“Single Piece Flow” in Medicine


I've always enjoyed my discussions with Sami Bahri, D.D.S., the “World's First Lean Dentist.” One concept he talks about, most recently in our video podcast, is the application of the Lean concept of “single-piece flow” to dentistry and his patients.

Dr. Bahri's brilliant question was to ask, “Why does the patient have to come back for multiple visits to receive their complete care?” This led him to change processes to take care of almost everything in a single visit – find a problem, fix a problem.

I got an email from a reader of a similar primary care situation:

I listened to the podcast with Dr. Bahri.

My wife was at the doctor Friday for what appears\ed to be heartburn / indigestion. They ran an EKG, which was normal. As  defensive medicine, I suppose, they want to run an echocardiogram. They could have done it at the doctor's office at the same time as the EKG, but  the insurance company won't pay for it there, so she has to take this afternoon off to go to the hospital instead.

So much for single piece flow – so much for taking care of the customer's needs in a convenient way. In this case, it sure sounds like the dysfunction comes from the insurance rules. I've heard of similar dysfunctions where outpatient physical therapy has a different rate than inpatient physical therapy — different pay for the same work.

Have you run into similar situations? Dr. Bahri was able to improve his patient flow since there wasn't a financial impact, it seems – same pay for the same work done in one visit or multiple visits.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. Mark,
    This one is interesting. Medical practices are usually rewarded for having clients come back so they can bill insurance another $100 or more. It goes back to how they are motivated and unfortunately the insurance companies currently pay per procedure instead for outcome.

    I actually did a base line assessment with a medical practice and covered single piece flow. They still had a hard time getting away from the doctor needing to be busy 80-90%. The practice agreed to try it but wanted to settle into their new building so decided to put off improvements till next year. Hopefully they will give it a try.

    .-= Ankit Patel ´s last blog ..Wiki Wednesday – Is Lean Different For Small or Medium Business? =-.

  2. In my entire life’s experience with the medical profession (hospitals, clinics, doctors’ offices, etc.), the only thing I’ve ever seen flow was bodily fluid (and even there I’ve had a few sticky situations with phlebotomists).

  3. I am an optometrist and deal with this situation every day. My practice does both routine care (checking for glasses and contact lenses) and medical care – diagnosis and treatment of eye diseases. We are reimbursed most of the time by a different carrier for a routine visit vs. a medical visit. To be legally paid for these services, they need to be done on different days or I can do it all and not get paid for some of what I do. Not very lean I’d admit. What is the solution?

  4. Hi Mark, unfortunately we have similar situations in the Netherlands. For example recently the payment system changed a while ago and now doctors get paid more in outpatient specialty care since when a patient undergoes certain diagnostic tests on a different day then the appointment (the old-way-thinking is that this is an indication that it’s a more severe disease that should be paid more). So some practices have reversed improvement project results where ‘one-stop-shop’ was introduced and let patients not have all necessary test directly but have them come back…
    .-= Marc Rouppe van der Voort ´s last blog ..How do you start with lean? =-.

  5. I couldn’t agree more with Ankit. While Toyota pulls the massive Andon to prevent shipping bad product out the door, the medical industry seems to collectively keep people comming back for repairs.

  6. From a patient perspective the dentist example is extremely convincing that lean is the way to go! I’m going to remember to use that as an example since so many people dread the whole dentist experience! It’s not the dentist, it’s the process!
    .-= Umbahli ´s last blog ..Calling all stormtroopers! =-.

  7. From this article, a ThedaCare example:


    “Now, the scans are provided at the time of consultation, thereby ensuring that a physician is present to verify that all the information required has been collected during the consultation. Then, the team looked for ways to remove waste from the treatment plan process. “Overall, these steps collapsed the time from referral to patient, increased employee productivity, and improved the overall outcome,” Barnas says.”

  8. Medical care continues to be driven by the tyranny of the visit. No compensation for doing the right things at the right time for the right reason. The compensation is attached to the visit. Having said that, there are other oddities that come in to play at times. For instance, if a patient is seen in our primary care clinic (a department of a hospital) today, then admitted to the hospital during the same 24 hour period (for any reason-related or unrelated to the earlier visit), we are not compensated by Medicare for the clinic visit. The hospital visit gets paid for – not the clinic. The rules for reimbursement are payor-driven, and often nonsensical.

  9. Unfortunately this is a very usual problem in mexican and other Latin American healthcare. A visit to the doctor will usually be deferred to another visit the next day or afternoon since doctors are too “busy” (mostly absent from their offices). This translates into the whole service chain where an X-ray analysis can be delayed as much as 14 months! (All this time the machine is working at a 40% capacity due to breakdowns or lack of trained people to operate). A lot of the problem is the corruption and null employee engagement mostly due to the union terms and a lack of leadership of the administration.


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