Virginia Mason is one of the big names in Lean healthcare. A standard and much quoted book, describes their experiences. They have been working on this a long time, and there are many presentations and interviews available on the internet.
A reasonable place to start is this video, which describes some of the flagship programmes at Virginia Mason. The themes are those you would expect – decreasing waste, including decreasing unnecessary investigations, increasing standard work, decreasing waiting, bringing supplies and staff to the patient, working in flow, and increasing multi-process working.
There is a back pain example in the video which is further developed in the Virginia Mason book. According to the book, change was driven by dissatisfaction by some of its major corporate customers, including Starbucks. Low back pain is very painful, and there is an understandable tendency for people to move as little as possible, and even to take to their bed. For coffee houses, baristas in their beds are baristas who are not selling coffee.
The traditional approach at Virginia Mason had been to offer people an appointment, undertake investigations – including, usually, an MRI scan – to exclude serious illness, and then to offer treatment. This is partly a US approach, where high technology, defensive medicine is often described. Delays in treatment, and undertaking investigations with a low yield are, however, not restricted to the US.
The net effect was to delay treatment, which tended to increase problems for the patient. Virginia Mason redesigned their system, so that people were seen very quickly – often the next day. They were seen by a physiotherapist, and then by a doctor, who was usually able to reassure the patient that they did not have a serious disease. Investigations were markedly reduced. Treatment began straight away, and most people lost little or no time off work.
A criticism might be that people with serious disease could be missed, because investigations were reduced. On the other hand, patients were being seen within a day or two, rather than six weeks later. The great majority of people with non-specific low back pain could be reassured, encouraged to mobilise, and could get on with their lives. The few people in whom low back pain was a sign of acute illness were being seen by an experienced physiotherapist and doctor very quickly, and could be promptly referred on for a specialist opinion if they had symptoms suggestive of more serious disease.
This is a good example of identifying streams within demand. The great bulk of people have non-specific low back pain that responds best to mobilisation. Identifying them and offering them a speedy, appropriate treatment, reduces costs, decreases waiting and decreases their exposure to unnecessary investigations. Dealing with this group of people as efficiently as possible also frees up resources to treat people who need investigation or treatment of less common illnesses: both groups benefit from this Lean approach.
There are mental health analogies in this. The Glasgow STEPS service is a good example of a mental health service that tries to see people very quickly, and offers services that are likely to benefit most people. As assessment is rapid – there is often a telephone discussion within two working days – people with very severe illness can be identified quickly and referred on to specialist services. For other people, the service seeks to match them against the level of intervention that is likely to be beneficial for them.
Virginia Mason reported increased satisfaction from their back pain patients, and from their employers. Are any of these ideas applicable in your area of work?