E133: Applications of Lean Six Sigma in Dermatology Clinics

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I share a presentation I gave in July 2025 at the Practical Symposium in Beaver Creek Colorado. The topic was titled “Operations Management – Make Practice More Efficient” which described my experience working with two dermatology clinics.

In the presentation, I explain my background in healthcare improvement using Lean and Six Sigma methodologies. I explain how statistical rigor and process mapping can identify operational waste, such as redundant paperwork and inconsistent staff protocols. By analyzing real-world case studies from clinics in Dallas and New York, I explain how data-driven analysis transforms anecdotal “gut feelings” into measurable, high-quality results, which can reduce patient wait times and enhance both staff engagement and patient satisfaction. I explain how a good improvement program can foster a collaborative culture where continuous experimentation and respect for people leads to better financial outcomes.

I was invited by Clay Cockerell, MD after he helped connect me with a small clinic in Dallas a few years earlier. He had researched Lean and Six Sigma, and wanted to have someone visit a clinic to find opportunities within dermatology practices. He presented some findings from the Dallas clinic at the AAD conference in Orlando in March 2025, and asked me to present at this symposium, including another clinic in New York City I connected with at AAD.

The Practical Symposium is an annual conference created by Clay Cockerell, MD that emphasizes real-world dermatologic topics and practical applications for dermatologic physicians and clinicians. To learn more go to https://www.dermatology.academy/

To learn more about Lean in Healthcare, check out our free course, Applications of Lean in Healthcare: https://www.leansixsigmaecosystem.com/c/applications-of-lean-in-healthcare/

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Transcript
Note: may contain typos and errors, generated with AI

A little background on myself. I have a statistics degree and a master’s in quality management and productivity. So I have no medical practice training at all. So I’ll talk about how I got into healthcare process improvement a little bit. I’m going to talk about Lean and Six Sigma. How many of you have heard of Lean or Toyota Production System? Okay, a few of you. Good. How about Six Sigma? Is that a term? Okay, a few. All right, great. I’m going to talk about these practices that have been around for decades. And they’ve been used pretty readily through many different industries, but they’ve slowly been working their way into healthcare, but I think there’s still a lot of opportunity in the dermatology practice. And so that’s what I’m going to talk about is some observations I’ve made at two different clinics and how these methods could be used to improve patient satisfaction, staff engagement in their satisfaction, improve finances and outcomes of your clinics. Also looking at just efficiencies and not just individual efficiency, but looking at efficiencies across the board, which is the patient flow through your practices. Let’s start with the mean, and let me define that. Think about this as getting your patients through your clinic quickly, but at high quality so that they get what they want, exactly what they want, no more or no less than what they really ask for. And so you have to really understand their needs, and that’s the value. that we define. What is value to those patients? And let’s deliver that value as quickly, efficiently as possible. And so it’s around the flow and how things progress from step one to step 2 to step 3. And there’s a lot of parts of this that involve engagement of everyone in the clinic, not just leadership and office managers, but every staff member has a say in how processes work and can be improved. There’s also coaching around not just telling someone, do it this way, but let’s try something. Let’s experiment. What do you think? And then respect for people. How do we do this in a way that is respectful of each other? So we’re not blaming people when something goes wrong, but say, let’s look at our process. Why did our process fail to deliver the outcome we wanted or get the steps completed in the right way? So my first introduction to healthcare was about 20 years ago. I got pulled into an AHRQ grant in our community. There’s a lot of adverse events around patients taking Coumadin and warfarin. And so we’ve studied the flow of that experience for patients. And they would basically schedule an appointment, come in, get a blood draw. Blood draw would get collected up, sent off to a lab. Lab would get back to them in 3 or 12 or 18 or maybe the next day, a number of hours later. And then those results would get sent to the physician, usually by fax, and then they would reach out and contact the patient and tell them how the results came out. Not a very good flow of information and response time. Now it’s probably more self-monitoring. They’re at home, they do a finger prick, they get instant results, they send those off electronically to their physician, and they get a response back within hours, maybe, of any changes to their medication. So that’s the difference in flow of getting information to the patients exactly what they need so they can make adjustments as possible. Six Sigma is a little bit more about trials and studies and research, all the statistics and p-values and box plots and analysis, bringing that same rigor that we have for those scientific studies that we do, bringing that to the business processes. Instead of a treatment on a patient, we’re looking at The way we set up the process, how does that look better? Does it go faster? Is it higher quality? So the outcomes are different, but we’re studying it using the same statistical methods and tools. And a lot of people have taken statistics classes, but what I end up doing is teaching people and reminding them what they’ve learned in school and showing how do we apply this to the business part of your clinics and in your organization. There’s also belt mentoring. So they adopted A martial arts system of belt levels for training and project work. So yellow belt, green belt, black belt. My role is actually a master black belt. So they have these different levels to try to distinguish years of experience and practice. One of the things with that study I mentioned was this gauge R&R study. which is a type of approach where you study how good the quality of your data is. And a lot of times we assume that if there’s a number, the number must be good. But in this research, the INR test was the result of what your, the blood test was being performed for Coumadin and Coreform patients. And what we found was the labs gave different outcomes by 15 to 20% difference in the test results. And we traced it back to figure it out the way they calibrated the equipment was done differently. Even though you’re using the same equipment in the same community, if that patient, their blood had been sent to a different lab, it could have affected the medication amount that they would be given going forward, which could increase the chance of an adverse event, either too high a medication or too low. So that was pretty eye-opening that those methods I’ve used in manufacturing for 18 years had application to healthcare directly. Clay mentioned the clinic in Dallas that I got an opportunity to go visit. Spent about a day and a half there. Came up about 20 or so recommendations for them based on what I saw as an outsider with a fresh set of eyes. And just looking at the flow of patients and talking to staff members and trying to get some insights of how do things work? What are things that frustrate you? How is this process for you? How is your onboarding? Do you feel like you have the training, the skills, and knowledge to do your job well? Then I also recently got a chance to go to a clinic in New York City, a little bit larger. They also did aesthetics, and I spent three days there and came up with nearly 100 recommendations. Again, all of them aren’t necessarily things they can go off and implement, but questions to ask to dig in and say, is there a better way of doing the work that you have here? So this is typically what I do, a little introduction. Here’s why I’ve been asked to come in. I’m not trying to find anyone doing something wrong. I don’t really know if you’re doing anything wrong. I’m just looking at the general process flow. And that’s what really my expertise has become is looking at the process, not necessarily what is being done and the process itself, but just how do things kind of move and operate. And then how do you methodically go about improving the quality? So then a little tour, here’s what we have, here’s our rooms, here’s our front desk, here’s where patients come in. Even a tour of the outside of the building, and there’s some interesting things we found there. Then watching patients come in and out, go through the waiting room. Hearing kind of side conversations, a common thing, making note of that, things that you may not have visibility. Interviewing with MAs and staff and doctors, collecting times and validating if you have an electronic medical record system. Do the times that the system says, does it match what the patient experience really is? Do those numbers match? And then doing some analysis on that, doing some statistics, just giving that data back to them that maybe they don’t look at regularly or often. And then summarizing and giving some recommendations for next steps of the pursuit. So in the Dallas Clinic, a couple of key things that stood out. A lot of multiple steps involved with doing certain operations or procedures, whether it’s updating patient records or scheduling patients or entering information into new patient screen, a lot of clicks, a lot of movement of the mouse on the screens, a lot of printing out documents, going to get stuff, maybe didn’t work the first time, you have to go back and do it again. So a lot of extra steps that probably add up over time to making their work harder. If we can eliminate these small little things in the work, it really frees up time. Lack of documentation, a lot of things done by memory. It wasn’t clear, what’s the proper best practice for doing this setup of this procedure? How are the trays? How should it be organized consistently so it has the same look and feel every time? It’s not dependent on who the MA was that day. Things like that, we always look for standardization of processes. Having patients in a faraway room, you know, it’s just a couple extra steps, but every day, that time adds up to time that you’re not able to be with that patient. Also being able to have a good, clear system to replenish supplies, especially these infrequent procedures that aren’t done all the time. There are established things through lean methods that do a good job of triggering reordering of supplies, not based on guessing or predicting, but based on actual usage. The things I bolded here are things I saw in both clinics. One was not really dedicating time to look at how do we improve the clinic. It seemed to be very haphazard or ad hoc when it was done. And to have a really good improvement program, you need to have structure in your system. It shouldn’t be when we have free time. It should be something we do every week or every day, including maybe a daily huddle that says we’re going to get everyone together and get on the same page each day and also talk about what happened yesterday and what do we need to change or improve so it doesn’t happen again today. And then the other thing was follow-up. We saw that there were patients that kind of fell through the cracks and there wasn’t a good process to follow up with them to say, you said you were going to reschedule. We don’t see you in the books after a couple months. Reminder, if you want to book a time, let’s get you on the calendar. So there seemed to be a gap where patients would drop out if they didn’t schedule right there at the clinic. Clay’s got two different documents on his websites I got a reference to at the back that goes into more detail on that particular clinic. This is one of the tools we use, a process map. The specific one is called a swim lane diagram. And there’s different lanes, and each lane represents a role or a job or position. And the steps involved in each lane tells you who’s responsible for that step. And sometimes just mapping out the processes can be really eye-opening. You might think we know what the process steps are, but when we put it on paper and get everybody’s input, we find out it’s a lot more complicated or confusing or may be inefficient and it really should be. Also from the Six Sigma standpoint, we look at data and statistics and say, all right, I hear what you’re saying, but let’s pull the numbers and let’s see for sure what’s going on. And maybe that doesn’t quite match what you think it is or what it feels like. So we always have to take a data-driven approach to say, it can’t just be, I think the patient wait times are good. What are the actual numbers? And let’s look at that on a regular basis. So what’s your average? What’s your standard deviation? What percentage of patients are here over an hour or over 90 minutes? We can run calculations, do distribution shapes with histograms. We can calculate this out and see the pattern and know, are these outliers that drive up our average or is it just the typical fluctuations? And we can even break down the variation if we need to by procedure type and really study the data using statistical methods. So that’s a lot of what Six Sigma does. From A Lean standpoint at the New York Clinic, credit card processing and uploading of patient photos took a lot of extra steps and it seemed very wasteful and inefficient. And it’s taking up the MA’s time, which they can’t then clean the room and then get to the next room to help the doctor. Transportation waste of any kind of document that had to be faxed out, they had to print it, go over here, and then go fax it over there and then take it over here to shred it. Again, taking away their time from doing real important work for the patient. Not this kind of extra work that has to be done, but we want to eliminate all the waste and inefficiency. A lot of clutter in some of their rooms, a lot of equipment. They want to have access to these tools, but it made it very hard for the patient to come in and navigate and for the doctors to kind of get around and get different angles on the patient. When the schedule started to get off track, we found that there wasn’t a good process to start communicating with the other patients, like, hey, we’re running 30 minutes late, we don’t have the race to get here. Especially in New York City, parking’s a premium and people are always running behind. So we say, hey, take your time, we’re running a little bit late. And just managing the patient expectations, we thought there was a lot of opportunity there. studying the data, getting feedback. They had patient surveys. I don’t know if they really went through them and really tried to identify opportunities to improve. And then again, without a system, it’s just going to be ad hoc. And you really want to build in structure. And one of the recommendations is at least once a week, carve out an hour with your team and say, what are the things that came up this week that we want to start fixing and addressing? And we’ll experiment and try out these ideas and see what happens. And try it for a couple days. If you don’t like it, just try something else. So it’s really about a collaborative, experimental approach to improving the process. Common standards didn’t really see a consistency between MAs on doing the same thing, like cleaning the rooms or documenting the visit. How much notes do you type up, this long or this much? They’re varied by the MA. When to communicate with the doctor, when you interrupt them in the room, or when you wait until they’re at a break. That was seen to be inconsistent and each doctor had their own preferences. So trying to get them more standardized so MAs know what the expectations are when they’re working with different doctors. And then those two recommendations there, you know, daily huddles. They did have some daily huddles where they were meeting, but it wasn’t all the doctors involved. Only some of them were involved. And it was just with their MAs. We thought that was a good practice. They should probably expand. And then also some follow through with patients that didn’t book at the time that they left. And then also going back to this respect for people, how do I make sure that people are heard, that they’re listened to, that they’re spoken to politely, kindly, so that they enjoy coming to work and there’s not this tension. And I know it gets stressful and things happen and things are critical, but we always want to make sure that everyone is treated fairly and kindly, no matter what happens. So we’ve got to assume people are trying their best and they’re not intentionally trying to make a mistake or an error. So some things we looked at, wait times, pulled some data. Their data was pretty good at matching what we did in our observations. So we pulled some records and had to work with their software company to figure out how to extract that data out. But we saw that there was some longer wait times with the median time between two of the doctors, so about 7 minutes for two of the doctors and three to 4 minutes for the other two. So we could study that and look at scheduling, we could look at their method. Is there some reason that there’s a couple minutes different? there. And that could make a difference in a patient’s experience. So learning for who’s doing it well, who’s not doing it so well, what can you learn from each other. But the data is a way to look at that. And there’s where we get into p-values and things like that you might have learned in your statistics class. This one was around wait times by day of the week. And it was fairly consistent. There’s variation there, but How much variation is statistically significant? That’s a question that you can answer with analysis. The times were about four to six minutes on the waiting time from when they arrived to when they were seen in the room. That 4 to 6 minutes was not a statistical difference. It was just noise. And if you continue the study, it might flip-flop over time. So that’s why we want to make sure that there are real statistical differences before we start making changes and making adjustments to our process. Things ran better when you guys were here. So I said, well, cool, let’s look at the data. But the data didn’t support that. So maybe there’s a perception there, or maybe we didn’t study the right metric to pick up what they were feeling that was different versus a typical Monday or Tuesday or when we weren’t there. So again, trying to bring some actual data to these discussions instead of it being just a verbal statement or a gut feel. We’ve seen LEAP or proliferate in healthcare quite a bit because it’s easier to learn and there’s not as much statistics that can scare people off. There’s a lot of great work that’s been done at Seattle Children’s, Virginia Mason, ThedaCare, Cleveland Clinic. I do a class for UC San Diego Health Systems. They’ve been doing a lot of great work with Lean Six Sigmas. It is new to dermatology and so looking to find more examples that we can share. Hopefully maybe future symposiums we can bring some more examples. feedback from your customers and patients and try to ask those difficult questions. Sometimes it’s hard to hear that negative feedback or those complaints or problems that come up, but that’s how you can improve because other people aren’t willing to speak up and say something, they’ll just won’t come back. So sometimes you have to have those difficult conversations and know that problems are opportunities to make the clinic run better. And look at that patient data on a regular basis. Don’t just assume you know where it is, but have a process that says every week we’re going to pull that data and look at it and look at the fluctuations and the outliers and see if that can give us an indication of what went wrong. And there’s patterns about day of the week, seasonality, even differences between doctors or staffing on certain days that you might pick up. These methods have been around a long time, especially in lean and healthcare has been at least 20 years of progress, but there’s still a lot of work to do. Six Sigma is still pretty new in healthcare. But they are effective. They are the best practices out there. They’re seeing it spread and proliferate even 40 years or more that it’s been out there. It’s still new in some areas. So again, the application of this, I think it’s pretty open for a lot of great opportunity to increase efficiencies, reduce costs, lower wait times, improve that patient and staff satisfaction, and their own productivity as well. with my contact information and this is the link to those two studies that go into a little bit more detail about the Dallas Clinic.

Clay:

If you want to do this in practice, he’s the guy.


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