Article 55. Obtaining Maximum Patient Throughput with The Highest Effectiveness

This example can be used for training Analysts as Facilitators in the implementation of Enterprise Lean.  The Ophthalmologist operation is broken down into Lean Teams.  Each Lean Team will meet for an hour once a week to do the lean process facilitated by an Analyst.  After their preliminary work is complete in finding the most effective and efficient way of doing their processes.  The several individual Lean Team Leaders are combined into a much larger Team led by the Ophthalmologist to complete the scheduling chart in the above example.  This chart will be documented by the Analyst in a spreadsheet along with the time to do each process and the name of the employee doing each part of the process.  The spreadsheet will become part of a database including all operations in the entire facility.  The total labor hrs is the functional budget for the facility excluding Management and overhead.  The total work hours for each employee will be used in the right-sizing process to be sure each employee has a full time job.

When the entire operation of collecting the Lean Data is completed a copy of the first data base will be made with employee names and personal data removed.  This database will act as Best Practices Database to be used in other facilities.

Example of Lean Team with Maximum Throughput
Some VA Hospitals it has been reported have a waiting list of up to one year for cataract surgery.  The following example is an approach for finding the maximum patient throughput with the highest effectiveness for a Medical Doctor of Ophthalmology.  The most critical parts of the approach is in how the Ophthalmologist uses his time in combination with the sets of patient processes, equipment and the activities of nurses.

The Main Objective:
To get the highest efficiency without compromising effectiveness.  Put another way to find the maximum flow of patients without compromising medical standards. 

The approach is in two parts:
Part A. implements Lean Teams to review the sets of patient processes found in cataract surgery with the Ophthalmologist and his nurses using lean to examine his own processes relative to an individual patient.

The nurses supporting the Ophthalmologist are organized into a Lean Team which will meet once a week until the review of all their sets of patient processes have been completed.  For each set of patient processes the current set approved for effectiveness by the Ophthalmologist is placed on a wall chart.  The improved method with increased efficiency is placed under the current method. The nurses will be reviewing the placement and use of equipment and procedures all within the context of effectiveness guidelines. The time for each process and the total time for the set of processes is carefully noted in minutes.

The second Lean Team lead by the Ophthalmologist with all attending nurses will place the current activities of the Ophthalmologist on a wall chart.  The improved method will show improvements for getting the highest effectiveness and efficiency.  These two Lean Teams will establish a base line for the scheduling of patients with a balanced work load.


Part B. We will use a manual scheduling system that is superior to a computer generated systems because it focuses on the main objective, Patient Throughput, and allows for team involvement.

What often happens in day to day activities the Ophthalmologist is concentrating on the processes that matter most in being effective and less on those things that are needed to backup the key processes. This is not bad, effectiveness always trumps efficiency but when efficiency is ignored it prevents us from getting to the goal of achieving maximum patient throughput.

The following manual scheduling method is used to demonstrate the plan for getting the maximum patient load:
1. Have each nurse and the Ophthalmologist set a time in minutes for each and every process that is done.
 
2. Then put the information on colored card stock using the color codes below with a time scale of approx ¼ inch for each minute in the process.  Identify clearly exactly what the process of steps describe.  Now you have a representation for each and all of the processes the nurses and the doctor do over several weeks with patient involvement color coded. 

3. List all staff members on the vertical left of the chart and layout all the processes into the sequence they should be done. Start by finding those processes that can be done in parallel (at the same time) followed by the next sequence.

4. Now look at patient access and equipment access.  With more patients you may need more equipment.  What you are looking for is the elimination of bottlenecks of wait time.
  
5. Because the number of patients available for cataract surgery can vary you may be able to put off doing those support processes that may have been included in an automated schedule and thought to be necessary to schedule.  These may a be set aside during periods of high patient flow and only done in periods of low patient flow or wait times.  For example when the Ophthalmologist is "in" and meeting with patients all non-patient support activities are to be done only when the Ophthalmologist is "away" in surgery operating on patients at another location.

6. Now we want to make a daily plan which extends several weeks showing the maximum number of patients that can be processed.  We will build the plan based on the activities of the Ophthalmologist.  Start by taking the card stock representations and collapse them into the shortest time span do not overlay equipment usage or the Ophthalmologist’s time. The result will equal the longest continuous process.  This may also be the patient's time, to process a patient for preliminary testing by the nurse followed by the time with the Ophthalmologist.  The plan will cover all activities based on Ophthalmologist/patient availability.

7. The key is in focusing on the Ophthalmologist’s operations to get the maximum number of patients.  There will always be lost time when times are slow because of a variable patient schedule.  This time is to be used for routine support activities that do not involve patients.

8. The efficient use of equipment may be simply be cycling through patients by appointment times but for the maximum number of patients you may want to buy more equipment to be sure the Ophthalmologist has a full schedule and is not waiting for the next patient.
 
9.  The final card stock layout will become the plan to be followed when processing the maximum number of patients.  The result from a computerized schedule will not produce the same results because it includes all activities.   Not considered in the automated schedule is the fact that the maximum number of patients are not always available.

The Real Manual Plan should show only the key operations for the maximum number of patients. Because we don’t care about being efficient in slow or lax times. 

10. A benefit is the staff involvement in the process which brings understanding of why and how processes can be done during maximum patient volume flow.

11. The economic benefit is that when there is a backlog of patients you have a plan to absorb the maximum number of patients knowing exactly how many you can process effectively and efficiently.


Color Codes:
1. White- all doctor activities with the patient color code pasted on it during all Ophthalmologist patient interactions.
2. Gray- all activities except for the Ophthalmologist that are related to all patients (done only in slow times).
3. Red- Patient number one.  Nurses will put hash marks on the coded process indicating steps involving nurse patient interaction.
4. Green- Patient number two.
5. Yellow- patient number three.
6. Blue- patient number four.