Purely Avoidable Waiting Waste During an MD Visit
I'm a bit hesitant to blog about a bad experience with a doctor's office and waiting time. There are multiple “draft” posts I've started to write, left saved out there without being published, as it seems a bit like a “hack” lean blogging topic. You know, I mean the term “hack” as it refers to comedians who use unoriginal material (not “hack” meaning an MIT prank). A hack comedian does routines about bad airport food or mother-in-laws. Nothing particularly insightful or new there.
So I'll try to write about a recent doctor's appointment in a unique or interesting way. I know, we all have to wait too long at the doctor, far too often. But, I hope you'll find this story interesting and not hack-y.
Last week, I went to an ophthalmology specialist for a problem with my left eye. I was in the office for about two hours for about 15 minutes of “value” – being diagnosed or treated. And the last 45 minutes of waiting was completely avoidable. Here's what happened.
The Visit Begins
After check in, I saw the first technician almost immediately. So far, so good. “Provider 1” did his checks and tests, interrupted by 5 to 7 minutes when he was gone from the room because standard eye drops that he expected to be in the room weren't present. So there's a materials management problem – not uncommon. A good assembly line has a better process for making sure production workers have the parts they need compared to some doctors offices or hospitals, where skilled professionals “hunt and gather” for needed supplies. They really should have a standardized process that supports them and their work.
In my previous consulting work, I watched a Physician Assistant enter and leave a patient room five times during a single encounter because she was having to go look for supplies and equipment. On the last trip out, she was on the hunt for a new box of gloves, since she was re-gloving each time in and had consumed a lot of gloves. If we're going to increase primary care capacity in the United States (with a shortage of doctors), we have to support the P.A.s and MDs to make sure a support employee stocks the rooms with what they need where it's needed.
So after Provider 1, I was sent back to the waiting area.
I saw Provider 2, another technician who performed some separate silo-ed diagnostic work. Then I was sent back to the waiting area.
It's too bad they can't cross-train the staff so one person could do both checks, but maybe it's a specialized technical skill. But maybe not. The patient would flow better if each person could do multiple steps without waiting in between.
After a short wait (a few minutes, certainly nothing to blog about in and of itself), I was seen by Provider 3, the ophthalmologist. He gave me a diagnosis and a treatment plan, nothing the least inefficient or uncaring about that part of the journey.
Lean and MRP
After being sent back to the waiting area, I realized I was being treated like a part in a factory being driven by an “MRP” planning system. For those of you without a manufacturing background, MRP is a notoriously inefficient (and non-Lean) planning and scheduling method for parts in a factory. It often relies on large batches, planned by complicated scheduling algorithms that are fed by inaccurate data. You have specialist resources all grouped together in parts of the factory without good flow. You get lots of WIP and long waiting times.
Many Lean factories do away with the detailed MRP scheduling and use manual scheduling methods (easier to pull off with a better layout and good flow). Instead of being sent to a warehouse and back many times, it was the waiting room I was sent to. Back and forth to lots of specialized providers (instead of machines) with lots of waiting. The focus in an MRP manufacturing system is on keeping expensive resources fully utilized instead of focusing on flow. Sounds like healthcare!
The Avoidable Delay
So the MD sent me back to the waiting area where, again after a short wait, I was brought to a fourth room to see another technician for another test, Provider 4. After the work, Provider 4 sent me back to the waiting room with the instruction that the MD wanted to see me one last time before I left.
I waited — and waited and waited. Instead of a short wait, this turned into 30 minutes, then 45. There was no “production control coordinator” as you might have in a factory. It was completely unclear who, if anybody, “owned” my patient visit. There was no “patient flow coordinator” as Dr. Sami Bahri, the “Lean Dentist” has in his office to make sure patients flow.
Being a bit impatient and wanting to get to work, I wondered if the MD was behind or delayed or if I had been forgotten about. I finally went back to the front desk to ask for some help.
After some checking, they came back and said, “Oh the doctor doesn't need to see you….”
I was a part in a factory with no “router” – or at least I had an inaccurate router. A router is a list of the steps you are supposed to go through in the process, often a piece of paper that's printed to go with a part through the factory. In Dr. Bahri's office, they use a patient “kanban” in exactly this way – the list of expected steps the patient will need. They use to track the patient's progress and communicate what work needs to be done.
What Went Wrong
It turns out that patients like me NORMALLY would wait after Provider 4 for the doctor. But, in my case, Provider 1 decided that wasn't necessary and noted it on my chart (I guess that's the router for the patient).
But, Provider 4 didn't look at the chart and assumed I had to wait for the MD. Bad process and missed handoffs led to a completely unnecessary wait – I was waiting for a doctor who didn't need to see me. If I hadn't spoken up, I might have been there all day!
What They Did – or Didn't Do
Everyone was pretty apologetic and nice about it. I didn't get upset or too frustrated, but I did calmly tell the front desk person that it was confusing, as a first-time patient, that I didn't know where I was supposed to be going and that the process was really disjointed. I didn't know who to go to for help or guidance. By going to the front desk, I might have missed them if they were indeed trying to call me back to see the MD again.
They said they recognized that it was confusing and they apologized. The front desk person said:
“I hope that doesn't happen again.”
Ah, hope. As it's often said, “hope is not a strategy.” That statement gives me ZERO confidence that there will be the least bit of follow up for process improvement. In a Lean setting, somebody would have pulled the andon cord and gathered an office manager or a small team, at some point during the day, to talk about the process and what went wrong.
How could they make the chart / router more visual so that it was more difficult for Provider 4 to realize I didn't have to stay. Could they have Provider 1 tell the patient “you won't have to be seen by the MD a second time today” or ask the MD to reinforce that? That way if Provider 4 said “wait” then the patient could say “that's not what the others said,” leading to some resolution before an unnecessary 45 minute wait?
I guess the presumed lack of process improvement bothers me more than the unnecessary wait. How would your organization react to a process problem like that? How should they react?
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Nice post. I think sharing these kind of real life examples can help us learn how to identify waste in our own processes. Many times people have difficulty recognizing these non-productive actions. It always amazes me that people in service functions fail to make the connection to the customer service. You would think that is a given but we all know it is not. I am sure many can realte to this. I know I can.
This is a really good example of comparing lean concepts in healthcare with manufacturing – a nice way for our mfg. compadres to see how lean thinking applies with healthcare as well.
Very early in my reading of this post I was thinking that this particular office could use to read Sami Bahri’s book and sure enough, Mark, you made the reference to it. Just wondering, do you think this office would be receptive to the lean way of thinking? Also, do you think you’ll ever go back there given your experience?
Mark – I have to go back in two weeks for a follow up. I won’t go through the same workflow, I’m sure, because that was the process for a new patient intake for my problem. Would I go back? I have to. Would I recommend them to others? Maybe. If they can resolve the problem, I’m willing to tolerate a little bad process – and that’s part of the problem here.
I’m reminded of the cancer treatment center I spent a week with, where a patient said, literally:
“They treat me sort of bad, but they are curing my cancer.”
Really makes you think. It reminds of Atul Gawande’s point that healthcare almost takes a perverse pride in being inefficient, as if it shows they are SO focused on the clinical stuff that they can’t be bothered with simple process stuff.
Thank you for sharing your story from the Lean perspective because it is only one example of tangible process waste. I am so glad for some of the challenging experiences I have had as a healthcare consumer because it has only enhanced my drive and excitement about utilizing Lean to see change in the healthcare system where I also work. Lean has provided a way to identify and solve the undeniable background noise that consumes a lot of the day and detracts from the patient care that as a provider you intrinsically want to give. I am glad you that the office was at least apologetic, I can think of examples in my own experiences where others have not been.
Thank you for this story and your take on what happened on why. Nothing is more valuable to me than a first-person experience backed by solid interpretation.
I’m curious where exactly the communication broke down between providers (something only they would know).
re. the idea of making the chart/router more visual: wouldn’t this indeed be nice for all relevant parties to be able to see visually the steps in the visit and where it ends? Beside reducing wait time, it would also help patients feel “in the know” rather than just a part in a (bad) assembly line. Ironically, greater use of Lean methods from manufacturing would have patients feel less like a machine and more like a human being.
Amiel -I *love* the way you put that:
“Ironically, greater use of Lean methods from manufacturing would have patients feel less like a machine and more like a human being.”
If I had been consultant (and not patient), I certainly would have gotten staff involved – asking them questions and teaching them how to map out the current state process, combined with actual observation of patient flow (or lack thereof!). I’m just pontificating here on the blog, which is actually not very good problem solving…