The 'Toyota-like' otolaryngology office

Ear, Nose & Throat Journal, July, 2007 by Christopher Y. Chang

There are almost certainly aspects of your medical practice that require improvement. (1) (2) Unfortunately, some of the suggestions for improving your office's efficiency that have been offered by medical societies and others can be expensive to implement. Fortunately, other solutions don't cost a dime.

One such solution is a business technique called PDSA--for plan, do, study, and act. The basic concept behind PDSA was introduced in 1939 by Walter Shewhart (3) and widely promoted by his protege, Dr. W. Edwards Deming. Deming went on to become an authority in his own right, and he is credited with establishing the management philosophy responsible for the success of the Toyota Motor Company. Toyota follows those principles to this day, and the company is able to quickly manufacture high-quality cars at lower costs and with fewer employees than many of its competitors.

Incremental changes add up

In the PDSA process, individual workers at every level of a company are encouraged to improve efficiency, cut costs, or simplify a process by making small changes on the spot and then seeing what happens. The 4 steps:

* Plan: Identify a small change that you think might improve a process.

* Do: Implement the change on a small scale.

* Study: See if the change actually did improve the process.

* Act: Decide whether to keep or abandon the change. If you decide to keep the change, deploy it on a larger scale.

A PDSA cycle can be completed in weeks or hours. As one small change leads to another over time, the accumulation of improved processes can result in significant company-wide adjustments.

All sorts of small changes may--or may not--have a significant impact. For example:

* What would happen if you moved a filing cabinet or the copy machine closer to the desk of the person who uses it the most? You might have something to win and nothing to lose.

* What would happen if you started faxing consultation reports instead of mailing them? In addition to saving money on postage and envelopes, you would use less paper and perhaps less time.

* What if the physician escorted a patient to the exam room when the staff was busy with other tasks? You might shorten waiting-room times and improve the flow of patients in and out of the office.

* What if you saved all paper that does not contain private health information and used the blank back side for temporary printing tasks? Again, you would certainly save on paper costs.

Although each of these examples represents a small change that would have only a minimal impact on any given day's efficiency, the cumulative effect could be significant.

Not every small change is going to turn out to be a good idea, of course. But because each initial change is small, a staffer needn't be afraid to fail because any change can be easily reversed if necessary.

Loosening the reins

There are many other ways in which small changes might lead to big improvements. All you have to do is ask your staff. That's another advantage of the PDSA system: The boss doesn't have to come up with all the ideas. Under the premise that every member of the staff knows his or her job better than anyone else, each employee is entrusted to make reasonable changes without managerial interference. It is the leader's job to empower employees to take a spontaneous, independent, and proactive approach to experimentation.

Getting back to the Toyota success story, Spear reported that over a 3-day period recently, members of one assembly-line team took it upon themselves to make 50 small changes to their specific jobs. (4) As a result, they cut the amount of walking that each did by about a half-mile per shift, which led to improvements in safety and ergonomics. Their ideas were relayed throughout the company so that others would benefit.

Taking an idea through a PDSA cycle is easy, but creating a work environment in which individuals feel motivated and free to do so without being specifically told to is more difficult. How do you enable staffers to take ownership of their jobs? How do you motivate them to take the initiative to independently execute small changes without managerial oversight? Can you trust them?

These were the questions that faced Ralph Stayer, the CEO of Johnsonville Foods, Inc. (5) But once he convinced himself to give up some control and involve his staff in decision making, his business blossomed. Certainly, it won't be easy if you're used to giving orders, especially when you disagree with a particular idea. But to do otherwise is to waste the experience and talents of your staff. The PDSA cycle is an inexpensive way to take advantage of their abilities and possibly create your own overachieving Toyota-like office.

References

[1.] Coye MJ. No Toyotas in health care: Why medical care has not evolved to meet patients' needs. Health Aff (Millwood) 2001;20(6):44-56.

[2.] Cleary PD. A hospitalization from hell: A patient's perspective on quality. Ann Intern Med 2003;138(1):33-9.

[3.] Shewhart WA. Statistical Method from the Viewpoint of Quality Control. Washington, D.C.: The Graduate School, U.S. Department of Agriculture; 1939.