Lean and 6 Sigma in
Primary Care
Cynthia Y. Paige, MD, MBA, FAAFP
Cypress Health @ Summit Medical Group
[email protected]
What is Lean
Flow
Value
Stream
Reduce
Waste,
Maximize
Value
Perfection
Pull
Forces
What is 6 Sigma
Improve
performance
Improved
profits
3 defects
per
million
Improved
quality
Reduce
variation
Patient care mandate
Improve quality
variables
Improve patient
experience
Reduce the cost of
care
Value =
Quality/Cost
LEAN in Clinical Care
Data
Visit
Scheduling
Preparation
Capture
Tracking
Distribute Prep Work
Game Plan
Schedule
Quality Management
Data
Chart Review
*PSR
MA
RN
MD
*RN
MD
*MD
The Game Plan
Game Plan
Date:
Patient
MD Plan/codes
Office procedures
RN tasks
Referrals
Screenings
Jones
PE is due, add
glimeperide
ECG, prep for
foot check
PHQ-9
CRCS, Eye ref.
Hathaway
thyroid scan f/u
Baker
BP
ECG
Hinkel
AWV
Microalbumin
DEXA,
AWV,
pneumococcal
Eye ref,
2. Quality
1. Appt.
schedu ling: Take
all meds, bring all
meds and logs
Management
Tab for pre-visit
preparation
PSR
MD
Nurse Manager
3. DM, LDL, HTN,
review past results,
input, CPOE, jot down
med changes,
procedures, HCC
coding
4. Order entry:
Ca Screenings,
DEXA
5. input lab
schedu le, prep
for procedures
CMA
Game Plan
Distribute to all providers and staff
Workflow Diagram for Addressing Prevention, Quality Metrics, and HCC
•PSR
•CMA
•NP/RN
Scheduling,
Reminder: 30
Minute Visit,
Bring Meds &
Logs,
fasting/nonfasting
Review QM tab,
Discuss Logs,
Reconcile Meds,
Prepare vaccines,
Referrals
(foot/eye
CA screen, lab)
Patient
education
materials,
prepare for
annual foot
check
Clinical decision
making, sign orders
Motivational
Interview,
Diagnostics needed,
Ref. to Care
Coordination &
Behavioral Health
•MD
Healthcare Assembly Line
Product – the
patient
Consumer – the
patient, insurer
Efficient –
Cost, Time,
Effort
Effective –
quality
improvement,
error reduction
Typical Day: Two physician practice based on 4 patients per
hour (28 patients per 7 hour shift), 1 nurse, 2 medical
assistants, and 2 front office staff
50%
Door to Door Time (Lead
time): Nurse + MD
Patient arrives
8/hour
NURSE
6/hr (10m)
67% util
MA
Vitals
15/hr(4)
27% util
RECEPTIONIST
12/hr (5m)
67% util
Wait
time for
nurse
19.8 m
131 min
Check-out
20/hour (3min)
40% util
Wait
time for
MD
Wait
time for
registrar
50 m
Wait time
for MA 30
sec
Patient leaves
Door to Door Time: Doctor
only Visit
91 min
1.8 min
Avg Length
of Visit Time
Wait time for
reception 10 min
111 min
Queues: 7
Value Added Time w/ Nurse and Physician: 35.8
minutes
Value Added Time w/ Physician: 36 minutes
Non Value Added Time w/ Nurse and Physician: 93.4
minutes
Non Value Added Time w/ Physician: 63.4 minutes
Operation Cycle (Lead) Time w/ Nurse and Physician:
128.6 minutes
Operation Cycle (Lead) Time w Physician: 99.4 minutes
09:00 - 09:10
Queue
9:10 AM -9:15
9:15AM
AM9:15
AMAM
- 9:19 AM
- 9:15
Receptionqueue MA
DOCTOR
4.5/hr (13m)
88% util
Wait
time for
MD
MA – Procedure
7.5/hr (8m)
20% util
DOCTOR
20/hr (3 m)
10% util
Wait
time for
MD
Wait time
for MA
30 sec
50 m
38 sec
09:19 - 09:38
09:38 - 09:48
9:48 AM - 10:38 AM
10:38 - 10:49
Queue
Nurse
Queue
Physician
10:57 - 11:00
10:49 - 10:5010:50 - 10:57
10:57 AM - 10:57
11:00 - 11:02
11:02 - 11:05
MDAM
Queue Proc. Queue
Q
Check-out
Improved Flow: Two physician practice based on 4 patients per hour
(28 patients per 7 hour shift), 1 nurse, 2 medical assistants, and 2 front
office staff
Patient arrives
8/hour
Door to Door Time (Lead time):
Nurse + MD
51.8 min
Check-out
30/hour (2 min)
27% util
RECEPTIONIST
15/hr (4m)
53% util
NURSE
8/hr (7.5m)
75% util
___60_%
Wait time for nurse _22
m_
NVAT: 22-13=9 min
Avg Length of
Visit Time
Patient leaves
48.8 min
Wait
time for
registrar
_36
sec_
Wait time for
reception
_4.8 min_
MA
Vitals
15/hr(4)
27% util
Wait time for MA
30 sec
Door to Door Time: Doctor only Visit
38.8 min
Queues: 5
Value Added Time w/ Nurse and Physician: 35.5 minutes
Value Added Time w/ Physician: 28 minutes
Non Value Added Time w/ Nurse and Physician: 30.9
minutes
Non Value Added Time w/ Physician: 13.4 minutes
Operation Cycle Time w/ Nurse and Physician: 66.4
minutes
Operation Cycle Time w Physician: 41.4 minutes
Wait time for MD
__20 m__
NVAT: 20-9-7.5=3.5
min
MA/phlebotomy – Procedure
7.5/hr (8m)
20% util
Wait time for
MA _30 sec_
DOCTOR
6/hr (10m)
66% util
__40_%
Wait time for MD
__20 m__
NVAT: 20-13=7
min
09:00 - 09:04
Queue
09:04 - 09:0809:08 - 09:09
VAT
Queue
09:09 - 09:21
09:21 - 09:30
09:30 - 09:37
09:37 - 09:41
09:41 - 09:51
Vitals & Procedures
Queue
RN
Queue
MD
09:51 - 09:51 09:51 - 09:56
Queue Check-out
LEAN flow in
primary care
Usual Patient Flow
LEAN Flow
Number of queues
7
5
Value added time
36
28
Operational cycle time 99.4
41.4
Non-value added time
13.4
63.4
Value of improved Lean flow
Quality

Increase patient satisfaction

Improve quality metrics

Reduce missed opportunities for
care
Cost

50% increase in physician
productivity

Reduce the cost per patient seen

Reduce complications of chronic
disease

Data analysis from January – October 2015

56% decrease in people with an A1c > 8%
A1c Decreased: 7.77 – 7.29%
Values
A1c Value Quarter 1 - A1c Value Quarter 4
Subgroups
LDL Decreased: 95 – 89 (p=.028)
Values
LDL Value Quarter 1 - LDL Value Quarter
4
Subgroups
Personnel Training
Why do the
numbers
matter?
Evidence based
guidelines (eg,.
Diabetes Care)
Demonstrate excellence
to ourselves, our
patients, and our
suppliers
How can this
improve the
office?
What do I need
to know to help
the patient?
Lean strategies improve
office flow and capacity
Six Sigma improves
quality
Use of Quality
Management data in
the EHR
Glucometer and home
bp use, carbohydrates,
screening guidelines
Patients receive more
coordinated care
before, during and
after their visit
Increase patient
satisfaction
Target numbers for
glucose, blood
pressure, and lipids
Value Based Care
Goals
The Goals
The Game Plan
Make quality a
team effort
Improve diabetes
metrics

Make everyone quality champions

Take charge of your schedule

Focus on patient flow

Eliminate missed opportunities for
care and revenue generation
Capture preventive
visits & HCC codes  Reduce the chaos
Maintain QOL