The waiting game: Dispatches from urgent care

After spending years as a practicing physician and later working with others to improve processes in health-care delivery, it’s still refreshing to spend some time on the other side of the exam table.

urgent careI recently lacerated my toe when a blender jar fell from the counter top and, bleeding profusely, went with my partner to a nearby urgent care, my toe tightly wrapped in a bandage. We entered a large waiting room with 20 chairs and only one other patient only to spend 10 minutes waiting for a medical technician to enter my information into a computer. This is after I spent five minutes completing the form on paper. This made me very, very pessimistic about how long I might have to wait to see a physician. The television playing a History Channel documentary showing bridges falling and the destruction of surrounding areas didn’t help.

The registration process triggered my lean thinking: Many hospitals are spending a lot of money installing kiosks for self-registering patients. The idea is great but the cost ultimately isn’t justified. Filling out the forms, I thought of how efficient it would be if the registrar had turned her own computer screen to me and asked me to enter the information directly on the computer. With a quick confirmation of some key information, that would save 10 minutes. Small change, big benefit.

Patient intake is only one challenge, though. Patient variation is an entirely different issue.

While in the waiting room, I saw a female patient in her late 60s arrive with her daughter. At least another 15 minutes passed as the new arrivals scrambled to find an insurance card and driver’s license and another patient in the waiting room was called back. Eventually, we were called back to sit in an exam room, where my mind was still lingering, thinking about the fate of the older patient and her daughter.

What transpired in the waiting room over a half-hour is nothing but patient variation: I was signed in within 15 minutes, while another lady waited for more than 30. So how do you apply lean/six sigma to the business of health care with so much variation? The answer: With empathy! Some experts in the field tend to downplay the very existence of patient variation, which only evokes defensiveness from health-care professionals who treat patients day in and day out. Ultimately, it’s important to examine data on the number of times events deviate from the normal and develop an improvement plan that incorporates that variation.

On our way to the exam room, my partner asked if I’ll need an X-ray. The answer: “I can take your X-ray if you want.” I was shocked. When I practiced medicine, patients weren’t entertained this way. I’d always have a reason for any labs or X-rays. In turn, I responded that I didn’t want an x-ray unless there was a reason for one. She shrugged her shoulders and said: “If you don’t want the X-ray, we won’t do it. It’s up to you.”

Once in the exam room, my vitals were taken and I asked to unwrap my bandage but was told “Not yet.” It’s essential to take vitals, but I was getting desperate for the provider to open my bandage, examine the wound and treat me.

We waited some more. I flipped through a WebMD magazine labeled “complementary waiting room copy.” This made me realize how much we’ve built waiting into providing care.

A half-hour later, my toe was finally examined but I waited another five minutes for the doctor, who went directly to the wound and got down to the suturing business. He explained what he was going to do, but didn’t say whether I should continue to sit or lie down. Four painful stitches later, he took off his gloves and left the room with the instruction to take painkillers on and off and change the bandage every day. But I realized that he hadn’t put any bandage on my toe. After waiting for about 10 minutes, my partner went out to get someone to bandage my toe. Five minutes later, someone arrived, put on a fresh pair of gloves and dressed my wound.

The doctor came after 15 minutes and handed me a two-page document, asking me to come back in a week to 10 days to get the stitches removed.

There are a multitude of problems here. The doctor didn’t put a bandage on my wound, but he had gloves on and it only would have taken a few more minutes. He preferred to leave me without a bandage and type out a two-page document, which, frankly, I still haven’t read. A physician’s assistant in scrubs had to waste a pair of gloves to do the dressing. Here, we’re providing more assistants and nurses so doctors can focus on clinical work – but a patient really doesn’t really care how or how much a physician writes notes. A hospital doesn’t benefit from wasting supplies, and a doctor isn’t doing clinical work when he or she is documenting.

The solution here is to help physicians by slashing the amount of documentation and keeping only value-added information. When I practiced, I used to take the vitals and history. I sutured and dressed the wound myself. There were almost no handoffs. I also documented with the patient sitting with me in my clinic. I could finish a regular visit in fewer than 15 minutes.

We’re asking providers to document a bit too much. And even though we are providing them additional resources to “save” them time, that savings isn’t benefitting who it truly should: Patients. This is never more apparent than when you’re the one on the exam table.

MBOE recap: What’s your sigma level?

For most of us, the sigma level – or defects per million opportunities – for New Year’s resolutions would be abysmal. We have 365 opportunities in a year to implement what we resolve to stick to and in reality, how many do we take advantage of? Whether it is skipping that dessert or going out for a run or practicing that hobby, rarely do we stick to our plan – but we keep complaining and hoping that we will achieve that goal. New Year’s resolutions are hard to keep.

MBOE faculty member Peg Pennington works with MBOE students on the SigmaBrew simulation

Thankfully, our Master of Business Operational Excellence students had an easier task at hand during the Six Sigma Week of the year-long degree program. In the four days they worked on improving the sigma level for a coffee company called Sigma Brew, a simulation created by Sigma Brew is fraught with many issues: Long lead time and wrong orders, to name a couple. Until now the students have been reading and learning the online MoreSteam modules on the Six Sigma body of knowledge. This week they had the opportunity to apply the theory to a simulated real business problem with the usual constraints of cost and resources.

Students first were challenged to define the problem correctly. Tons of data were provided but their job was to pull only those data that made sense to the business and helped them make meaningful decisions. This is not very different from what happens in companies. The true problem is hidden well below myriad symptoms. Data are available but they may not be relevant. It is only after defining a problem one can start to think about what data would make sense.

Data provide the baseline for the current performance of the company. Measuring the correct metrics guides you to not only make right decisions but also show you the impact of the solutions/countermeasures that you implement.

If the problem is not analyzed correctly, the countermeasures will only address the symptoms and the problem will continue. A cause map helps you drill down the root causes of the problem. Statistical tools such as hypothesis testing, regression analysis, ANOVA and others help you understand the degree of impact different root causes can have on the outcome you are measuring.

Improvement occurs when you implement the countermeasures in a systematic manner. It is important to track the metrics to confirm improvement. If there is not impact or the metrics are going in the opposite direction, it becomes important to start from the very beginning to identify the root causes and experiment until you are able to improve.

Improvements last only so long, especially if there are no controls in place to check the progress of the project. Control charts and standard work for leaders can take organizations a long way. There must be a system in place that helps visualize not only the progress but also any roadblocks that come up in way of progress. It is the job of all involved to solve and/or to escalate matter at the right levels to resolve the issues.

Students went through the DMAIC phase to address the issues that Sigma Brew was facing. Each group positively impacted process and the sigma levels went from a one to six up to eight!

MBOE recap: How confident are you?

One of the greatest challenges organizations face is choosing among multiple alternatives for improving a product or service. Our Master of Business Operational Excellence students last week got a crash course in a great decision-making tool.


Holly Stein, director of operational excellence at Cardinal Health, introduced our students to the “design of experiments” concept, which helps organizations facing options where each alternative by itself or in combination with others could have a positive or negative impact on the business goal. Students in this exercise were tasked with creating paper helicopters with different characteristics: Some short, some long, some with wide wings and some with narrow wings. Their goal was to create a helicopter that, if dropped from a height of 6 feet, would fall exactly or very close to a target on the floor. Using design of experiments, teams created models that met the business criteria.

Design of experiments is very commonly used in product development and in clinical trials, but the health-care and service industries don’t use it on a day-to-day basis. The goal of the helicopter exercise was to help students see the applicability of the concept and trigger any ideas for how they can use it in their organizations.

But how did students make the final decision on which model worked best? Stein also introduced the concept of statistical analysis, which businesses use to help them make meaningful decisions. An option at a 95 percent confidence level, for example, means you are willing to take the risk of 5 percent that the decision could be wrong.

“How nice it would be if you knew that 95 percent of the time you’re right about the decisions you make every day!” Stein told the students.

Analyzing data is key in driving decision-making, but continuous improvement is all about designing small experiments and observing the impact on the business problem.

Are your meetings a waste of valuable time?

itln crowd

McKinsey & Co. Partner Krish Krishnakanthan shared a number of sharp insights about the application of lean principles to the world of information technology, but what seemed to resonate the most were his thoughts on how we view two very important features of any organization: Meetings and managers.

krishnakanthan mckinseyMeetings, Krishnakanthan (pictured) told a crowd of 80 at last week’s IT Leadership Network forum, often serve the function of an all-hands-on-deck “firefighting” session. Here, issues that could be resolved on individual team members’ time instead are tackled en masse, contributing very little value or eroding what value there is.

“Staff meetings truly have become problem-solving meetings, not status-reporting meetings,” Krishnakanthan said.

Check out photos from the event here.

Where organizations often fail to contain much-dreaded waste in processes, he said, is in firmly establishing objectives among individual team members and leveraging “huddles” or meetings for valuable communication – not triage.

This same attraction to firefighting, Krishnakthanthan said, has seeped into the role of managers. These leaders, he said, should find themselves coaching their teams to develop the skills they need to solve problems – not solve the problems themselves.

“Most managers, though, would love to just solve the problem,” Krishnakanthan said, “and they get rewarded for this. A reward system must be built to reward really good problem solvers, not crisis managers.”

The key, he said, is to be a leader who knows how to ask the right questions, not jump to provide the answer.

Krishnakanthan was the featured speaker at COE’s sixth forum in its IT Leadership Network series, which began with a visit from Lean IT co-author Mike Orzen in April 2012. Check out for a look at past speakers and our upcoming events.

COE women ‘lean in’ at book discussion

Facebook COO Sheryl Sandberg’s bestselling book Lean In didn’t so much create buzz in the biz-book world as it did a jet-engine roar. Nearly six months after its release, Lean In seems still as talked-about as ever – so much so that at least a few of our member companies are hosting ongoing discussions centered on the blockbuster.

Sandberg’s manifesto and its subtly powerful stance – that in a male-dominated world, women unwittingly hold themselves back too – resonated with us at the Center for Operational Excellence. And like some of our member companies, we decided to do something about it.

lean in women
Topics at COE’s “Lean In” discussion included “The Search for 50/50” and “Are You My Mentor?”

Last week we hosted an experimental “book club” discussion on Lean In featuring more than 50 women from COE member companies. Instead of a panel or a “breakout” into small groups, we decided to make a cocktail out of them both: Eight tables, eight topics, eight facilitators, and 15 minutes for a group to share their thoughts before the next rotation.

Click here for a look at photos from the event.

We’re thrilled with the results of our round-robin book club, which provoked some provocative discussions on topics that are crucial to our professional and personal lives, but not always easy to talk about: Self-doubt, career mobility, finding balance with a partner, parental guilt, and a number of others.

Some of the women who attended wrote down their thoughts during the discussions, and we thought we’d share some of the best:

“Accept that there will be guilt” – This, from our table on “Raising Future Leaders,” echoes Sandberg’s own struggles with being a working parent.

“Expectations are an invitation to resentment.”

“Are you an arsonist at your own fire?” – This, at our table on finding balance with a partner.

“Have difficult conversations now!”

And, an audience favorite: “Laundry is always a problem.”