Pull

With you process map, value stream understanding, and goal of continuous flow, there is one more thing that is critical. How much work is done at each step along the way, how many resources are necessary to insure that work is “pulled” between steps instead of “pushed”. This basically means your staffing and work distribution should be such that when a patient has completed one step, the next step is ready for them, etc. The assembly line should pull rather than each step pushing.

This can be managed by doing a process map of each of the stops in the cycle. The smaller process map will tell you how many tasks, when the time required to complete that step is understood you can consider the staffing required. For example, the triage step requires vital signs, weight, reason for visit, and perhaps other activities in your practice. How much time is required for each activity to achieve the total time? Can each MA manage this step while the prior patient is in with the provider? Or will it be necessary for additional staff since there is more than one provider utilizing the triage station at the same time?

If we break down the cycle time for a typical patient visit we might see:

• 4 minutes for check in
• 8 minutes for triage
• 12 minutes for the provider
• 4 minutes for post visit
• 3 minutes for check out
• 31 total minutes of VA time

How much time was involved in between each step, e.g., waiting room, waiting in exam room, standing in the hallway at check out, etc. This NVA is what is involved with the pull idea. The “ideal” staffing pattern should be such that there is a pull at each step along the way.

I know this all sounds great but it won’t work in your practice. You are a solo provider, the other providers will not be as efficient as you are, etc. All of this is true.

We do not expect that all principles identified will work for everyone. We do not expect that you will fix achieve the ideal every day or may be never. But that does not mean that you should not consider trying to accomplish things.

One simple tool you have in your arsenal is “5 Why”. It is always interesting to ask staff why they are doing that particular task. The common answer is that’s the way we’ve always done it. Ask the second why and the response is that’s the way I was taught. Ask the third why and you may begin to find that they don’t really know why they are doing it. The fourth why might reveal that they have no clue but think that it could be done differently when combined with another step. It may not be necessary to ask five why’s all the time but I hope you get the idea.

The simple goal is to have as many “pull” days as possible, eliminate the gaps and bottlenecks, the push days and there will be continuous flow!

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