Dear Gemba Coach,
I work in healthcare and I struggle with how the concept of flow, which I can well understand in production, applies in service?
Let’s think like a patient for a second. Last time I went in for surgery – a minor problem with my hand – I had to first come into the clinic for preliminary appointments, where (1) administrative paperwork was filled in, (2) the anesthetist filled in some more forms and (3) I had an interview with the surgeon – and then I was sent home. It’s a good clinic, and I didn’t have to wait too much between each of these people, but it still took half a day.
Then, on the dreaded way, I was put in a booth, where I waited. A nurse came in and gave me pills to take and I waited. Another nurse prepped me for the operation, and I waited. The moving bed came to take me to the theatre. I was operated on (fervently hoping they were doing whatever they were doing right – I could not see my hand being worked on behind a sheet) – and then sent back to the booth. I waited again until I felt better and was checked that there were no immediate side-effects. I was finally put into a cab home. All and all, very efficient, I have to say, but, still, one day total. I then had a check-up appointment with the surgeon, and one more to have the stitches pulled out.
My point here is that all went well, no bad side effects, problem solved, an astonishing feat of medicine when you think about it. But it is still a terrible process.
Continuous flow is an ideal where all the things done to me would have been done continuously, seamlessly moving from one to the other, and I would probably have been out in two of three hours total instead of a day and two half-days of follow-up drawn out over a month (not counting waiting list time). Continuous flow is hard to achieve because of very real constraints:
- Wait time to get to use the central “monument” resource, such as the operating theatre. All patients have to come through in sequence, so there’s a waiting queue;
- Wait time between several specialists since they don’t work as a continuous cell. You shuttle from one to the other, and even when the process is pretty good, there will be waiting before each.
- Waiting time to check there are no immediate adverse effects after each critical step – check time, if you will.
Paging Dr. McCoy
Ideally, the patient would come in, would be settled in a place and be checked by all specialists in sequence, prepped and all operating machinery would be brought to the patient, which is currently impossible. But still, as I writer I need good coffee to write well and in the old days, I’d have to go down the street to the café for an expresso whereas I can now do it myself with the George Clooney machine – technology does help us to break monuments in small, flexible tools we can integrate in the process.
The second aspect of continuous flow is the continuous flow of work for the caregiver:
- Smooth fluid sequence of operations for one person, without obstacles or waiting
- Smooth relay from one person to the next in the case of team work.
Now obviously it’s extremely hard to organize both a continuous flow of care for the patient and a continuous flow of work for the caregiver – nurse, doctor or administrator – which is why continuous flow is an ideal: science fiction! In “Star Trek,” Dr. McCoy examines and heals all in one go. One day maybe …
Therefore, we ask ourselves: how can care flow better for this patient, and how can we better flow the work for the workers. Then we see the obvious gaps and try to fix them. This will reveal a first layer of waste in the way we organize care, and then a second as we keep peeling the onion.
Continuous flow always applies inasmuch as it means flowing work for the client seamlessly and flowing work for the worker smoothly. This is a mental experiment we can conduct in any situation. Very obviously, this can’t be done in practice because some analysis needs centralized equipment, such as X-rays or other tests, while others need to coordinate a great number of people, such as operating theatre, and others again would seem very inefficient if we did this way.
No matter, by comparing what we do to continuous flow we can always find opportunities to get closer to flow. Try it, see what happens, then think again and try something else.
Seeking flow is the key to increasing a third flow, the flow of ideas, which is the key to both better patient care and greater healthcare efficiency.