient-focused care at lower costs and better quality… so you wonder why everybody doesn’t have that now, with such excellence being demonstrated at a relatively small number of hospitals that everyone can learn from.

You wonder why the federal government has to chip in a billion dollars to drive innovation and quality improvement in healthcare, when that should already be the goal of any healthcare provider (and you can read how to do it for free online at sources like the AHRQ or for $8 (Kindle version Its Harder to Tolerate Waste When You Know What Good Looks Like... lean) in books like On the Mend).

I wonder when we’ll hit a “tipping point” in healthcare when enough people are now getting excellent care, as opposed to average typical care, when word will spread that “what good looks like” is out there. I think people often accept what healthcare throws at them because they think it can’t possibly be better. But the truth is, it can be better – better quality, lower cost, and less waiting all with happier healthcare providers and personnel.

The frequent news reports about 100,000 Americans dying each year due to preventable medical errors and another 100,000 dying due to hospital acquired infections don’t seem to be convincing anyone that things can be better. Maybe they’re just convinced that things are bad…

 


mark graban lean blog Its Harder to Tolerate Waste When You Know What Good Looks Like... leanAbout LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as the new Executive Guide to Healthcare Kaizen. Mark is also the VP of Customer Success for the technology company KaiNexus.

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31 Comments on "It’s Harder to Tolerate Waste “When You Know What Good Looks Like…”"

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  1. Tim McMahon says:

    Great story and lesson Mark. I think everyone can relate to this. Once you stop listening to your customers you are headed for demise. It is not surprising that Lean transformation must start with understanding customer value.

    Thanks for sharing.
    Tim McMahon recently posted..Lean and Green Reduces WASTEMy Profile

  2. Mark – great post. First of all, I’m so sorry to hear about your back. Can’t be very comfortable.

    It’s odd timing that you’d post this story because I just had my first appt this week with a new gyn for my annual exam and had an experience that has me telling everyone in my neighborhood about this great doctor. After being very impressed with the staff who greeted me and the sign-in process (I’m rarely impressed with either), I sat in the waiting room for too long for my taste. After 30 mins. and watching people who had come in after me get called in, I asked the woman who checked me in about it. She responded far differently than the people in your doctor’s office. She was extremely apologetic and said they had my chart and it’d only be a few more minutes. But 15 more minutes passed and I grew irritated. The woman had set my expectation for a “few” more minutes, not 15. When the nurse came and got me, I mentioned the wait to her. She was so-so about hearing my feedback. But then — and this is what gives me hope about healthcare — when the doctor came in, she apologized over and over. Without knowing what I do for a living, she said “we apparently have a process problem, and I’ll get to the bottom of it.” After my exam, she offered to validate my parking (which they don’t usually do). Yes! A doctor who “gets it.” That it’s not all about him/her. That I — her CUSTOMER — mattered and my time was valuable.

    As for the duplicate info, I hear you. It also fries my fanny how many times I have to enter long account numbers into phone systems, then give it verbally to a customer service rep. I often probe and they usually say it doesn’t show in their system. So why they make customers enter it escapes me.

    Finally, I love Dr. Toussaint’s line! So true. It’s tough being a customer when you are a Lean practitioner and know how it can and should be done. Have you considered writing a letter to the doctor and sharing this with him? Granted it’s something you shouldn’t have to do and you may not have enough interest in helping them to take the time. But it’s great when those of us who know “what good looks like” share our experience with the decision-makers who may or may not be motivated to do something about it. Even if your letter doesn’t result in immediate improvement, you may move the needle just enough for something to happen down the road that will improve service for all the patients-to-come.

    • Mark Graban
      Twitter:
      says:

      Karen – thanks for sharing your story. I know one doctor who told me (in my capacity as a consultant) that “I wish I didn’t have to start each and every patient encounter by apologizing for running behind.”

      As for my doctor, I tried to call him. It reminds me of the line from the movie Airplane, “Chump don’ want no help, chump don’t GET da’ help!”

      Physician, heal thyself.

    • Richard Carlson says:

      “When you know what good looks like….” Our jobs as health systems engineers and Lean practitioners are both a joy and a curse!

  3. Mark – I loved this post.

    Here’s why: I often wonder how useful talking in our own “lean” group is. We can debate semantics, share stories, etc. But to get real traction for real change, we need to engage a whole different audience. I feel that this post is a step in that direction because it hits home in our everyday life outside of our “lean” groups.

    I think the “tipping point” you refer to is coming. When the masses begin to vote in mass with their dollars for improvements, we’ll see real change. I hope!

    • Mark Graban
      Twitter:
      says:

      Thanks Tavan. So one takeaway or idea is to take this post and craft it into a more general purpose article (without my bitching and moaning about my own doctor) about people needing to demand more of healthcare by giving them exposure to “what good looks like” in the dimensions of patient safety and quality, access and waiting time, and cost.

      Serigraph, the company I mentioned in the post, has their employees voting with their feet by choosing high value (great quality / low cost) providers in the Milwaukee area or beyond. This is a good trend that starts to put healthy competitive pressure on hospitals that have been somewhat isolated from too much competition in their local markets.

      When companies start flying patients to Wisconsin to have lower cost / higher quality surgeries (a form of “medical tourism” within this country) then we might see more pressure for improvement (not that all Wisconsin healthcare is perfect, don’t get me wrong).

  4. Mark Graban
    Twitter:
    says:

    From Facebook #1:

    “Great post. I believe part of the reason that offices can behave this way is because the vast majority of people accept this behavior as normal. I recently made a decision to return to Mayo Clinic even though it is a long drive from my home and a higher co-pay but they get me right in, make me feel important and respond to my needs. You can’t put a price tag on that! Good luck in your search for a new PCP!”

  5. Mark Graban
    Twitter:
    says:

    From Facebook #2:

    Hey Mark, This is such a hot button for me. As a mom of 3 I very rarely make time for myself to go to a doctor, and when I do, it’s a big hassle arranging childcare, etc. It drives me crazy to be waiting. I absolutely believe I am a paying customer, and feel they should treat me as such. I am a squeaky wheel who will ask how much longer before I am seen. I did have to leave once before being seen because I had to pick my son up from preschool. The worst is that they wanted to charge me for that “missed appointment.” I hope it becomes common practice to post those statistics on their website. Thanks for sharing your blog.”

  6. Mark Welch says:

    Perhaps we as patients should leave the receptionists bills for our time wasted while waiting.

  7. Brian Buck
    Twitter:
    says:

    “I guess their business is doing just fine without me.” I think is the key phrase that will inspire a tipping point.

    Once a provider or hospital really means to have patient-centered focus that is reflected in their behaviors and not just empty slogans will we see a shift towards improving. These organizations that make the committment to make things more convienient for the patient and not just the provider will be far more competitive. Then orgs like your PCP will no longer have their business doing fine without you because patients will leave once they know of better options.

    Great post. I really like how you reflect the patient’s perspective.
    Brian Buck recently posted..Do You Have A Play LabMy Profile

    • Mark Graban
      Twitter:
      says:

      With the coming shortage of primary care providers, I’m afraid the balance will shift more toward the provider having an attitude of “you’re lucky to be our patient.” I’m glad I can go find a good office (I’m going to use Angie’s List and physician service reviews before making a choice and I might even spring for some version of “concierge medicine” for not just waiting time but more of a total health maintenance perspective, instead of isolated episodes of reactive care).

      I have a friend in the business world who would love to leave her Medicare provider, but it’s becoming increasingly hard to find somebody to take a new Medicare patient… so the lack of choice and inability to “vote with your feet” will make things worse, from a service perspective.

  8. Jonathan Baum says:

    Hi Mark – great post. I happened to recently see a large billboard off the highway. This sign from a local hospital was touting it’s average ED wait time (who knows what their variability is) and listed a number to call if you want to know current wait time. I saw a similar billboard not long ago for another hospital. So although this is far from perfect perhaps it’s a sign of improved transparency.

    • Jonathan – great point. I especially like the billboard with a number so you can ask what the current wait time is. That said, I’ve worked with a number of hospitals with those billboards and, unfortunately, they’re not communicating reality at all. In my view, false advertising is more dangerous than staying silent. So… we do indeed have a long way to go in creating a customer-focused, well-oiled healthcare machine.

    • Mark Graban
      Twitter:
      says:

      I’m all for efforts to reduce E.D. waiting, but I tend to side with the critics of the billboards who say that advertising short times drives overutilization and inappropriate use of the E.D. instead of, say, waiting days to get into your primary care provider or waiting, ahem, an hour past your appointment time.

      I think the day of real transparency will be when a hospital has a billboard showing the number of people who died last month due to hospital-acquired infections or some such patient safety measure.

  9. John Hunter says:

    I agree, I am very frustrated at having to put up with lousy service. It actually can provide a benefit in looking to improve – in that I am extra sensitive to waste and bad results. I don’t usually have any trouble spotting plenty of things that could be better.

    I can manage my situations a bit. I have been able to find a great dentist, no wait time, very effective… I’m sure I could find cheaper options, but I don’t mind paying at all. I wouldn’t say his practice is “lean” at all in as far as know what lean thinking is and using tools and concepts. Basically he is just very focused on providing great service. He respects people’s time.

    However, noticing how bad so many things are done isn’t useful in making you blissfully happy :-( My father was much better at not letting bad service bother him. I wish I could do that while still being able to work on improving the system (it is certainly perfectly possible to do that, he was much better at management improvement than I).
    John Hunter recently posted..Personal Finance Basics- Long Term Disability InsuranceMy Profile

  10. PT Wonk says:

    I can sympathized and empathize. I too fired my PCP about 4 years ago. One reason being the excessive waits and the second being a close to retirement physician with practices that were established 20 years ago.

    I ended up at a family medicine clinic that is part of the teaching hospital that I work at. Very little wait time, but I will spend about twice the time in the examination room as I first have to be seen by the resident before my “real” doc sees me (and occasionally a med student, as well). One of the effective aspects can be trace to the staff physicians being on salary and not fee-for-service… there is no driver to overbook.

    Saidly, they are forcing the physicians to move to fee-for-service in the near future and I expect to be on the hunt for a new GP as don’t expect any of the physicians to actually stay in the clinic.

  11. Richard Chapman says:

    Mark, slightly off topic, but you mentioned chiropractors

    doctors in Australia similar to what you’ve described, but the chiro I was going to was great.

    Walked in, his assistant offered me cup of coffee or fruit juice while I sat in very comfortable, scenic waiting room. If anything, the coffee/juice was more of a hindrance to the start of the session as I was interrupted many times by the chiro becoming available.

    Always asked me exactly what I was expecting, whether I was getting it and how I felt the program overall was going.

    I’ve never seen anything like this from doctors. I paid considerably more out of pocket for the chiro than the doctor but that’s an artefact of insurance systems, not the cost of the service.

    I don’t know if his practice was Lean, but he did understand the idea of value, and delivering it. I’ve yet to meet a community doctor who did.

    • Mark Graban
      Twitter:
      says:

      I’ve been to the chiropractor about 8 times for my neck and the service has been WAY better, like you said. I’ve only waited in the waiting room once maybe, and that was for just 5 minutes. Things flow really well. They are experimenting with patient “self rooming” which works fine after the first stumble or two of (me) not putting the chart in the right place on the wall (which messed up their visual signals and they tried to put a 2nd patient in my room).

  12. Richard Chapman says:

    I’ll also mention I was at emergency at my nearest big hospital last year for suspected gall stone I was triaged quickly account ruling out heart issues, then placed on trolley in cubicle for registrar to see.

    The young female doctor was absolutely focused on patient needs, communicative, listening and so on. They must be training them better in med school than before. Hopefully a new generation of docs will appear without the attitude I remember from before.

  13. Barry Render says:

    This reminds me of the exact opposite treatment I received at my old (now retired) doctor’s office. No waits, respectful staff. You might find a blog I did on it interesting. Just go to my site and click on Module D, Waiting Lines.

    (Mark’s edit — adding link: http://heizerrenderom.wordpress.com/category/chapter-correlations/module-d/)

  14. Chet Frame says:

    Great post, Mark. MY ex-PCP would never show up and would, after the 60 -80 minute wait, have me meet with his PA. She misdiagnosed a tumor which led me to one of my best medical experiences ever with Texas Oncology. Very little time waste, great service from all of the stakeholders, involvement in how you feel about your treatment, and a genuine caring attitude. They have asked for suggestions for further improvements and taken action. There are winners and losers.

  15. Freek Dekker says:

    Wow Mark, This post impressed me even more than most! I find that, whenever personal experience, both from a professional point of view AND that of the patient are being put together we, as professionals in healthcare, start to really and intrinsically want to ACT to improve our processes. Therefore I’ll be sure to share this post among colleagues. Much appreciated! And maybe it’ll help your ex PCP to share it with him and his co-workers. Freek.

    • Mark Graban
      Twitter:
      says:

      Thanks, Freek. I think my former doctor’s office is beyond help. They seem to not want to improve. As Dr. Deming said, “It is not necessary to change. Survival is not mandatory.”

      I know many or most healthcare professionals WANT to make things better. Lean helps provide a method, a minset, and a management system to help make that happen. I love working in healthcare because of the caring, smart, motivated people…

  16. My fiancée and I were recently at a local ER to get a splinter removed from her heel. It had been in there for two months and was now causing her discomfort.

    We entered a relatively bright building with high ceilings and waited at the front desk. My fiancée’s driver license was taken, information annotated, and she was asked why she was there. We were then told we’d been seen by a nurse shortly.

    An hour later, we barely made out her name being called — the high ceilings lost the nurse’s shout. There were no speakers, no display indicating we were next, nothing of the sort. Rather, people constantly walked near the room and spoke a name, only to have their voices lost to the high ceilings.

    We then saw the nurse. She took the SAME information as the front desk plus a few small additional pieces pertaining to pain and then rapidly sent us back to the waiting room. Where we waited.

    And waited. And waited.

    We picked out my fiancée’s name anew and were ushered into another room where every detail of our life, relationship, and employment was filed into some giant entry system that involved more typing than I do in a day (as a programmer). Unceremoniously, we were sent back to the waiting room.

    More waiting.

    Finally, we were brought by a nurse to the actual ER with beds and all that jazz and were sat down and told a doctor would be with us shortly. And waited.

    Lots more waiting.

    The doctor appeared, asked what happened, which we recited, and vanished, ordering an x-ray.

    The x-ray was the smoothest part of the process. It took around ~20 minutes from being ordered to it being in the doctor’s hands. We saw the doctor look at the images, yet had to continue to wait.

    While waiting, we were subjected to gossip being thrown around between the doctor, various nurses, and even cleaning staff. This gossip was spoken very loudly, loudly enough to interrupt conversations my fiancée and I were having.

    Finally, a new doctor arrived, a podiatrist. Her jacket was on and she spoke quickly, briefly glancing at my fiancée’s foot. Within a few seconds she said it was nothing, to take advil, and if it continued to bother her to make an appointment with the hospital’s foot center.

    We then waited approximately 20 minutes to be discharged and were on our grumpy way back home after 4 hours.

    Bleh.

    • I totally need an edit button :) anything that looks like a typo, is a typo.

      • Mark Graban
        Twitter:
        says:

        Let’s draw a value stream map of that encounter together….

        It can clearly be better than that.

        She was probably the victim of triage. I have a journal article I’ll blog about that demonstrates how triage, while intended to get high acuity patients back faster, actually slows EVERYBODY down, including those urgent cases. That’s why many E.D.s are rethinking triage and putting a doc at the front door basically. Triage seems more designed to keep everyone away from the doctor.

  17. This is such great timing for me. I actually went to the dr. today, and had a similar experience to yours. I waited 45 minutes PAST my appointment time to even get back to the office. When I asked the receptionist she just gave me the, “the dr. is running behind” answer. Once I got back to the room I waited about an additional 25 minutes to see the dr.

    Instead of discussing my medical concerns I decided to ask him if he was aware of all the waste in his practice. He looked at me sideways like I was crazy. After we discussed my medical issues the dr. got up to leave. As he walked to the door I said, “Hey doc, you just charged me $140 for a 10 minute office visit. I’ll be sending you a bill for my 75 minutes of waiting.” He kind of chuckled, and I added “at a rate of $125/hour” so I think that makes us even…

    Sorry for venting, but this post hit a cord with me!

  18. Mark Graban
    Twitter:
    says:

    Following up on the “waste of duplicated information,” I found the new patient questionnaire on the spine specialist’s website and, to their credit, it’s very clinically focused and not just a repeat of the insurance info, etc. that I gave them over the phone.

    But try this experiment — how many clicks (and how much searching) does it take you to find the new patient forms on this website?

    http://spineteamtexas.com/index.aspx

    I eventually found them…. customer centered to have it that hidden?

  19. I love all the great comments that you’ve generated, Mark! Seems you’ve struck a nerve. I have two additional thoughts to share. To me, triage has always felt like an unnecessary “traffic cop” step. If patients could get to doctors quickly, it wouldn’t be needed. I understand the need to differentiate based on urgency, but I’d like to see the medical profession experiment with letting patients triage themselves. We need to trust patients more than we do. Bottom line: triage wouldn’t exist if we had true flow.

    Secondly, Mark mentioned giving his wife’s SSN. I STRONGLY advise all patients to NEVER give their SSN to a healthcare provider. Some may refuse to give care if you refuse to give it, but now that identify theft is so common, most will now accommodate patients’ requests for privacy. Always begin with saying “I don’t share my SSN” and then decide what to do from there. Here’s a good post from Experian on the subject – http://bit.ly/evRZCF. Just because they ask, doesn’t mean you have to give it.

    • Mark Graban
      Twitter:
      says:

      Thanks for the reminder on SSN.

      Here is an article about how triage can SLOW care for even those who are most ill/injured:

      http://www.acep.org/Content.aspx?id=49469

      Part of the problem, she noted, is that triage has expanded beyond simply prioritizing patients when they can’t be seen immediately by a doctor. Instead, it has become a “primary assessment tool,” she said, used to gather information that often has little to do with making that call.

      “We triage everyone with the same process, regardless of complaint,” Dr. Weber said. As a result, triage clogs with low-acuity patients who don’t really need to go through the process.

      “Do we really need to know the past medical history, blood pressure, and oxygen saturation on a 20-year-old who sprained his ankle on the basketball court last night, before we determine whether he’s higher or lower acuity?” she asked.

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