Systems, Value, Flow and Respect

Part of the mindset of thinking Lean is seeing and understanding your practice as a collection of systems. Individually, they seem appropriate and functional. However, many times our different systems unintentionally “bump” into each other. When this happens, chaos and waste can result.

Consider this collection of systems found in veterinary practice:

A multi-doctor practice operates on a “base or percent of production” format to pay associate doctors. The base salary is low to encourage production. Very typical within our industry. However, there are some problems.

First, the paperless computer system is slow and the doctors are required to input not only their original medical notes, but also generate any necessary supplementary reports and summaries. 

Tech staff are not allowed to have anything to do with inputting any part of the medical records other than a simple history, primary complaint, weight, temp, pulse and respiratory rate (TPR). They are not permitted to enter any of the physical exam findings, test results, diagnoses (differential or definitive), treatment orders or client home instructions. 

It is estimated that for every minute spent by doctors seeing patients, at least one other minute is needed to perform this non-value adding work.

Appointments are capped at two 20-minute appointments per hour per doctor. By the time the client is checked in by the receptionist, escorted to the exam room by a tech, and subjective information entered into the (sometimes mind-numbingly slow) computer system, the doctor notified of the appointment and briefed, half, or more, of the 20-minute time has passed.

There are four exam rooms for two doctors seeing appointments. The doctors (and, therefore, the exams rooms) are appointed at the same times each hour, i.e. at the :00 mark and at the :40 mark.

Tech staff are not allowed to have anything to do with entering any part of the medical records other than a simple history, primary complaint, weight, temp, pulse and respiratory rate (TPR). They are not permitted to enter any of the physical exam findings, test results, diagnoses (differential or definitive), treatment orders or client home instructions.

Systems thinking. As one can probably figure out, with only 60 minutes in an hour and every 20-minute appointment actually consuming 40, you are 20 minutes behind after the first hour and that increases linearly each hour thereafter. 

The first slot each hour has a 20-minute break afterwards until the next appointment at the last 20 minutes of the hour. However, this appointment butts up against the next first appointment of the next hour. There is no 20-minute “safety” period here.

Over an eight-hour shift, one of two scenarios can result. 

First, this allows twelve of sixteen potential appointments to be professionally serviced appointments per shift. This may be fine provided the takt (basically, the rate of demand) is less than that. But, if you are growing, it means hiring more doctors, thus increased overhead. Hardly in line with “do more, with less resources, with higher quality, and less waste” motto of Lean.

Second, and much more realistic, is that the 16 scheduled appointments will be seen, but many, if not all, of them after the first hour will be seen late. And, the doctor and staff will need to stay almost three hour longer than their shift to finish everything required per appointment. (Or, if the practice is willing to forego 16 appointments per doctor shift, then they concede to only see twelve; a 25% cut in production!).

From an associate doctor’s perspective, who is paid mostly on production, this is a problem. It severely caps their ability to earn income. We talked, in one of the first blog posts, about systems and how workers can be at the mercy of systems in which they have no control.

The associate doctor has very limited control over the systems that affect his/her ability to earn, e.g. appointment systems (number of appointments/hour, who gets which appointments and so on). There are systems that affect the extent to which staff are trained to assist and facilitate, computer systems, HR/payroll systems (contracted production percentage, hours/weeks, time of shifts, days on surgery), etc. Systems are the domain of upper management or practice ownership.

Respect. One of the two main pillars of Toyota and Lean is "respect for people" (the other is continuous improvement). This situation, as described here, is disrespectful to doctors and veterinary technicians. It disrespects doctors by forcing them to spend so much time performing work other than what they are uniquely trained for and can earn from. But, it also disrespects the trained techs that are not being utilized (or trained) to their fullest capacity.

Lean promotes the idea that resources should only be used when they are needed, where they are needed and only in the amount needed. Anything else is waste (muda). Doctors are highly trained, unique resources. Their use should be very purposeful and intentional. The only person in a veterinary office who can diagnose and treat patients, i.e. generate fees, is the doctor. Any other "job" than these should be seriously reconsidered - and maybe assigned to somebody else.

Value. Remember, part of the Lean definition of “value” from the client’s point of view is something they want and are willing to pay for. How much do you think a client is willing to pay for a take home “Examination Report” or a  “Welcome to Our Practice” card handwritten by the doctor they saw? How much do you think they value being able to get in for an appointment and being seen promptly by a doctor, having their pet diagnosed correctly and promptly, and efficaciously treated?

Flow. As I have blogged about before, flow directly and profoundly affects value from the client's perspective. All of the above scenario negatively impact flow. So, value likewise suffers. And this is a form of disrespect to the client.

I spent about five years working for a major corporate veterinary practice. As a solo doctor, I was able to routinely see 35 to 40 patients each day, including six surgeries. One way I accomplished this was by instituting a system of forms and tech training that freed me from much of the medical records input without sacrificing accuracy or neglecting my responsibility for those records. 

I never had any issues with routine audits of my records by my directors and in one of my last years with the practice, was one of the top 20 producers in the entire national practice. 

The vast majority of my time was spent in the exam rooms and surgery doing the work I was uniquely qualified to perform, improving flow and creating value for my patients and clients. But, from my very first days on the job, my practice manager and I invested extensive time and effort in tech training and doctor/tech “choreography.” Staff members are one of the only practice assets that has the potential to appreciate and get better over time.

At left is the simple, quick form I used. I would draw it on the back of the “Permission to Treat” form generated by the front desk whenever a patient was seen so I wouldn't use a new sheet of paper each time.

I divided the sheet into six sections as shown. Each section corresponds to a specific part of a “SOAP” medical record as indicated.

I would write my notes, findings, lab results, differential diagnosis or tentative diagnosis, treatment orders, client instructions and follow ups in the appropriate sections. I then gave the form to the tech on the case for input into the electronic medical record (EMR) and headed off to the next patient with a different assistant. This typically consumed about ten minutes of the 30 minute slot. The tech would then present the treatment plan, collect and/or run any lab tests, give any injections, prepare take home medications, go over home instructions and set follow up appointments. They would also enter the line item fees for invoicing and escort the the client to the receptionist for check out. It was at this point that they would input the EMR, before starting all over with a new client and patient in a different room.

We typically scheduled six or seven 15-minute exams per every two hours of available time, This allowed some flexibility in the schedule as the techs and I “leap frogged” from appointment to appointment. In addition, we tried to only book three of the four exam rooms each hour. If the value stream of an appointment could not be completed within 30 minutes, we asked that pet be dropped off and techs in Treatment took over. I would come back to that patient later, when I had a break between exam rooms.

The understanding (and training, training, training!) was that the techs were to put everything I wrote on the form into the appropriate ”SOAP” section of the EMR. If there was other information or details they felt were important, then they should include that, also. They signed their initials at the bottom and put the form in a specified area on my desk for review and editing later in the day. The final responsibility for the medical records was mine and only mine, as it should be.

We also, at a later date, did away with a separate tech history and tech physical exam. The only history and exam that was important was the doctor’s. The newly available tech time was utilized to input the history, physical exam findings, treatment orders and home care instructions into the EMR in the exam room in real-time as I informed the client.

Note: This is also a good example of Standardized Work!

Tell me what you think. How does this impact your concepts of respect? How much of the daily work in a hospital should staff be allowed to do? Understanding that doctors are ultimately responsible for the medical records, are they the only individuals that can input them into the electronic medical records (EMR)?  What situations have you been involved with where you felt at the mercy of systems; a “catch-22?”  How was it resolved? How many clients actually value “the personal touches,” such as doctor-written welcome cards or examination summary reports vs being able to get their pet seen (and out!) in a timely and cost effective manner? One client out ten; one out of 100; 1000? Where do (would) you balance a conflict between flow and “that personal touch?”

Thanks for stopping by.