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    Christian Green
    Christian Green, MA

    Lean can be an effective project management methodology for improving efficiency in your medical group practice, and you don’t have to be an expert to reap the benefits. In a recent MGMA webinar, Owen Dahl, MBA, LFACHE, CHBC, LSSMBB, medical practice management consultant, laid out how practices can apply Lean methodologies to address staffing challenges.

    However, before considering incorporating Lean, Dahl suggests that practices should ask: “Will your culture enable you to move forward and to change and improve?” A big part of this is determining whether your practice is adept at managing its culture, rather than culture managing your practice.

    Five principles of Lean

    As Dahl relates, the primary benefit of Lean is to create more value with less work. “The concept of value and the concept of waste really become very important as we think about how we can become more efficient,” Dahl says. The Lean process starts with value and ultimately strives for perfection.

    Whereas Lean attempts to eliminate waste to improve efficiency, Six Sigma focuses on effectiveness. Practices “want to become effective by not having any defects or broken parts,” Dahl says. “One of the other key things is the idea of continuous process improvement.” To meet their business goals, Dahl maintains that practices need to apply these principles on a routine basis.

    Although value is tied to the customer, the patient doesn’t always hold this role. Dahl notes that practices could be serving the patient’s family, a fellow employee, a referring source, an imaging center, or even a payer. “The idea is that every customer comes with a set of expectations, and they want to see results,” he says.

    The five principles of Lean are:

    1. Value: Defined by the customer. Practices will want to ask, whom is the process serving? What is the practice delivering as the producer of the service in that process?
    2. Value Stream: How does the practice identify necessary actions that will help bring a product or service to the customer?
    3. Flow: How smooth are processes in the office, from patient visits to claims submissions to onboarding employees? Are there gaps and waste during the process?
    4. Pull: Is the practice following the correct process in providing the customer with what’s needed, when it’s needed, and the right amount needed? Pull complements flow by bringing it forward.
    5. Perfection: How do you strive to attain no waste? It’s dependent on successfully carrying out the first four principles.

    Identifying waste and implementing Lean

    A factor that affects value stream is the concept of waste, or muda in Japanese. The components that make up muda can be illustrated by the acronym DOWNTIME:

    • Defects
    • Overproduction
    • Waiting
    • Not using employees’ abilities
    • Transportation
    • Inventory
    • Motion
    • Excess

    Practices can use DOWNTIME to identify and focus on their areas of waste.

    One of the most important pieces of this acronym, according to Dahl, is “not using employees’ abilities,” which comes back to the practice’s culture. “Does your culture enable and encourage you to have a staff member ask a question or offer a suggestion about what they could do or what could be done to improve?,” he asks. “If you’re not taking advantage of their brains, you’re really wasting a lot of talent and a lot of resources.”

    Lean deployment platforms: DMAIC and PDSA

    DMAIC and PDSA are two deployment platforms practices can use to improve upon existing processes when implementing an innovation or change. “When we talk about Lean and Six Sigma, we really want to have a good baseline … that tells us where we are in the process so that we can come up with a demonstrated concept of improving the process,” Dahl says. The first is DMAIC:

    • Define: Start with reviewing the project charter, and end with developing a project schedule.
    • Measure: Take a deeper look at value stream mapping, and end with determining process capability.
    • Analyze: Determine critical inputs, and end with prioritizing root causes.
    • Improve: Develop potential solutions, and end with creating a full-scale implementation plan.
    • Control: Implement mistake proofing, and end with transition monitoring/control process to owner.

    Dahl adds that practices often come up with solutions before they measure or analyze. Conversely, there are times in the measure stage when practices gather too much information. “You want to narrow your scope and keep your project and your focus as defined as possible,” says Dahl of the need to improve strategies that will change outcomes. 

    The second deployment platform is PDSA:

    • Plan: Identify problem statement, measure, execute plan
    • Do: Set plan in motion, review actions taken
    • Study: Determine what was learned and goals met
    • Act: Document what happened and revisions implemented.

    “You take the DMA — the define, measure, and analyze — and put that in your plan, then you … do a pilot test,” Dahl says. “Then you study the results of the process improvements, whether the goals have been met.” Finally, “you act or put it into that control stage, where you go well beyond the pilot study and implement it across the practice.”

    A big part of both platforms is “process,” which is defined as “a repetitive and systematic series of steps or activities where inputs are modified to achieve a value-added output.” For example, Dahl says that every patient and every claim filed are part of the process. Whereas, the other big component, “project” is “any temporary, organized effort that creates a unique product, service, process or plan.”

    Project charter and team roles

    One of the first steps in completing a project is to develop a project charter. According to Dahl, it’s a useful disciplinary tool that helps practices identify team members who will work on the project, establish a problem statement or business case and set goals. The charter can also be used to help identify tasks that need to be accomplished, who will be assigned each task, when tasks are due, and to whom tasks are reported. Milestones, communication strategy, and budget can also be logged. To determine return on investment, a key component of the budget is to assess cost in terms of time, team members involved, materials, and so on.

    When starting a project, it’s crucial to select team members who have clearly defined roles. “One of the keys is that you’re never going to be able to solve all the problems yourself,” Dahl says. “You want to have a team of folks who come together.” As such, a team is composed of:

    • Champion: Project sponsor who holds a leadership and supportive role
    • Facilitator: Keeps the project on schedule
    • Team leader: Project manager who is responsible for project success
    • Process owners: Individuals who do the hands-on work
    • Inside subject experts: Employed advisors who provide knowledge
    • Outside subject experts: Contract workers or vendors who also provide knowledge
    • Recorder: Tracks progress of project.

    Staffing from a Lean perspective

    Practices may have several goals related to staffing, but some of the most important are reducing turnover, increasing retention and hiring the right employees. As Dahl mentions, it costs around 70% of an employee’s annual income to replace them when they leave.

    “You’re looking at the use of resources — the cost of downtime, the cost of interview time, the cost of training time — to try to get that position going from where it was in terms of production back to where it is expected to be,” Dahl says. He adds that if a practice can eliminate one or two turnovers a year, it can save a significant amount on waste.

    To do so, practices should follow these steps:

    1. Establish a project charter: Create a specific action to reduce turnover and assign a process owner and team members to the project
    2. Define the current state: What’s the practice’s current turnover rate? Set a target to achieve.
    3. Tools to carry out the project: What do you need to succeed?
    4. Analyze: Who is responsible for what? What type of training will they need?
    5. Implement: Move forward with the project
    6. Maintain new approach: Carry out the project to completion.

    Tools for staffing improvements

    Keeping the Lean methodology in mind, several tools can be used to improve your practice staffing processes.

    SIPOC diagram (see Table 3)

    Dahl says that the first tool that can be used during the hiring process is a SIPOC diagram:

    • Suppliers: Where do you find candidates; e.g., Internet, placement services, staff member referrals
    • Inputs: Determine whom to interview through a screening process
    • Process: Recruit, interview, select and onboard candidates
    • Outputs: Hire the right candidate
    • Customers: Candidates, current staff, physicians and patients.

    “What you want to do is get your team together and think about the process,” Dahl says. “Instead of starting at the supplier, I might start at the process, or I could start at the customer. The idea is to fill in all these columns, so that you have a way of looking at the hiring process.”

    Cause-and-Effect diagram

    The second tool practices can use to address staffing is a Cause-and-Effect, or fishbone, diagram. Dahl notes that this can be applied to employee turnover during the analyze process, explaining that “the concept is that the big blue line in the middle is the spine of the fish, and the little bones off to the top and bottom of that spine are identified as fish bones.”

    From there, categories can be created to identify why turnover occurs. In the diagram (see Figure 2), Dahl separates the categories into process, compensation, training, and manager and places corresponding issues in the form of sticky notes under each category. “What you do with your team is ask, ‘what is it about our compensation program that you think contributes to staff turnover?’ And then ask the same question for each category.”

    Once that’s accomplished, the team can determine the biggest issue and fix it first. “Now you can say, ‘well, we can’t fix everything, but let’s fix the process, or let’s fix the training, or let’s fix the compensation, or let’s do management training,’ whatever it happens to be,” Dahl says.

    The Five Why’s

    Another tool that can be used in conjunction with the Cause-and-Effect diagram is the Five Why’s. Dahl notes that practices can select any of the sticky notes and ask, “why.” For example, with training, practices can ask staff, “Why don’t we have a training program?” and then come up with follow-up questions that build on each answer.

    “What you end up with by asking the ‘why’ is you come down to the real reason why you didn’t have a good training program,” Dahl says, whether there wasn’t a budget for the program, there wasn’t enough time or there wasn’t enough emphasis placed on the program.


    Considering all the above, Dahl says that there are six main takeaways, all of which can be accomplished by following Lean principles:

    • Deliver value efficiently
    • Eliminate waste (muda)
    • Enable the team to contribute their best
    • Discover better ways of working
    • Align practice strategy and purpose to day-to-day work
    • Transition to a new way of improving staff experience.

    But he also points out that practices don’t have to do everything at once — incorporating one or two tools at a time can go a long way in making improvements. “What we try to get people to do is to improve by 5% to 10%, not 80% or 100%,” Dahl asserts.

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    Learn more

    • MGMA members can access Owen Dahl’s on-demand webinar, “Moving Beyond Survival: Lean Methodology to Solve Medical Practice Staffing and Financial Challenges,” including learning how to apply Lean principles from a financial perspective, at
    Christian Green

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