Mark-

This is the problem. I believe LAME is too high level and providing examples like this story give more relevance. The variety that a doctor's office receives may have six patients that require 8 minutes with the doctor and One make take 60 minutes.

Understanding variation and designing systems that can absorb variety of demands has to be paramount for service. Takt time in service seems silly if you take this view. I have been writing and studying on Scientific Management. Lean folks needs to understand there is Taylorism Lean and Deming Lean. Where the former is a bad path and the latter opens new perspective to solve problems in a less tool-oriented way.

I know you have been interviewing and talking with the Deming community - this cannot be a bad thing. There is no TPS or Ohno without Deming. Tripp

Looking at the example this looks to me to be confusion between TAKT and the relationship between cycle time and what manufacturing would call “operator loading”, other industries tend to describe as “staffing”. In the doctors’ office, there are likely a number of steps to the visit. Some would be performed by the doctor, some by a nurse, maybe some by a lab technician, etc. I propose a truly “lean” ways to approach this scenario is from a standard work perspective. Let’s start with a hypothetical standard work: I imagine that the standard work would follow something like:

1. office staff: greet patient, collect insurance information, collect co-pay, notify medical staff patient is ready(8 minutes);

2. nurse’s aide(maybe nurse): greet patient, take to exam room, confirm identity, confirm reason for visit, collect vital signs(time 5 minutes);

3. nurse(maybe doctor): greet patient, perform preliminary examination, collect information(7 minutes);

4. doctor: greet patient, perform examination, issue instructions (8 minutes);

5. nurse(maybe doctor): confirm patients understanding of instructions, release patient (5 minutes);

6. nurse(maybe nurse’s aide, maybe office staff): update patients chart and visit information(8 minutes);

7. office staff: prepare billing, submit to insurance, update billing records (10 minutes)

Those who are math savvy notice the “cycle time” far exceeds the Takt time of 20 minutes. From my fabrication of times, the total cycle time is 51 minutes. At this point, many “lean” practitioners are scrambling to do one of two things: 1) identify all the “waste” in the process to get the total cycle time to under 20 minutes or 2) justifying the rationale(s) that the time not spent in front of the patient doesn’t count towards Takt, by among other tactics, splitting the patient time and office time into separate “value streams” or “work flows” and showing that the time spent with the patient is under the 20 minutes and therefore OK.

I propose a slightly different viewpoint: The adjustments needed are not with the timeline, but with the number of staff involved in the process. For any given organization, there will be more people than absolutely necessary at any given point. There will be supervisors, managers, etc. and each function in a process will have varying degrees of “slack”. SO, for a given patient, the delay will happen for a given skill set. The concept of cross-training comes in here. For a number of the tasks (not all in this example and not all in many examples), the skill sets of the staff can overlap, office staff can be nurses and aides, doctors can step in and perform nurse functions, etc. As in a manufacturing realm, there are a few functions that require specialized skill and cannot be cross-trained effectively. Those functions could have “back-up” to assist if the schedule gets too far behind. At a worst case, the time line for “not patient facing” could be extended or temporary help assigned to “catch up” in “off hours”. This would be analogous to “calling in the 3rd shift” in manufacturing.

I like the suggestion of building “gap”(could be “change-over time”) into an office schedule. The time could be managed to buffer the “inventory in progress” of different patients and still meet the patients needs of a quality visit.

In reality, any way an organization decides to define “lean” or act “lean”, the bottom line: Patients (e.g. customers) are not kicked out, unless you want them to never return.

I'm glad to stuck to your guns with the professor.... My response to the professor would have been "SQDC".  After working for JTEKT, the fourth largest supplier to Toyota, who is 20% owned by Toyota, the priorty is Safety first, then Quality (take care of the patient), then Delivery (takt time) and finally Cost. Whenever we made improvements to the bottleneck operations, we had to get "Chokko" (First Time Thorugh) up to accepatable levels of 98%, them 99% then 99.6% before we could focus on Bekido (OEE).

@RAJohnson:

You added up the times of the steps.. the total time of 51 minutes is irrelevant. All we need is for each step to be faster than takt since the steps are sequential and flow from one into another.