Lean Six Sigma and Process Improvement in Healthcare with Owen J. Dahl

The 19th and early 20th century merchant, James Wanakot famously said, "Half the money I spend on advertising is wasted. The trouble is, I don't know which half." Determining the sources of waste and inefficiency in healthcare is not easy. As resources contract, it has never been more necessary to promote streamlined delivery of medical services. My guest today has a career of experience and a passion to do just that. You are moments away from learning about Lean Six Sigma and processes to improve provider and patients’ healthcare experiences next on SoundPractice.

This transcript of their discussion has been edited for clarity and length.

Michael Sacopulos: My guest today is Owen Dahl. Dahl has spent a career as a healthcare executive. He is the author of numerous articles and books, including the second edition of Think Business: Medical Practice, Quality, Efficiency, Profits. Owen Dahl, welcome to SoundPractice.

Owen J. Dahl, MBA, FACHE, LSSMBB: Well, good morning, and thank you very much for having me. I am really looking forward to this opportunity to chat about something that is near and dear to my heart.

Sacopulos: I am looking forward to it as well. Before we jump right in, maybe you could give our audience a little bit better of an understanding of your background.

Dahl: Well, like you said, I have been around for a while, and I started out in hospital administration and for the past 50 years I have been consulting with physician practices. Adjunct professor, as you mentioned, author, doing consulting, doing a lot of webinars, a lot of seminars, a lot of keynote presentations, different things like that. Principally because I have this passion for what can we do to try to make healthcare more efficient. And I believe that it starts with the physician and the physician practice, and that is the entree into the system. So, we must really start there and keep focusing. It may sound like it is a micro perspective as opposed to a macro perspective of who is paying for what, and what the government is doing and all that sort of stuff. But I still believe that we as individuals have an impact on and can have a significant impact on that patient experience and the outcome of the care that is delivered. So that has been my passion for, well, almost 60 years now.

Sacopulos: Sounds good. And that gets us, I think, nicely into the topic. What is Lean Six Sigma?

Dahl: It is a principle or a concept that dates way, way back. And it is built on metrics. It is built on the idea of if you can measure it, you can fix it. If you cannot measure it is hard to fix. So total quality management, re-engineering, Frederick Winslow Taylor back in the late 1800s-1900s, talked about scientific management. So, it has been around for a while. And Lean and Six Sigma really are two different concepts, two different perspectives. Lean is more looking at efficiency and workflow and how things function. Toyota's been big in that area in that the Toyota processing or Toyota production system. Talks about how their assembly line actually works and how it flows. So Lean looks at that, where Six Sigma really looks more at a defect kind of thing. So, it's not efficiency, it's effectiveness. Are there broken pieces and parts in the process that we go forward with?

So, when we apply it to the medical world, I like to think about the patient visit as an assembly line, just like Toyota would be. You check in, you get your triage, you see the provider, you do follow-up activity, you check out. That kind of is a flow. And in that flow though, there are defects because you can order the wrong prescription, you can do a procedure on the wrong leg, you can do this, you could do that. So, there is really a need in our world to consider both the Lean and the Six Sigma concepts as we move forward in providing care to our patients.

Sacopulos: It strikes me that both the Lean and the Six Sigma approaches originated in, I think as you said, manufacturing facilities. Does it translate well to healthcare?

Dahl: Well, that is a good point. And many, many times when I talk about this, especially with physicians, they say, "Well, I don't want to use a manufacturing concept or principle as it applies to my patient care." But as I just mentioned, if we take apart the patient visit and being check-in triage, provider, immediate activity after, assigning, scheduling, different things like that, and then the checkout, that really is an assembly line. And how efficient is that assembly line? So, when you think about manufacturing, you think about how efficient is that assembly line as say, in Toyota's case, the automobile going through and starting out with nothing and ending up with a vehicle? Well, we start out not knowing what the real issue is, what the symptoms are, what the kinds of points are that the patient has for their visit, and we end up with a care plan. It flows that way.

And then you think about the manufacturing components. Well again, a car works, but a car will break down. Well, how can I say this? The airplane episodes that we have had recently that have been on the news, those are manufactured processes and there are broken parts. Bolts are not put in the right place, tires blow. There are different issues like that. So those are the defects in the manufacturing world. Well, defects. What about the wrong prescription? What about doing a procedure on the wrong leg? What about the supply process, giving the wrong medication and different things like that? So, there are broken pieces. So, I do think that the Lean Six Sigma manufacturing concept applies very well to the medical practice.

Sacopulos: It uses a variety of what are termed belts. And could you describe the belt system in this Six Sigma program?

Dahl: Sure. Well, it follows, in the karate world. It starts with a white, yellow. Goes white, yellow, green, black, and then master black. What it would be in principle is an introductory level to the concepts of Lean and Six Sigma is the white belt then. So, you are just learning what the terms are, what the principles are, what the concepts are. A yellow belt is a little bit more advanced in dealing with that, so it is more detailed, but you are still really in that learning phase. So you're like in elementary school, secondary school. And then when you get to the green belt, typically a green belt program requires a project, requires a lot more in-depth work. So, you try to apply those terms and concepts and principles to some reality. And then the black belt gets much more into the metrics, gets much more into what can we do and how can we go about it and applying it more than on just one project, but applying it on several. And then of course, the master black belt is the highest level where you have accomplished different projects, you have done different kinds of things and moved forward.

Now, applying that to the medical practice or to the medical organization is interesting because everybody should have the white belt. Everybody should understand the principles behind what Lean Six Sigma is about, so that they can then contribute to what goes on. But beyond that, in a smaller practice of say a solo practice, even a 5-10 doctor practice, probably not going to have a master black belt: you're probably not going to get into a lot of the detail. But a large hospital system will probably have several master black belts that are involved with how that particular thing works. And this brings to mind, and I should have mentioned this earlier, but it brings to mind one of the principles in the lean world or two principles in the lean world that I think are critical.

One is the focus on the customer. So, the customer is our patient, or the customer is ourselves in terms of the customer relationship in that flow that I talked about. Well, if the front desk does not do their job correctly, then the triage or the medical assistant cannot do their job. And if the triage medical assistant doesn't do their job correctly, then the provider has problems. So, it is really customer service and customer focused. And how does that then relate? So, if we think of ourselves as customers one to the other, what we are doing is helping each other accomplish our goal of providing that improve patient experience and to achieve the outcome.

The second concept that is really critical is the idea of waste. And if you think about the idea of waste in this flow, well, a defect is a waste, but I always think about it, even insurance claim denial is a waste or that is a defect. But how did that defect come about? Well, it came about because this, this and this, and there are 100 different reasons why. But what it means is that we wasted time, we have wasted our resources, and statistically, roughly 25% of the work that occurs in a flow is wasted. So, if we can reduce that 25% to 20% to 15% and continue to work in a continuous process improvement idea, we can try to get it close to perfect. And will we achieve perfection? Heck no. Not at every visit, but we can have some of those kinds of things.

So, if we can focus on the customer, if we can eliminate waste by applying these principles of Lean and Six Sigma to that patient experience, we will have an incredible patient satisfaction survey. We will have an incredible patient experience, a positive patient experience. And the ultimate goal is to achieve an outcome that gives that patient a quality of life that is a result of the experience that they have had with us.

Sacopulos: As you talk about customer service and satisfaction scores, it makes me think that oftentimes quality in medical care is not easy for the patient to evaluate, and that there is often a conflating of quality for caring that is displayed. And as a patient, I may not be able to evaluate whether the stent placed in me was appropriate or appropriately placed, but I can evaluate whether I feel that the provider cared for me. Is this an issue that causes problems in management?

Dahl: There are actually two components of what you just said there. One is the experience itself. And many, many times the experience is critical to the success that that patient feels. And the interesting thing is that if you actually took a look at that flow and talked about how many different encounters or interactions that that patient has in total, let's say that's 100%, well, okay, maybe 20% of those engagements or encounters are with the provider, 80% are with the support staff around the provider. So, it is one thing to think about, "Well, how did I do in my interaction with my provider, with my physician or my advanced practitioner?" It is a whole other thing to think about how well I was treated when I walked into the office, and how well when I checked out. Even the billing process, did the claim get processed correctly, etc. It is that experience that becomes very important. And the patient is very much aware of that. They are tuned into that all the time.

But the second part of it is the outcome or the quality of outcome that they get. And it is funny, I was talking with my nephew the other day, he is 21, and he made a comment that was really interesting. He says, "I don't like to go to doctors. My dad," who unfortunately my brother-in-law has passed away, "but when my dad went to the doctor's office, the doctor would spend three minutes with him and then give him pills. I don't want to go to a doctor's office and get pills." So, there is a little bit of experience there, but there is also a little bit about the idea of what does that really mean for the outcome? And I know that a doctor cannot cure all the diseases, but they can help improve the quality of life that I would have left, or whatever that might mean. So, it is really becoming, and I really like the idea of focusing on what can be done with the outcome that goes on.

So, when I think about applying Lean Six Sigma and the idea of efficiency to a medical practice, one of the key things that I like to start with, say you're in an office and you're thinking about, well, we're not efficient, or we've done this or we've done that and we've tried this and we've tried that, nothing seems to work. Well, let's take it apart and let's look at the reception area, that initial phone call, an initial appointment and decide, "Well, wait a minute. We do not need to keep that patient on the phone for 20 minutes trying to get all that data. What can we do electronically? What can we do otherwise? And other ways to help them get that."

So, when we think about applying this concept to the medical practice, I like to think about everything around that physician or that provider visit. In other words, the 80% that goes on, what can we do to effectively and efficiently make that work eventually? Sure, there needs to be some fixes within the physician or the advanced practitioner encounter, but let's get this other stuff working first. If we get that working first, that will make that patient visit much more efficient, and we will give that patient experience a plus as opposed to a negative or a neutral response to what goes on.

Sacopulos: Do you find that when certain areas in the process are fixed, it raises expectations and other areas then become more fixable or resolve things on their own?

Dahl: Well, yes, especially if you go back to the idea of the customer and the customer component. Because if you take apart that five-part visit that I have talked about and the flow with the check-in and then the triage and then the encounter, and then the immediate post. If a practice can focus on them as silos, what do we have? We have five components, but not all interactive and not all related. So, what you really want to talk about is how can we relate those experiences? If the efficiency process works really well with the check-in and we've got all the appropriate data and the patient's greeted, and the patient is happy and yada yada. And then they go back to the medical assistant and the medical assistant had a bad day and sits there with a grumpy look on her face or whatever, what does that mean?

Well, if I got it right in the first place, the patient comes back happier. So that can be contagious, and the contagion can work all the way through as we move forward. So, part of the goal is what can we do in all those areas around that encounter, that provider and advanced practitioner provider activity, what can we do around that? And then how does that then relate one to the next, to the next, the next? So, the billing office can be happy and very efficient if the front desk has the right data. So, if the front desk reduces its error rate, guess what? The denial rate reduces. And if the denial rate reduces, then what happens? One of the key wastes in the process is that we do not allow the employees to use their brains. We sit as managers and say, "Do it this way, do it that way." Well, the employee’s the one that does the work. So, if the front desk gets fixed and then the back office, the billing office has fewer denials, guess what they can do? They can engage their brains to try to help fix other parts, or they can engage their brains by reaching out to the patient or being more effective in relationship to the insurance company and so on. So that it removes that busy work, that wasted work and frees them up to be able to do more effective work, in terms of relating to either each other or the patient or the insurance company in that example.

Sacopulos: What are the reactions you have seen from physicians to the use of Lean Six Sigma?

Dahl: Typically, the physicians have to commit to it. So, your culture must be one that says, "We are inefficient, and we need to put some resources into figuring out how we can become more efficient." It really starts at that level, at that physician level, that ownership level where they commit to the idea that our culture is going to be one where we believe we can become more efficient, we can improve that patient experience, we can improve that patient outcome. So once the physician makes that commitment, then they are tuned into the idea of what can be done better. So once that has done and then they begin to see the results, it becomes infectious and contagious as well, where then they say, "Well, can we fix this? Can we fix that?"

So, there is a lot of buy-in that occurs at the physician level once they see the benefit of what goes on. So yes, I have seen physicians that have been, "Wow. This is really something else." I just had a practice that went through a transition from an administrator that really bought into the idea and really put a lot of these pieces and parts together. A new administrator came in. Well, that new administrator did not have a great deal of knowledge about how the processes worked, and it was fun to watch the physicians actually help that new administrator see how the processes worked and what really happened. And it became much more effective than in the outcome or the result was because the physician bought into it and said to the new administrator, "This is what we've been able to do. We want to keep this going." So, keeping it going is on the idea of continuous process improvement, because again, as I said earlier, you are never going to be perfect, but you can always improve.

You can eliminate from the 25% waste factor to the 20 to the 15 and so on and keep going to eliminate that waste. Which reports or relates directly to two things. One, an improved customer experience. But frankly, another thing we have not mentioned at all is it improves the bottom line because if you can see one more patient every day, a 99213 at Medicare rates, you collect the 20%. So, you get it all. That translates to about $18,000-20,000 a year in gain revenue. And what is the expense against that? You have already got the resources already there.

So, the idea is that not only then do I improve that customer experience and I improve that outcome, but I can also improve my bottom line by becoming more efficient. In today's world, what is one of the biggest issues we face? Access. Well, if I can see one more patient and if I have got three physicians or three providers in the office and each one of them can see one more patient a day, we have reduced that access demand and improved that outcome. So conceptually, it would be wonderful to be able to put all of that together and then achieve that experience and financial reward.

Sacopulos: So, manage my expectations. Which resources need to go into the program before benefits are seen?

Dahl: Well, again, I go back to one of your first comments about the white belt, yellow belt and so on. And to pick up on the concept of the waste, the idea is that we don't get our employees involved. So, it is one thing for the physician, the lead physician or the lead administrator or someone else to become a white, yellow, green belt, black belt, master black belt or have some understanding of that. But if that information does not go back down to or go through all of the office into the staff, then the staff does not buy into it. So, one of the bigger issues we have as well today is the cost of turnover and retaining employees. Well, what is one of the better ways to retain employees? It is to get them involved. To help them grow personally. To give them personal growth and development opportunities. Well, why not do it in terms of helping them help you become more efficient?

So instead of sitting in your office and saying, "Well do it this way," why not say, "I think there's a problem here. We did some metrics, we looked at it, and our denial rate was 18% on UnitedHealthcare. Well, what can we do to fix that?" So, you've got your metrics, you've got your baseline, but then instead of saying, "Well, I want that fixed by improving our coding process, or I want that fixed by improving the front desk or whatever it happens to be," you say to the staff, "What's the problem? How can we fix that? What can we do?" You get a team of folks together.

In the parlance of the Lean Six Sigma world, we like to talk about the individual employee doing the work. We call them process owners because they own the process. So, if the process owner can fix what they are doing to achieve that improved patient experience, wow, I did not have to take my time as a manager to do that. I enabled and empowered the employees to come up with a solution that achieved the desired result. So, by getting that kind of thing going, you then come up with a retention model that improves and reduces your cost of overhead and cost of turnover. And similarly, you've increased your access point. So, you have improved your bottom line by reducing turnover costs, but you have also improved your bottom line by increasing your revenue, and it is done by getting people involved. So, taking time to read, to go to resources and so on that talk about Lean Six Sigma in the medical practice, those kinds of things then open up a whole new world to that employee. And that employee then returns a big favor to the practice by giving you that improved experience and that improved outcome.

Sacopulos: Well, this certainly is an important and somewhat intricate topic. Thank you very much for helping guide me through something that I did not know much about. As our time together draws to a close-

Dahl: We can talk for another hour or two about this.

Sacopulos: I know and Owen, I feel like I might need another hour or two to fully wrap my arms around this. Unfortunately, we do not have it, but if audience members are interested in learning more and working with you, maybe you could describe what you do and how they could reach out to you.

Dahl: Well, as I said, I have gone to consulting in the physician practice world for a number of years. So yes, they can reach out to me. I have a website, Owen Dahl Consulting, so they can take a look at that. I have been blessed and AAPL has helped in terms of publishing books that I have written. I know that there are a couple more articles that are going to be coming out in the future that I have written, so they can hopefully read a little bit more about the kind of things that I have talked about today and that I believe in. So, reaching out, go to my website, you will find my phone number. You will find different things like that, and I would be honored and thrilled to be able to, even if it is a five-minute conversation and I can motivate somebody to think about the idea that if they take a Lean Six or another approach.

And let me back up for just one more second, and that is with Lean Six Sigma, I talked about the flow and that sort of thing. Well, there is a structured approach to it, so you get that structure to go through, but really the important thing is to buy into the philosophy and the concept. So that's why I say, if it takes a five-minute phone call, if somebody wants to chat about it for a few minutes and that helps them buy into the philosophy, helps them look for the resources that would help them, then I know that I've contributed to the improvement in the patient care. So that can be done independently and indirectly, or it can be done, obviously, I would love to do some consulting projects. I would love to do some more webinars, seminars, podcasts, different things like to talk more about this whole idea. So, reach out, I would be happy to chat about it.

Sacopulos: Well, your expertise is certainly needed across the healthcare system. My guest has been Owen Dahl. Owen, thank you so much for your time.

Dahl: Well, thank you. And I really hope this helps people get more enthused and motivated about the whole idea of using these tools and principles to improve that patient experience and healthcare outcome. Thank you.

Sacopulos: My thanks to Owen Dahl for his time and guidance, his passion for improving healthcare through efficiency and systematic processes which benefit clinicians and patients alike. My thanks also to the American Association for Physician Leadership for making this podcast possible. Please, join me next time on SoundPractice. We release a new episode every other Wednesday.

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