“One Piece Flow”
Can adopting the principles used in building a Toyota Camry really improve the outpatient practice of medicine? “One piece flow” (also known as “single piece flow” or “continuous flow”) defines a manufacturing process in which all of the work on a single product (the Camry) is completed before moving onto the next unit. This contrasts with a “batching” model in which some portion of the work is done on multiple units (batch) before moving onto the next step in the process. The batch analogy in medical practice is seeing 30 patients daily but not finishing the work on any until later, i.e. not completing the notes until the evening or next day. Pioneered by Toyota, adoption of one piece flow manufacturing in the auto industry has reduced cost of production and increased efficiency. How would such a model apply to clinical practice?
Physicians in busy outpatient clinics are typically pressured into practicing in a “batch” fashion. Time constraints and documentation requirements, along with an unwieldy and user-unfriendly EMR commonly means a “batch” of patient notes aren’t completed during the actual encounters but must be finished at the end of the day when the details of the history and exam and even the assessment may be difficult to recall. Busy physicians, including many of my colleagues in Cleveland may spend several hours after clinic finishing notes in the EMR. In contrast, in a practice organized along a one piece flow model, the entire visit including orders, consults, documentation and billing would be completed before the patient leaves the office. Clearly this could reduce errors of omission in documentation performed hours after the visit. However, would this model actually improve efficiency and reduce the after-hours “paperwork” burden or would the clinician simply fall farther and farther behind schedule while trying to complete his or her documentation before moving to the next patient?
In the hospital setting, hospitalists at Virginia Mason Hospital in Seattle who have adopted a one piece flow model on rounds report reduction in the workday of about 90 minutes. Similarly, at the same institution, a recent study (Journal of Graduate Medical Education, December 2014) reported initiation of a one piece flow model on a medical teaching service significantly reduced violation of intern work hour rules and improved timely discharge order writing.
There are some intrinsic barriers to fully implementing a one piece flow strategy in the outpatient area. Completing a visit from the patient’s perspective includes arranging tests or procedures. In our spine practice, the primary reason for delay in scheduling an MRI or spinal injection was the need for insurance approval. However, the key element in adopting a one piece flow strategy is the availability of a truly clinician-friend EMR which facilitates real-time documentation during the visit. If integrated into a well-conceived clinic process, technology with built-in decision support and ordering capability which fits a real clinical workflow would permit the physician to efficiently complete the work with each patient while not falling further and further behind schedule. Reducing or even eliminating the after-hours “chart work” would be a most welcome consequence.
Obviously providing patient care isn’t the same as manufacturing cars. Variability, unanticipated complexity and psychosocial factors are frequent and may disrupt the most well designed process. However, the core concepts of the one piece flow model are worth exploring in the evolving value-based approach to medical care.
In a broader sense, the Toyota one piece flow technique could be applied to any activity with linear "assembly line" features and warehousing of needed components. In this old model, a missed or delayed step can crash the entire process. The disruptive single flow manufacturing approach offers innovative opportunities for enhanced efficiency if adapted to information technology processes requiring multiple steps in series - think too many clicks or scrolled pages.