Quite frequently healthcare organizations face financial dilemmas where service demand exceeds capacity and it appears additional resources are needed. However, the service’s productivity and margins are not meeting expectations. Adding additional providers and/or facility size may increase capacity, but the service will continue to operate below productivity and financial expectations.
Before investing in additional resources, a prudent manager may apply a Lean tool called Swim Lanes to determine if there is an opportunity to add capacity without adding resources. The following steps show how the Swim Lanes approach can optimize productivity.
Step 1: Measure your current production levels, list the resources utilized and identify your financial status. The following example identifies the production level and resources used in operating one suite of an ambulatory procedure center. In this example we have the following key resources and results:
Step 2: Use the Swim Lanes tool to identify how those resources are being utilized to achieve the current productivity level. This assessment involves a detailed, time-based review of the patients’ flow through the center, the sequence of activities deployed to serve the patient and the resources utilized for delivery.
The Swim Lanes approach involves listing resources and the services they provide in rows (lanes) by their sequence of occurrence. Meanwhile the columns provide a timeline allowing for the assignment of completion time to each activity. This step will provide you with a clear understanding of why your current resources generate the current capacity.
Exhibit 1 illustrates the flow of patients though the procedure center. In this example, the initial procedure center capacity is just 3.4 procedures in the first hour. Table 1 provides a summary of the utilization of manpower and key resources. This data reflects high utilization of the physician’s time but very low utilization of other resources. The procedure volume capacity under the current process averages 3.8 cases per hour over four hours. The actual workload achieved of 3.1 cases per hour represents 84% of capacity.
Step 3: Use the Swim Lanes illustration to analyze the current resource assignments and determine if there is any opportunity for improvement in the process. Below are some key issues to consider:
- Are all the activities necessary?
- Does each activity in the process bring value to the service? - Are there opportunities to reduce the time required to complete each activity?
- Are we optimizing the use of each resource?
- Are the roles for each position appropriate for their skill level and costs?
-Have we minimized inactive time for each resource?
-What percentage of the time is space or equipment being utilized for its intended purpose? - Is our process feasible?
- Are we assigning resources to multiple activities at the same time?
In the procedure center example, the primary area of opportunity involves assigning duties to the physician. In this case the physician is the most highly utilized resource and also the most expensive resource. Generally the highest price resource should be the process-limiting factor to optimize productive efficiency. But the physician shouldn’t be the limiting factor because he or she is performing duties someone at a lower skill and compensation level could perform. Obtaining the patient’s consent is a potential activity for reassignment. There are also multiple periods of staff and equipment inactivity in this example. This resource inactivity must also be addressed in order to optimize process productivity.
Step 4: Take advantage of the opportunities identified in Step 3 to reorganize the service and improve productivity. The Swim Lanes approach helps you understand which opportunities significantly increases the probability of successful process changes.
In this example, the first step is to relieve the physician of a major portion of the consent activity and assign initiation of the consent requirement to a nursing assistant. The physician will complete the process prior to the procedure. Use the physician’s added time to complete procedures more quickly which will serve to increase the productivity of all resources. See Exhibit 2 for a Swim Lanes diagram containing the results of this improvement.
Table 2 summarizes the productivity capacity for each of the key resources after applying the process improvements. Reassigning activities to the appropriate resources allowed for accelerated procedure activity and a significant increase in productivity. The procedure volume capacity under the improved process averages 5.75 cases per hour over a four-hour period.
Step 5: Project new production levels, resources utilized and the new financial status. At 84% of the new capacity, the production level jumps to 4.83 cases per hour while using the same resources. As a result, the margin jumps from 8% to 36%
Conclusion
In this example we were able to use the Lean Swim Lanes tool to add an additional 55% to system capacity without adding resources simply by reorganizing the work process. As a result, we experience a significant jump in both manpower and facility productivity, eliminating the need to invest in additional resources to meet demand. Producing more volume with the same resources also drives improved financial results and eliminates the low-margin dilemma discussed in the introduction.
One important lesson from this analysis involves the ripple effect of reduced physician productivity on overall system efficiency. To achieve a meaningfully useful EHR we must remember this lesson as we assign new documentation requirements to health system resources.
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