How to Increase Efficiency and Profitability

Although the term Lean Six Sigma (LSS) may sound like complicated business school jargon, the principles behind it are relatively straightforward—simply to reduce variation for optimal quality control¹—and when applied to eye care clinics, they can have a significant effect on direct patient care (Figure 1).

The evolution of LSS as a management philosophy originated in companies such as Motorola, Toyota, and General Electric. This philosophy combined the LSS approach to quality control in manufacturing, which relied on recording data to identify potential process flaws, and the LSS principles of increasing operational efficiency and ensuring that limited resources are only used for purposes that add true value.

The underlying principles, therefore, become a powerful tool that any business, including eye care clinics, can use to improve performance. Anyone with the right data and insight into a clinic’s workflow can use that information to put scarce resources (eg, providers, staff, and space) to more effective use. This translates into measurable improvement in the most valuable area to patients: the percentage of time devoted to their direct care.

APPLICATION IN EYE CARE

The essence of an LSS initiative in eye care is identifying sources of inefficiency throughout the patient journey and reducing or eliminating them. This then frees up existing resources and increases the clinic’s capacity to serve more patients and increase revenue. On the surface, this sounds like a rather simple exercise. However, this hyperfocus on patient–provider interactions can uncover underlying inefficiencies and significant opportunities for improvement.

The first step to unlocking the hidden value in any practice is understanding current resources and how they are used. Only by capturing and analyzing real-time data can we gain insights into the efficiency of our day-to-day operations. When performing this exercise, it is not uncommon to find that more than 50% of eye care resources are expended on non-value–additive activities.

REDUCING WASTE IN A CLINIC SETTING

The purpose of any eye care practice is to bring together three key resources: 1) a patient with a need; 2) a provider to fill that need; and 3) the staff, space, and equipment required to complete the visit. The percentage of time each of these resources is used in a direct point-of-care encounter is an important measure of how effectively they are being used.

The Patient Factor

The percentage of time spent in direct care (versus waiting) is a key factor in the overall experience. It is important to stay above 50% direct care, with a target of 70% or greater. Visual Clinic has developed these benchmarks through experience across many practices and over years of working with them on this topic.

The Provider Factor

The percentage of time spent in direct care (vs other activities) is a key factor in clinic capacity (patient access) and efficiency (cost; Figure 2). Providers should aim for between 60% and 80% direct care, depending on the provider’s specialty and care model. In a delegated care model with care extenders, for example, it is difficult to achieve a provider direct care efficiency above 80%.

Staff, Space, and Equipment

The effective allocation of rooms and equipment avoids bottlenecks and is an important factor in capacity and utilization. An empty room, or idle or harried staff, could point to a need for change. Accurately measuring these data can uncover the potential to increase clinic capacity, lower clinic costs, and improve the patient experience. Any improvement in the length of time required to secure an appointment (ie, the sooner the better) and/or in-clinic wait times will contribute significantly to a positive patient experience.

KEY AREAS TO EXAMINE

There are several key areas to look at if your practice is not meeting your stated benchmarks. Let’s review them.

Scheduling

The arrival rate of patients is the key starting point for addressing any patient flow issues that could be negatively affecting the patient experience or provider efficiency. By understanding the provider’s work patterns and the length of time required for examinations and procedures, practices can adjust and maintain the rate of patient arrivals to match the flow pattern of the provider.

Workflow Time Balance

As discussed, understanding provider work patterns and pace allows an eye care practice to schedule the patient’s arrival rate appropriately. The next step is to organize all the activities upstream of the provider so that they can be accomplished at the same pace and rhythm. Although there can be many different factors that come into play, accurate insights into patient flow mean that practice managers can effectively balance activities to stay on pace while maintaining the highest level of care.

Room Constraints

An important point to consider is whether the practice has enough rooms to operate at the full pace of the provider. Delays in rooming patients because none are available can cause stress—to both staff and patients—as well as inefficiencies. This is sometimes misinterpreted as a scheduling problem, but space constraints are usually revealed during a thorough workflow analysis. If clinics react too hastily and pull back on the number of patients to address perceived space constraints, it can lead to capacity being compromised, direct care being reduced, and revenue being left on the table. If true space constraints are identified, the number of rooms must be increased to meet demand.

Staff Constraints

As with room constraints, if we do not have enough staff to stay on pace with the provider or if existing staff are not performing optimally, we should acknowledge this and adjust to keep the practice operating at the optimal pace.

No Constraints, Just Waiting

We tend to place blame for wait times on a lack of resources (eg, rooms, staff, or equipment), but we can all recognize this scenario: A patient is waiting, a room is available, and a staff member is available, but no direct care is happening. Here, there are no constraints, just a slow response. This is the worst and most expensive waste in the system.

The good news is that this problem is also the easiest to solve, and it does not require any great investment. With better workflow communications, team-based problem-solving, and management engagement, this type of “controllable” wait can be minimized and throughput enhanced.

USE LSS IN YOUR PRACTICE

Long wait times can have a disastrous effect on an eye care practice. Research shows that not only do longer wait times severely affect patient satisfaction, but the longer a patient waits, the lower their overall perception is of their provider and quality of care. This can go on to change how patients perceive important instructions and information given by their provider,¹ as well as how likely they are to return to your practice or refer you to others.

The effects of “waiting” goes far beyond the patient experience, however. It cuts into the bottom line by exposing performance gaps. Through a careful analysis of patient flow and resource allocation, every eye care provider can use the basic principles of LSS in their clinic. The result? More efficient use of resources leads to less waste and a more responsive team resulting in happier patients, satisfied staff, lower operating costs, and increased profitability (see Lean Six Sigma in Action).

Lean Six Sigma in Action

By Selina McGee, OD, FAAO

Applying Lean Six Sigma (LSS) principles to clinic flow is critical for our practice. We have benchmarks that we review weekly alongside our key performance indicators. For example, we recently moved into a new building, and we developed these benchmarks and key performance indicators. We knew that for us to maximize our efficiency, we needed to see 1.9 exams per doctor per hour with two full-time equivalent employees working 36 hours a week for 48 weeks per year. Our average revenue per patient is $674.

We also knew that a patient needs to reach the optical in 55 minutes for the best patient experience and maximized capture rate. In our clinic, to help measure the total wait time, we measured times at every stop through our office so we could see if we were consistently hitting our desired metrics. Although these are the base metrics we reflect on in our weekly review, there are many other metrics that reflect the patient experience.

To more fully implement LSS principles, we pre-brief and de-brief clinics to evaluate improvement or areas of concern and address any problems that are apparent. When we see patterns, we go back to our system and ask ourselves the following questions:

• What’s working here?
• What’s not working?
• Is this adding value to any of our metrics?
• Do we really need to keep doing it this way?

This keeps our systems running smoothly and efficiently so our team can focus on patients having the best experience possible.

Selina R. McGee, OD, FAAO
Founder, Chief Optometrist, Executive and Visionary, BeSpoke Vision, Edmond, Oklahoma
Co-Chief Medical Editor, Modern Optometry
drmcgee@bespokevision.org; Instagram @drselinamcgee
Financial disclosure: None