by Jim Womack of Lean Enterprise Institute shown at the Frontiers of Lean Summit 2005 on 31st October 2005 run by the Lean Enterprise Academy

1. “Don’t Waste My Time”
Healthcare Examples
James P. Womack
President, Lean Enterprise Institute
Frontiers of Lean Summit
October 31, 2005

2. Time Wastes in Healthcare
Primary care (the visit to your doctor):
• The waits on hold and the call backs while trying to
schedule an appointment.
• The wait for the appointment if you want to see your
own doctor.
• The wait in urgent care if you can’t see your own
doctor.
or
• The wait in the waiting room when you get an
appointment to see your own doctor.

3. Why?
• Belief that using minimally trained staff for “triage” – at the
point of first contact with the patient – will send the patient
down a path that makes most efficient use of the healthcare
provider’s assets.
• Belief that a queue will insure that the most expensive asset in
the healthcare system – the doctor or the monument diagnostic
machine – is never idle.
• Belief that demand is highly erratic, so that queues are
unavoidable in any case.
• Belief (fostered by insurance companies) that doctors must
see/touch patients to provide appropriate care.
• Unstated belief that the patient’s time is worthless!

4. Lean Solution Number One
The current-state at Kaiser Permanente (California) 1990s:
• Clerical staff triaged patients calling for appointments.
• Time consuming for patients and staff because of difficulty
contacting busy doctors and nurses.
• Many call backs; lengthy “phone tag” to set appointment.
• Complex, computerized scheduling system introduced to solve
problem, which actually got worse.
• Two-month wait to see patient’s own doctor, with stable queue
length.
• Lengthy waits once at the doctor’s office, particularly later in
the day.

5. Lean Solution Number One
Open Access (pioneered by Dr. Mark Murray):
• Rather than triaging patients, have them come in to
see their doctor that day. (Required some overtime
to work down the two week backlog.)
• Lengthen scheduled appointments from the
standard 15 minutes so doctors could complete
paperwork after each patient and stay on time.
• Schedule longer daily hours for doctors and nurses
but get them home immediately at the end of the last
appointment rather than staying hours to catch up
with paperwork.

6. Lean Solution Number One
Results:
• Patients wasted practically no time on scheduling.
• Practically all patients could see their doctor that day.
• Most appointments started on time.
• “Doctors were doing today’s work today and discovered there
was a lot less work to do.” (The same for staff.)
• Outcomes improved: diabetics had lower blood sugar; heart
patients had lower cholesterol; stroke risks had lower blood
pressure.
• Costs of the practice fell substantially because less staff and
investment was needed to manage the practice.

7. Lean Solution Number Two
Current state in most primary-care practices today:
• Doctors need to see/touch patients to bill for
services. (90-95 percent of care takes the form of
office visits.)
• Widespread belief that seeing/touching provides a
higher level of patient care and better outcomes.
• To be seen/touched, patients must make time-
consuming trips to the doctor’s office (which also
costs the provider time and money.)

8. Lean Solution Number Two
Dr. Charles Kilo, a primary care physician, noted
several trends:
A rising fraction of care is for maintenance of
patients with chronic conditions – diabetes, high
blood pressure, high cholesterol.
Chronic care will steadily increase in the advanced
economies as baby boomers age.
Rapid advances in personal healthcare technology
for home use permits patients to do their own
testing.
• Kilo then asked a simple question:
Why do many patients need to go to doctor at all?

9. Lean Solution Number Two
Greenfield Health (Portland, Oregon, USA):
• Kilo set up a new multi-doctor practice applying all
of the open-access principles pioneered by Mark
Murray.
• Introduced new technology to create accurate,
computerized history of each patient for instant
retrieval.
• Arranged for patients to obtain appropriate personal
technology at home.
• Made immediate access to each patient’s primary
care doctor easy with e-mail and voice-mail.

10. Lean Solution Number Two
Results:
• All the benefits of open access, including a very high
chance of seeing one’s personal physician the same
day if needed.
• 50 percent reduction in the number of annual office
visits per patient.
• Higher reported satisfaction with the practice than
with Kilo’s previous HMO.
• Better outcomes on chronic care measures.
• Lower total cost of the practice.

11. Lean Solution Number Three
Current state in most primary-care practices today:
• Large, complex HMO facilities with large, expensive
overheads to manage the complexity.
• Contributing to the time wastes already described.

12. Lean Solution Number Three
Dr. Gordon Moore asked several simple questions:
• Why does simple treatment of individual patients
(who are relatively small) require massive facilities?
• Why is so much capital needed (along with space
and complexity) for the amount of value actually
being created?
• What would happen if a doctor tried to set up a
practice with practically no capital investment or
facilities?

13. Lean Solution Number Three
Dr. Gordon Moore primary care practice (Rochester,
NY):
• A true “sole practitioner”: A small office (sharing a
waiting room with another doctor), no receptionist,
no nurse, no record keeping staff.
• Practically no assets or overhead.
• Except sophisticated (but now inexpensive) medical
records and communications technologies.
• Open access plus reduced need to come in.
• Patients all dealing directly with their doctor who
knows the details of their personal situation.

14. Lean Solution Number Three
Results:
• 99 percent chance of seeing doctor same day.
• No waiting arranging appointment or upon arrival
• Large reduction in need to come in.
• Higher reported satisfaction than in previous HMO.
• Better patient outcomes than same patients in
previous HMO.
• Dramatic reduction in the total cost of running a
practice with a given patient population.

15. More Time Wastes in Healthcare
The complete diagnostic cycle:
• Consultation with the primary care physician.
• Referral to a specialist in the suspected problem.
• Lengthy travel by the patient through complex
facilities, often far away.
Let’s take a walk and count the steps and time required
to diagnose a simple problem (chronic hoarseness):

18. Lean Solution Number Four
The current state in a typical healthcare system:
• Massive facilities for diagnostic referral and
treatment.
• Co-mingling many diagnostic and treatment paths.
• Managed by complex scheduling systems.
• Located considerable distances from patients.
• With low velocity through the system.
• With high costs of complexity.

19. Lean Solution Number Four
Dedicated Diagnostic Path:
• Disaggregate co-mingled treatment paths.
• Re-locate each path to smaller, closer, cheaper
facilities as appropriate/possible.
• Line up steps in diagnostic path in adjacent
sequence.
• Conduct the steps as nearly as possible in
continuous flow.
Let’s take a second walk, through the dedicated
treatment path for the problem just discussed
(hoarseness):

22. Lean Solution Number Four
Potential results:
• Patient time commitment reduced by 80%
• Provider time expenditure reduced by 50%.
• Lower cost due to smaller, simpler facilities and
elimination of complex methods for managing
complexity.
• Higher quality as well?
But…
• Highly threatening to existing investments and
organizations.
• Harder to implement than Solutions 1, 2 & 3.