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Lean Six Sigma tools have been successfully applied to the manufacturing industry for years. Can you apply to your own office? This is the Business Of Medicine. I am Dr. Larry Kaskel, your host. My guest today is Owen Dahl, president of Owen Dahl Consulting, which specializes in medical practice management and we will be discussing the practical application of Six Sigma principles to patient scheduling.
DR. LARRY KASKEL:
Owen, Welcome back to the show.
OWEN DAHL:
Well, thank you sir, its nice to be back.
DR. LARRY KASKEL:
I would like to start if you will with a simple explanation or definition of what Six Sigma is because I am not familiar with it.
OWEN DAHL:
Well, Six Sigma is a mathematical phrase, but basically the idea and application for the business environment is to suggest that there is a way that we can measure successfully processes and identify what we would call defects in those processes and the defect could be something that is broken, something that is wasteful, something that is redundant. It means that there are steps along the way in doing processes that we would have in our offices that in fact don't work well.
DR. LARRY KASKEL:
An if the goal to get the defect rate down to is close to 0 is possible.
OWEN DAHL:
Yes that's true. Six Sigma itself, of course, speaks to 3.4 defects per million.
DR. LARRY KASKEL:
Wow!
OWEN DAHL:
Occurrences and obviously were not going to be, well, it would be great if we could, but chances are that we are not going to be successful in doing that.
DR. LARRY KASKEL:
I mean, I could do that myself, but I have to rely on office staff to help.
OWEN DAHL:
Well, I realize you are perfect, but sometimes you have a team of folks to be involved and that's the key to this. Is that you as a leader of your practice adopt the philosophy, take a look at it and then see what you could do to make sure that the defects don't occur or don't repeat.
DR. LARRY KASKEL:
Can you give me an example of how Six Sigma is used in the rest of the world? For example, airline industry.
OWEN DAHL:
Well, the airline industry is pretty fascinating when you think about it because million passenger miles or million flights, something like that we have 3.4 errors that would be a very high rate of issue. So, I certainly don't want to be one of those 3.4 and as million flights. I think that were successful, but on the other hand, the issues of lost luggage.
DR. LARRY KASKEL:
Right, I was just going to say and as I applied Six Sigma to finding my luggage.
OWEN DAHL:
No, but the point on that is, is that what they did and what we need to do in the practice of medicine is to take a look at what our real value is and what things we can offer to our patients so that it makes a most sense, so the thing that we are talking about with airlines is safety and clearly safety and customer service are important parts of what we do in our medical practices on a daily basis. So, if we focus on what our purpose is and what our mission is, what application of the Six Sigma concept that makes sense and in this add one more comment and I think its important that we think about this as a concept, not as an absolute, and if we have to buy into the philosophy that there are wasted things that we do in our practices on a daily basis that we probably don't have to have, we need to find way to fix it.
DR. LARRY KASKEL:
All right, so lets get into the actual details. When you go into a practice, what do you see as the most inefficient area that this application would apply itself to?
OWEN DAHL:
There are number of them, but one of my favorite ones to look at is the concept of scheduling because scheduling, frankly I don't think is wrong doctor, but you know scheduling is probably the most important thing you have in your practice, even above you. Because if you don't get your patient's scheduled, you don't have anything to do.
DR. LARRY KASKEL:
Agreed, agreed, and I don't think it the wrong way. The problem is, you know, the front office staff is making decisions in scheduling patients and I would probably be the best one to know how much time this patient needs, but I can't be answering the phones.
OWEN DAHL:
Well then one of the things that could _____ respond to that is that you need to take some leadership and say here is a triage list with the types of patients that I am going to see on a routine basis and therefore what our goal is, is to schedule routinely and what we can use Pareto is another principle here, but now 80% of the patient you see are going to be fairly routine and they might have 3 different parameters within which they would be measured whether this be a basic visit, intermediate visit, or a very complex visit, something like that, that you would tell your staff here is what you need to look at. But beyond that one of the things that Six Sigma talks about is to take a look at what those defects are and see whether or not we can fix those. So, assuming you set the _____ with your triage model then you stop and take a look at it and measure the effectiveness of what you set for. Find out what those defects are and see what you can do to fix it.
DR. LARRY KASKEL:
You threw out another term there Pareto and that's as Greek to me as Six Sigma, so can you tell us what Pareto or who he was?
OWEN DAHL:
Pareto was, I believe, a Greek from centuries ago who had the _____ 80% of the issues that we have are caused by 20% of the occurrence.
DR. LARRY KASKEL:
So, he is the 80-20 guy?
OWEN DAHL:
He is the 80-20 guy.
DR. LARRY KASKEL:
Wow!
OWEN DAHL:
Ya, so actually we are looking for is that in principle when you stop and take a look at it there are repetitive defects that occur in your practices in which you want to do is to try to identify those repetitive things, fix the top 1 or 2 without trying to fix the entire system and then go into another primus or principle which I would call continuous improvement. So that I can fix that 80% and then take another look at it, say 3 months from now and find still having problems, but the problem that I saw, the initial problem were 2 that I saw, got fixed, then my defect rate drops dramatically.
DR. LARRY KASKEL:
You mentioned earlier that this really has to start with the physician or the practice leader and if they are not really on board, then it won't work.
OWEN DAHL:
Then, I would forget it and I think that you are wasting time.
DR. LARRY KASKEL:
So, a practice manager coming in and saying "all right doctor you have to do this as I won't work," the doctor has to buy in.
OWEN DAHL:
That's correct because one of the things that we have to have is that leadership that says this is what I am going to do and again a physician in this capacity is the producer and as the producer its just like a pilot on an airline or an individual on the assembly line at Ford or General Motors, each one of those players are very important and they have to do their part just like you as a physician has to do your part to make sure that the system works.
DR. LARRY KASKEL:
If you've joined us, you are listening to the Business Of Medicine on ReachMD XM 160, The Channel For Medical Professionals. I am Dr. Larry Kaskel and my guest today is Owen Dahl, President of Owen Dahl Consulting and we are talking about the real life application of Six Sigma Principles to patient scheduling.
So, lets go little deeper into patients scheduling. Assuming that every one is on board and they are buying in. If we start with just defining the problem, what can we actually measure and analyze?
OWEN DAHL:
Well, you can measure and analyze the number of aspects of the scheduling process. I mean, just looking at scheduling alone, it's taking the theory of a 50-minute slot, did we get 4 patients in? did we get 6 patients in? Did they get in, in the timely manner?, then did they get to the physician in a timely manner?, and I think if we start to analyze the entire process, we start with scheduling, but the scheduling has to make it right for when you as the physician are walking into the exam room. You need to be there timely. We don't want you to have any waste of time and we don't want to have you scrambling around looking for report or needing of set of gloves or tongue depressor or something basic like that. We need everything to be in place for you, so each one of those components really fall back to, did we schedule properly? and then do you have the support staff to make your schedule work?
DR. LARRY KASKEL:
So, I have a question on. I am a very strange physician. I actually like to run on time and if not be a little early and so I find my self waiting outside the patient room for the nurse to be done so I can go in, so I am thinking I got a problem here. I am not scheduling enough patients per hour or I need another assistant to get people roomed.
OWEN DAHL:
Or there is something else going on.
DR. LARRY KASKEL:
Or I am unseen.
OWEN DAHL:
I am not going to argue that one, but lets pretend like you are seen and that you yourself are efficient, but the support structure that's around you is not and that's where Six Sigma starts since lets take a serious look at this entire process and it could be scheduling and that you shouldn't schedule every 15 minutes, may be you should schedule every 10 minutes and see 6 patients instead of 4 or something like that, but more importantly that medical assistant or nurse who is helping you on the front end might be tied up on the back end. In other words, you may have just seen another patient and now they are busy scheduling the patient
DR. LARRY KASKEL:
Right.
OWEN DAHL:
For diagnostic procedure or something like that or another visit taking their time on the back end and not having enough time on the front end to prep the patient for you to be able to see him in the exam room.
DR. LARRY KASKEL:
Okay, so solve my problem. I mean, do I need, I mean I am there and I see the problem, I realize it, but it sounds like any other consultant to tell me what time it is and tell me what to do.
OWEN DAHL:
Well! I mean, obviously I am a consultant, so I would like to say of course that's the solution, but I don't know that that always is the solution because number 1 component that this is the awareness of and so what we want you to do is we want you to think threw the scheduling process and the visit process meaning that I would define a 5 steps, you got to check in, you got the prep by the EMA to get to the exam room, your time in the exam room is number 3, number 4 is the exit from the exam room and then the reschedule or schedule or diagnostic whatever we do and then the check out. Each one of those are almost like we are on assembly line and if 1 works and 2 works and 3 works and 4 works and 5 works we are in good shape, but if there is a bottle neck at 2 or a bottle neck at 4, it has a big impact on the rest of the process, so you need to be aware of that and you should tomorrow when you go back to your office or today when you take a look at your office, you should actually say, I wonder if may be the back end piece isn't causing me more problems for the front end because I've got too much of a burden on the back, so just throwing an employee at it may not work. I may need to either fix my systems, may be I can do an EMR, may be I can do some other electronic components and so on or may be instead of saying I need another MA, may be I could be better off with the clerical staff to help me do the scheduling on the back end. You don't know that right now and even I can theorize on this all day long, but until you stop and take a look at that and say okay what are my defects, where is my biggest bottleneck and then what can I do to measure that. In Six Sigma what we are talking about is actually measuring it. So, what we are trying to do is to identify that 80% result from the 20% problem, see if we can identify that, fix that 1 or 2 little pieces and then continually work to fix it until the entire process is smooth and is efficient as you want it.
DR. LARRY KASKEL:
But I am a physician and I just want to, kind of, make an executive decision and I think that's what a lot of doctors do. We don't know how to sit and analyze the flow of our office and I think all I have to do is get another person there and get the patient in and I will be able to see an extra patient in hour and 1 patient would pay for that persons staff for the day.
OWEN DAHL:
You know your right, that's logical to think that through because if you get 60 bucks for a patient visit, you pay an employee 50, you know, you are ahead of the curve, but I would argue that throwing that employee at it or another employee at it may be yes, its an alternative, but it may not be the best alternative, so here again I go back to perhaps another set of eyes, trying your practice manager on some of these theories and just as a sideline I did a quick study, it took a look at the number of primary care physicians in the country, assume that every primary care physician would be efficient enough to see 1 more patient 4 days a week, 48 weeks out of the year. If we trained everybody in the country to understand that system, we could eliminate our issue of the uninsured and the visits to the emergency room and so on.
DR. LARRY KASKEL:
Wow, that's an impressive statistic.
OWEN DAHL:
It could be fixed just by us in our business, thinking business and getting ourselves more efficient.
DR. LARRY KASKEL:
All right, so what would be the next critical process in terms of scheduling that we haven't discussed.
OWEN DAHL:
The next critical process in terms of scheduling that we haven't discussed. I guess goes back to each of those components. For example, we talked about the efficiency of you in the exam room and being either prepared for or being able to deal with the orders that you have post visit. Well, I would let's go to the front desk and address what goes on at the front desk. May be we have system in place that doesn't work in terms of getting good demographic information or getting the kind of thing that we want to have so that we can collect at the time of visit and so on. So, we've got aspects of that scheduling part for the components that fit in there that are working as well as they should either. Has nothing to do with you in the exam room, but could be a cause of the delay doesn't have in terms of getting that patient ready for you and catch you in a position where you are not collecting the money that you should be able to collect.
DR. LARRY KASKEL:
As you are talking, I am thinking about some of the processes in my office and we have an EMR and when I see the patient, I may order some orders for them and some x-rays or some prescriptions and then I'll say go up to the front desk, they'll print these out for you and you'll be on your way and so they have to go up to the front and say Dr. Kaskel has something to print out for me, they print it out and they could have been doing something else, for example, checking someone in or taking a co-payer making another appointment, so do you see doctors that have printers in the exam rooms and are printing out these orders and say here you are done, good bye!
OWEN DAHL:
Certainly, I mean any kind of functionality like that that you could put in place. What does it cost you, $79 for a printer that you can put or if you get a, you know, a good one, may be $150.
DR. LARRY KASKEL:
Not much, right, right.
OWEN DAHL:
So, that's again is opposed to hiring another employee if you spend for 3 exam rooms $500 for printers and support at the toner and paper that you'd have.
DR. LARRY KASKEL:
Toner is the killer.
OWEN DAHL:
But the toners are already being used at the front desk.
DR. LARRY KASKEL:
You are right, you are right.
OWEN DAHL:
And also that's not something we have to worry about. So, I think that kind of thinking is where we want to go with how do you it, but lets jump back to your question about scheduling because most EMRs scheduling systems, put us in 15-minute slots. How many visits do you have on the 25 or 30 patients you see every day that are actually there for 15 minutes?
DR. LARRY KASKEL:
Not many. They are either much less or more.
OWEN DAHL:
Ya, so I mean the 15-minute thing gives us at least a structure. Okay, but it doesn't mean that we have a way of dealing with it. So, lot of things I would like to suggest is that we have a huddle.
DR. LARRY KASKEL:
Right, the pre-day huddle.
OWEN DAHL:
Pre-day huddle, so we sit down or we talk to every body including the receptionist and find out who is coming in and what we expect and how we can better manage the flow. That's not a Six Sigma tool, just practical, but by doing that we might be able to find out what areas we have is issues and we can measure those issues and see if we can find ways to fix it.
DR. LARRY KASKEL:
Well, every time I talk to you I think I need to hire you for a week and I still may do that. Owen Dahl of Owen Dahl Consulting, thank you so much for coming on this show.
OWEN DAHL:
Well, thank you Dr. Kaskel. I hope this helps you and all of our listeners.
I am Dr. Larry Kaskel and you've been listening to the Business Of Medicine on ReachMD XM-160, The Channel For Medical Professionals. Please visit our website at reachmd.com which now features our entire library through on-demand podcasts and thanks for listening.
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Many successful Fortune 500 companies have used 'Six Sigma' for years to systematically increase their revenue and operational efficiencies. Mr. Owen Dahl, president of Owen Dahl Consulting, discusses with host Dr. Larry Kaskel how those same proven principles can be applied to patient scheduling and other medical office operations. Mr. Dahl specifically outlines how a physician could analyze the patient scheduling process by focusing on the quality of each process step.
Many successful Fortune 500 companies have used 'Six Sigma' for years to systematically increase their revenue and operational efficiencies. Mr. Owen Dahl, president of Owen Dahl Consulting, discusses with host Dr. Larry Kaskel how those same proven principles can be applied to patient scheduling and other medical office operations. Mr. Dahl specifically outlines how a physician could analyze the patient scheduling process by focusing on the quality of each process step.
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