Steven L. Mansberger, MD, is a glaucoma specialist with Legacy Good Samaritan’s Devers Eye Institute in Portland, Oregon, where he is Chenoweth chair and director of glaucoma services. Devers Eye Institute has one of the largest glaucoma practices in the Pacific Northwest. Dr. Mansberger incorporated several concepts from the lean management system, originally developed by Toyota Motor Corporation for its automobile manufacturing, into the glaucoma services at Devers Eye Institute. Glaucoma Physician spoke with Dr. Mansberger about how these changes have benefited the practice.

Q. What inspired you to learn about lean for Devers Eye?

A. About 7 years ago, a provider left, we hired a new provider, and I took over the entire administration of the glaucoma practice. At the time that I took over, I was getting notes from our technicians that they were overworked, they were burnt out, they felt like administration wasn’t listening to them. We were getting complaints from patients about wait time. We were seeing between 50 and 70 patients a day. There were all these things happening, and so we held a retreat and we identified about 3 things to work on. This was a standard retreat where we talked about what’s working and what’s not working. We decided that we needed to get our waiting room to be a little bit more modern. We needed to buy some machines to help with our testing. And we worked on how to move patients through the clinic, but the experience was really unsatisfying. We had spent a full day but we really didn’t have any concrete solutions. It did help a little bit with morale, but it really wasn’t as productive as I had hoped.

Q. How did you introduce lean to your practice?

A. Our hospital system happened to be exploring lean, and I became fascinated with it. I got some training, and I developed an online survey that all of our office took. The front office staff and technicians listed anything they’d noticed in the clinic over the last 3 months that affected safety or created waste, meaning they were doing things that turned out not to be of value to the patient.

There was a question on the survey that asks what is of value to the patients, meaning what patients would pay for. The staff listed things like accurate refractions, excellent consultations, getting out of the clinic as quickly as possible, and not waiting. That opened the group’s eyes to the patient's perspective — not what I might want as a physician, not what a technician might want as a technician, but what the patient would want.

We identified various forms of waste. That year, I believe we came up with 22 processes to change. Over the next year we made all of the changes and it was revolutionary; our wait time went down by 50% and our patient satisfaction and staff morale went up.

Q. How did you implement the changes?

A. We prioritized which changes we were going to make first. We did minor things like moving the indirect ophthalmoscope right next to the physician, so the physician didn’t have to get up from the chair to grab it. We changed how we loaded rooms. We only loaded rooms from one direction, from left to right, so the physician never had to decide which was the next patient. They just went to the next room down the hallway, so there was less provider movement. We moved the machine so the patients wouldn’t have to move.

And then we organized all the roles. We wrote down all of the roles that we had in our clinic, and we created standard templates for those roles. So if you’re a visual field technician, you get a one-page bulleted list about what you do when you’re a visual field technician in our clinic. We did the same for all roles, like workup technician, a technician handling the phone, someone handling urgencies. Everybody rotates through those roles.

So over the last 7 years, I think we’ve implemented 140 different improvements to our clinic. We’ve done several retreats, and everyone has been involved: all the physicians, all the technicians, all the back office and the front office. Our patient volume increased by close to 30%, our revenue increased by 50%, and we’ve had no increase in costs. Now, Legacy Devers as a whole is planning to implement lean.

Q. Any specific tips on getting started?

A. I used Survey Monkey to create the survey. It was helpful to use an anonymous survey, so people could say whatever they want, good or bad. They can air their grievances and also share ideas that might be really innovative. And we talk about it as a group and then we decide on focus areas.

Q. Were there any specific glaucoma-related changes that you made to the practice that improved the bottom line?

A. Some changes don’t necessarily improve revenue, but they improve value. If you save one minute per patient on a 60-minute day or 60-patient day, that saves an hour of work time. Routinely, our technicians were working 1 to 1.5 hours of overtime every day, and we paid them time and a half. Now that’s gone completely away.

As far as revenue goes, we try to do things at the right time. If patients come in and for some reason we have missed that they needed a visual field that day, instead of seeing them, taking them out to do the visual field, and then bringing them back in the room, we just have them do the visual field on the way out of the office. If there was some sort of major change, we would call them. Or, if they needed to be dilated, we wouldn’t move them out of the room. We would dilate them and keep them in the room. That saved 1 to 2 minutes per patient, because moving them in and out of the room took time and then we would sometimes lose track of them.

We also really organize the subsequent visit. We have very clear guidelines about follow-up. We don’t just tell the front staff to schedule a 3-month follow-up; we tell them exactly what they need to have at that testing on that day, and we try not to deviate from that, unless there’s a new complaint that we need to do a workup on.

Q. How would you recommend that other glaucoma specialists looking to implement this would go about learning about it and implementing?

A. The lean process is easy to find information about.¹ I created the survey myself because I have a background in survey development. But anyone can create a survey, really. Some questions would be: “What are examples of unneccesary work?” “What are examples of unutilized creativity?” “What are examples of waste from patient movement?” “What are some examples of waste from employee movement?” or “What are some examples of oversupply, like buying supplies and then not using them?”

We were buying brand-name glaucoma medicines. We stopped doing that. We just bought the generic versions if we need to use those in the clinic. We had supplies that were sitting in our cabinet for months, never being used. So we just only started buying them when we got low. What’s great about the lean process is that you’re constantly improving. You’re never satisfied with how you’re doing.

Q. Do you redeploy the survey and go through the process every year?

A. Yes. We did our last retreat last year, we fixed around 15 things and now I’m going through the survey to see what were our priority issues that we still haven’t fixed. Once we get through that list, we’ll do the lean retreat and survey again.

Q. Any other comments?

A. I just wish I had done it sooner. The physicians spent a lot of time thinking about what needs to be fixed by the clinic, where the whole point of lean is you go to all the people who are actually doing the work. You think about the practice as a whole, not just what’s going to make the physician’s job easier. So there were a fair amount of things that we changed that actually were difficult for the physicians but were better for the patient and better for the technician. And in the end, that works out better for everyone. GP

Reference

1. Albanese CT, Aaby D, Platchek T. Advanced Lean in Healthcare. CreateSpace Independent Publishing Platform. 2014.