The Lean Doctor’s Office: Using Value Stream Mapping to Improve Your Workflow
An inefficient workflow is a problem in any business. In doctors’ offices, workflow inefficiencies create longer waits for patients, frustration for office staff and burnout for physicians.
A process called value stream mapping can help practices identify workflow inefficiencies—for example, time spent hunting for patient charts or tracking down a doctor for an exam room—and implement improvements. This article will explain value stream mapping and how you can use it in your practice.
Value Stream Maps Help Doctors Visualize Patient Flow
A value stream map is a visual depiction of a process or workflow. With origins in the lean manufacturing movement, it’s a tool that helps organizations identify and minimize waste in a process. Although manufacturing still sees the most institutionalized use of value stream mapping, many other industries—such as healthcare—also find it valuable.
A value stream map follows a product through a process from beginning to end, accounting for what’s happening to that product at every second along the way. Each step in the process is marked to indicate whether it actually impacts or improves the product in some way: in the lean manufacturing world, this is known as “adding value.” Any step that doesn’t add value is considered “waste.”
If you’re a physician, your product is the care you’re providing your patients. By following the patient through their office visit, you can identify when patients are getting value during their visits—and when they’re not. Dave Hallett, Owner and Operator of PullScheduling.com, gives a pointer for identifying value: it’s something the patient would be willing to pay for, or possibly even pay extra for. Once you’ve identified where value occurs, you can make changes to eliminate the “waste,” or the time that a patient isn’t getting any value.
This may sound straightforward, but Sue Kozlowski, Director of Healthcare Consulting at process improvement company TechSolve, says it’s a new thought process for many practices. “Most physician practices are very busy,” Kozlowski says. “Everybody is trying to do more than they actually have time to do.” It can be difficult, she explains, to take a step back and think about what the process looks like to a single patient.
To better understand how value stream mapping can be applied to medical offices, I spoke to several experts on the subject. With their help, I’ll explain value stream mapping in four easy steps that you can replicate at your practice.
Step 1: Defining Your “Current State,” or Existing Process
In order to use value stream mapping effectively, you’ll need to create multiple maps. The first step will be to create what’s known as a current state map, which represents your current flow.
Although software does exist that can be used to create value stream maps, old-fashioned pen and paper will work just as well. The map may get large, so you’ll want a bigger surface area than a standard 8.5” x 11” printer page (Kozlowski uses butcher paper).
You’ll also want to involve your entire practice in the value stream mapping process. Hallett emphasizes, “A team is always going to be more effective than just one individual.” And since you’ll ultimately be making changes to your process as a result of the value stream map you create, Kozlowski explains, having your entire team involved means everyone will be invested in implementing those changes.
A High-Level Process Outlines the Most Basic Components
Before creating a detailed current state map, Kozlowski starts with what she calls a “high-level” outline, which represents the most basic building blocks of a doctor’s appointment and serves as the framework for the current state map.
For many practices, the high-level flow will look something like this (if yours looks a bit different, you may want to draft your own high-level outline):
Obviously there’s more to a doctor’s appointment than these six stages—remember, we want to account for every second of the process. So your current state map will need to fill in the details.
The Current State Map Details Every Step of Your Existing Process
To create a current state value stream map, Kozlowski recommends using sticky notes, which can be easily rearranged as needed. Break down each stage of your high-level outline into discrete steps, recording each step on its own sticky note. Then stick the notes to butcher paper according to the order created in your high-level outline.
Note that things you may think of as a single activity, such as patient check-in, may be comprised of many individual steps: (1) waiting in line at reception, (2) providing insurance and identification cards, (3) receiving paperwork, (4) sitting down in the waiting area, (5) completing paperwork…
Your map should also include steps that aren’t an intentional part of your process, but end up as such—for example, if you often have to leave the exam room to find medical supplies, or commonly have to spend time searching for a patient’s chart. A one-time problem doesn’t need to be accounted for, but unplanned issues that come up multiple times require sticky notes.
Collect Data for Each Step in Your Process
When you begin creating your steps, you’ll probably be working from memory. But while you may be aware of what happens to a patient during an office visit, there’s no substitute for experiencing the process firsthand. Primary data collection is key.
You’ll need to follow patients through a complete office visit, recording in a notebook exactly what happens at each step—and just as importantly, how long each step takes (which you can clock using a stopwatch). Follow enough patients to get a clear picture of a typical patient experience. Timothy Hagerty, CEO of Capital Marketing Services, tells me his team spent about two weeks collecting data for a value stream map at The Internal Medicine Clinic at Akron General Hospital.
Your team members can take turns shadowing individual patients through the entire process, or you may prefer to make certain team members responsible for certain parts of the process—e.g., someone in reception records front-end steps, while someone on your clinical support team records exam-related steps. Or, you may decide to hire a consultant to do the work for you.
Once you’ve collected your data, average the times you’ve recorded for each step, write the averages on their corresponding sticky notes and stick the notes to your map. Draw arrows to connect the steps, depicting the patient’s movement through the process. Of course, you’ll have forks in the road where patients could follow one of multiple pathways. Kozlowski represents these forks—what she calls “decision points”—using a sticky note turned sideways, creating a diamond shape. The diamond note might say, “Does patient need lab work?” and might have a “yes” path and a “no” path stemming from it.
While there are a variety of annotation symbols commonly used on lean manufacturing maps, the only symbol Hagerty borrows is a triangle to denote a time when the process is at a standstill. Hagerty draws a yellow triangle next to any step where the patient is waiting, such as at the check-in line, in the waiting room, in the exam room and so forth.
Below is an examples of a current state map created by Hagerty and his firm when working with The Internal Medicine Clinic at Akron General Hospital:
Click to view full image
Step 2: Identifying Waste
Once you’ve created your current state map, the most time-intensive part is over. The next step is to identify the waste in your process.
Look at each step on your map and ask yourself whether that step is directly valuable to a patient. (Receiving treatment? Valuable. Waiting in the waiting room? Not valuable.) Mark each step to indicate whether it delivers direct value. Kozlowski puts red and green dot stickers on the steps: green for value-added, and red for non-value-added steps.
Any step with a “wait” triangle should get a red dot. Hagerty points out that motion (such as the doctor moving out of the exam room to find supplies) and duplication (such as the doctor repeating questions the medical assistant just asked) are other forms of waste, so they’d also get red dots.
You’re identifying the waste in order to eliminate it. Of course, it won’t be possible to eliminate all waste. Some steps that aren’t directly valuable for patients are necessary to your practice (such as proper coding). “Perfection” isn’t achievable, says Hallett, but it’s the benchmark to work towards.
Step 3: Creating a “Future State Map,” or Ideal Process
You’ve created your detailed current state map and identified areas of waste. Now it’s time for your team to create a future state map representing your ideal flow.
Hallett recommends creating multiple future state maps: one that represents perfection, and one that represents a more realistic future state. He calls this idea “go to utopia, then back off for reality.”
Your utopia map will represent the “perfect” process. It doesn’t need to be limited by what’s cost-effective or even completely realistic: it will help you reconceptualize how the process could work without getting mired in the constraints of your existing process.
Finally, you’ll need to create your more attainable future state map. Look to your utopia map for inspiration, but temper it with reality by comparing it to your current state map. To create this final map, Hallett suggests asking your team what realistic steps might allow you to achieve 80 percent of the benefits identified in your utopian map in one year’s time.
Below is an example of a future state map for the same Internal Medicine Clinic at Akron General Hospital:
Click to view full image
Step 4: Taking Your Practice from Current to Future State
Once your attainable future state map has been created, start brainstorming changes to your workflow with your team, asking yourselves what you could do to implement the process outlined in your future state. The changes you make will be up to you. “There’s not a magic list of 10 things to do to make your office better,” says Kozlowski. “It’s very unique to each office.”
Still, Kozlowski says she does encounter some commonalities. Here are a few examples of solutions that may inspire you:
To eliminate the wasteful step of hunting down the doctor to enter the exam room, mark each room with a colored flag. Each color would represent a different role—e.g., doctors might be red. When the nurse leaves an exam room and it’s time for the doctor to enter, the nurse would place a red flag on the door. The key to implementing this solution, Kozlowski says, is that every team member must commit to placing the flags for every visit.
To eliminate the need for the doctor to leave the exam room during a visit to track down supplies, Kozlowski suggests coming up with a list of standard supplies that should be in every exam room, and stocking them accordingly. Label the drawers or closets to make the supplies easy to find.
To solve the problem of the doctor leaving the exam room to pick up something from a printer, consider placing a small printer in every exam room. Kozlowski says many practices think buying one printer for a central location is more efficient than buying multiple printers. But when the doctor leaves the room to pick up printed forms, the patient is left waiting while the doctor is often bombarded with interruptions.
To eliminate interruptions during an exam from staff delivering messages to the doctor, consider adding message boards to the outside of exam room doors. Alternatively, if you worry this might waste staff time tracking down which room a doctor is in, Kozlowski suggests using one central message board, with sections for each doctor, that doctors can check after each exam.
You may notice that most of these solutions are fairly simple. According to Kozloski, that’s in accordance with the lean principle of making small, incremental improvements. “Everybody thinks that you have to do something dramatic and expensive,” Kozlowski says, “but you usually don’t. Many of the solutions take brainpower, but they don’t take a lot of money.”
Hagerty further points out that making small improvements lets you accomplish easy gains quickly, which signals to your team that changes don’t have to be painful. That validation, in turn, makes your team more willing to find other ways to improve.
Just remember to keep measuring and evaluating once you’ve made changes to make sure those changes are working. That’s what the “lean” movement is all about: If something isn’t working, don’t continue doing it. Instead, alter it or try something else.
How Your Practice Benefits
The benefits of value stream mapping aren’t hard to predict. You’re minimizing inefficiencies and reducing the number of steps that aren’t valuable to patients: chances are, your patients are going to be happier with their experience. For example, the Internal Medicine Clinic Hagerty worked with reduced wait times by an average of 35 minutes per patient.
Kozlowski tells me doctors and staff see plenty of benefits, too. The biggest change she typically sees is staff getting out on time. Stress is reduced. Work-life balance—and as a result, job satisfaction—improves. You may also notice an improved team dynamic. Kozloski says problem-solving together helps unite your staff: “They become much more of a team, and less of a collection of people who are just trying to survive the day.”
Reduced overtime also saves your practice money, both in overtime paid and in overhead costs for extra operating hours. Inventory costs may also decrease due to more efficient allocation and use of supplies. (One practice Kozlowski worked with had been ordering supplies on a weekly basis, only to discover a six-month surplus scattered throughout exam rooms.)
Although Kozlowski admits the effort and teamwork value stream mapping requires is challenging, she says all of the practices she’s worked with have ultimately testified that “the effort is extremely worthwhile.”
If you’re interested in learning more about value stream mapping, here are some additional resources you may find helpful.
Lean.org. The website of the Lean Enterprise Institute, a non-profit organization that was at the forefront of the lean movement in the West, includes detailed resources on value stream mapping, and even offers a one-day course for its application in healthcare.
Learning to See. One of the first books about value stream mapping, Hallett tells me Learning to See is an authoritative work used by the Manufacturing Extension Partnership (MEP) Network in its value stream mapping training modules.
Consultancies, such as Hallett’s PullScheduling.com, Hagerty’s Capital Marketing Services, and Kozlowski’s TechSolve. Consultants may be more expensive than simply managing the value stream mapping yourself, but their expertise and experience may make the process simpler and more efficient for you and your staff.