Lean Design Engineering in Private Therapy Practice
Lean design engineering aims to efficiently manage our processes by creating more value with fewer resources. Originally applied to manufacturing processes, such as in Toyota Production Systems, these core concepts have seemingly permeated throughout business cultures.
My thesis capstone project as an undergraduate in Industrial Engineering was to consult with a hospital and apply lean design principles. Our analyses revealed significant waste, in particular, how they managed their records, and we were able to save them significant amounts of time and labor by streamlining their processes. While working in the Kafkaesque world of community mental health, I also noticed a lot of waste in their processes and would tirelessly vocalize my concerns. Lean design appears to be widespread in other industries, but community mental health seems decades behind how other organizations operate.
When I established Neurodiverse Counseling Services, I wanted to create a practice that would be efficient and allow me to focus on being a therapist, teacher, writer, supervisor, and consultant. I wanted my time to be spent doing the things I loved rather than mindlessly creating reports that no one would ever read or attending meetings that no one wanted to be at. I also wanted to simplify and streamline the processes. And I wanted to minimize our expenses so I could pay clinicians more than they were getting elsewhere.
I frequently revisit my engineering roots and now hope that other therapists can try some of these ideas in their practices. It also excites me to hear how others might creatively apply lean design in their practices. Allow me to introduce rudimentary lean design principles and provide some examples on how you can apply them.
Lean Design Principles
Define Value
We define value through our customers and what they want and expect from us. In private practice, our “customers” are people looking for mental health services. Our customers may also include insurance panels since we often provide services on their behalf. As a group practice owner, we may also consider our employed clinicians to be customers, which is how Alma, Headway, and SonderMind appear to view their Independent Practice Associations. The following are examples of what therapy clients, insurance panels, and therapists value in mental health counseling.
What do therapy clients want?
Hope that their situation will improve
An experienced and knowledgeable therapist with immediate availability
A clinician who they expect will be helpful for them
A clinician who may share their lived experience
A clinician who understands how their insurance works and can ensure claims are properly submitted for them
An accurate and clear estimate of the costs
People are often anxious about their finances, so be mindful and help them understand their expected investment. They want to know the cash rate, which should be clearly displayed on your webpage and/or directory profile. If they are using insurance, they want a quick estimate of the expected out-of-pocket costs for their insurance plan. Even if you are not in-network, they likely want you to help with out-of-network benefits and super bills.
What is it that insurance payers value?
Insurance wants clean claims submission and typically prefer (or even require) electronic submissions
Appropriate and accurate use of medical billing codes
Treatment record keeping
Assessment and information gathering at the onset of treatment
Diagnosis that is consistent with the assessment
Notes that demonstrate medical necessity
Clearly defined treatment goals based on the given diagnoses
Progress on treatment goals that is reflected in your documentation
Diverse case mix on your caseload
They want to see a diverse mix of diagnoses
They compare your case mix to other providers
Minimal cost per episode of care
They compare your cost per episode of care
Reduction in overall cost of care for the patient
Timely response from providers for members seeking care
Coordination of care with other providers
What do clinicians want from community mental health agencies, group practice owners, and independent practice associations?
Maximum pay and benefits for their work
Employers that care about their wellbeing and quality of life.
Work-life balance to minimize burnout
Support when they feel lost, ineffective, incompetent, or experiencing imposter syndrome
Trustworthy and supportive leadership.
Opportunities for supervision, consultation, and ongoing training/continuing education
Comfortable and inviting office space
Minimal travel time to offices
Easy-to-use technology that does not fail them
Support and coaching to establish their own private practices
Empowerment to provide clinical work in the way they prefer
Flexibility in how their sessions get scheduled
How do you know if you are actually providing something valuable? You may need to track and measure that you are meeting expectations.
Audits from insurance payers
Request case mix and costs per episode of care from the insurance payer.
Solicit feedback from your employees
Understand their needs to provide helpful services
You want to help them be their best selves
Compassion fatigue scale for therapists
Workplace satisfaction
Turnover rates
Exit interviews
Map the Value Stream
Value-stream mapping allows us to deconstruct our processes so that we can identify value-added and non-value-added activities. We often use flow charts to visualize, especially with more complex operations. In order to map the value stream, we start with the customer(s) in mind and work our way backward. We break down all operations into their simplest components to identify the moment-by-moment processes. For instance, in a private practice, we can begin by examining the process in which prospective clients request services. Below is the beginning of an analysis of the referral process for a private practice.
Prospective client wants to make a request for therapy services
How do people find you?
We want to make it simple for people to connect with you
What are your prospective clients’ preferences for connecting?
Some people don’t have the energy to even send out a detailed inquiry
Some people don’t want to call. Some people only want to call
Many people are adamant about using their insurance and will only work with someone who accepts it
What are your referral sources?
Most likely, this will include online directories, other therapists, medical professionals, Google searches, and your website
Which sources lead to the most meaningful connections in your practice?
Track where your referrals are coming from.
How clear is it that you are capable of helping?
Have you established a niche? How clearly is this communicated?
Explore and identify the people you would like to help. When do you notice you are at your best in the therapy room?
A lot of people have tried several other therapists and have not been able to find someone suitable. What makes this interaction different from previous disappointments?
What is the user experience like when they arrive at your website?
Is it clear how to immediately connect with a therapist?
There needs to be a “call to action” on your landing page that tells people exactly why they are on your website and what they should do now that they’ve arrived.
How many mouse movements, click, eye motions, and/or other actions does it take before prospective clients find what it is they were looking for?
Guide people toward the resources they need
We need a “let’s go” button that gets people exactly where they want to go and find the help they need. This will either be us or a resource that we can point them toward.
From this analysis, we can determine specific processes that contribute to value for prospective clients. We can complete a value-stream map for all processes in private practice. For most of us, these are the most important operations in a private practice:
Process referrals
Process billing
Psychotherapy practice (clinical documentation, assessment/diagnostics, treatment planning, case consultations, etc.)
Self-care routines and burnout prevention
Accounting and bookkeeping
Website design and maintenance
Social media maintenance
From this high-level view, we can begin to break down the specific processes and tasks that make up our operations.
Create Flow
Lean design engineering aims to create continuous flow in and between standardized processes by eliminating waste (muda). Waste disrupts flow, creates bloat, and leads to inefficiencies.
Mura is a type of waste, which means unevenness, non-uniformity, and irregularity. Mura is a type of waste that is driven by inconsistent, non-standardized processes. The goal of a lean design is to level out the workload so that there is no unevenness or waste accumulation between our processes.
Muri is another type of waste, meaning overburdened. Muri is a type of waste driven by requiring systems to operate at a higher or harder pace, with more effort, for longer periods of time. In the mental health field, this is what can lead to burnout.
The following are definitions, examples, and solutions to commonly occurring forms of waste in the practice of mental health care. As you read through the types of waste, try to conceptualize how this may apply to your current practice.
Types of waste (muda)
1. Transportation is anything (primarily information in our work) that moves more than necessary. Transportation is a waste of labor. One of the most common forms of transportation waste is the double handling of information, which in the field of mental health, leads to increased handling of protected health information (PHI), communication errors, and queuing times.
Examples of Transportation
Entering the same data in more than one place on a form or in software applications
Transporting information submitted on a questionnaire into another assessment document
Using a form to submit billing information to a billing department, which they’ll use to create a claim from the information you submit
We are moving the claim information more than necessary
Hand-writing claims forms
Manually typing demographics into a claim form
Manually typing information from the explanation of benefits into your EHR
Manually categorizing the same transactions in your accounting software.
Solutions to Transportation
Automate your processes where possible
Use QuickBooks to automate bookkeeping process
Set-up rules for common transactions to automate categorizing transactions.
Use an EHR that enables you to preload information into the CMS form
When set-up properly, you should only have to briefly glance at the claim form prior to submission.
Set-up ERA and ETF
Automate entry of deposits into your bank account and input of claims remittance data into the EHR.
Cross train clinicians in billing processes at your practice
It is helpful so clinicians are able to respond to questions about billing/policies themselves rather than back-and-forth messaging with an administrator/biller
2. Inventory is excessive storage. We want to minimize storage through “just-in-time” systems that continuously pull information to ensure no bottlenecks are formed, which minimizes waiting. Often, inventory can be data waiting to be processed and transformed. Another form of inventory is information waiting to be accessed. We want to be mindful of storing excess and/or obsolete information. As HIPAA providers, we want to store the minimum amount of PHI and delete anything that is not necessary. We want to minimize opportunities for a security breach of PHI.
Example of Inventory
Phone calls, emails, other inquiries that you have yet to answer
How many emails and voicemails are sitting unanswered?
How many obsolete or irrelevant emails/texts/messages do you have sitting unread in your inbox?
Claims waiting to be processed
How many claims do you have that have not been filed?
Open time slots on a clinician’s calendar that need to be filled
Equipment or product that you’ve purchased that is going unused
For instance, excess office supplies, business cards, assessments, and flyers
Unpaid invoices
How many invoices have been created that need to be deleted or paid out?
Incomplete clinical documentation
How many notes do you have waiting to be written so that you can submit billing?
Solutions to Inventory
We want to minimize response wait times, but also cannot sit at our phones and emails 24/7. Some practices hire virtual assistants to ensure quick response times
How many prospective clients do you have on a waitlist that you’ve created, waiting for a referral?
Maintain an updated calendar that accurately reflects your availability
Develop a system for completing notes
Implement concurrent documentation (simpler with telehealth). We can even incorporate the client into the note-writing process as part of a “check-out” procedure during the final 5-7 minutes of the session. We can also collect information on how helpful they found the session. We may even have the client complete a session rating form.
Create a system on how to respond to voicemails and emails
Develop a queuing system
Set up your voicemail to give option to email you, which can minimize the back-and-forth of trying to connect on a phone call
Use batch checks for emails rather than reflexively responding to them as they come in, interrupts other workflows
Use time blocking to focus on the task of responding to inquiries
I’m able to maintain this boundary by setting up separate email addresses for billing and referrals
We want to create an organizational system for our important data and information. This includes notes from books and trainings, which should be easily accessible. Similarly, we should use proper storage systems for financial data, health records, and employee records. You should be able to access any of this inventory with minimal motion.
3. Motion is any excess movement by laborers. It often occurs when we are searching for or retrieving information.
Examples of Motion
Time/clicks spent searching for a resource, email, file, etc.
Excess mouse clicks searching for buried information
Switching frequently between open tabs
One of the most frustrating things with my community mental health EHR was the amount of time clicking through to get what I needed, going back and forth between pages and files.
Solutions to Motion
Reduce excess motion by using multiple screens to have multiple windows open at the same time
Put frequently used web pages on your home screen when you open your browser and/or in your shortcuts
Learn keyboard shortcuts to minimize the number of key strokes and mouse clicks
This is especially useful for those using laptops who want to minimize motion of using the trackpad
Place items nearby on your screen to ensure minimal mouse movements
You can use the 5S of sort, set in order, shine, standardize, and sustain to improve your workspace
We want to use a simple system to sort folders to minimize click
If you are handling a lot of data in your practice, this is essential, as it could lower your risk of repetitive motion injuries
4. Waiting occurs when something is not immediately processed. Waiting typically occurs because there is not enough labor to pull the work through the system, so tasks wait until labor is available to process. These tasks are considered to be in queue as work in progress (WIP). We can reduce this form of waste by increasing available labor to clear out queued tasks and/or limiting opportunities for waiting through waste reduction/elimination.
Examples of Waiting
Claims not yet submitted following a completed session
Unread emails/texts/voicemails
Transactions yet to be categorized in bookkeeping
Supervision notes yet to be signed by a supervisee
A costly form of waiting in private practice occurs when potential clients reach out for therapy services and wait to be admitted. These prospective clients are likely waiting on several processes, including a response to their initial inquiry, insurance verification, consultation with a therapist, and available time slot for their intake assessment. Minimizing wait time for prospective clients is essential as they most likely are reaching out in urgency at a time when they are already in significant distress.
Solutions to Waiting
Enable clients to schedule directly with you through your EHR rather than waiting for you to confirm availability
Solicit necessary information from prospective clients prior to reaching out to eliminate creation of inventory that requires waiting
Obtain insurance information (date of birth of primary insured, member ID, and provider), best time to call back, preferences for telehealth versus in-person sessions, preferences for time slot in counseling, preference for counseling modality, presenting issues and identified needs in counseling.
This can allow us to quickly identify client needs and properly refer.
For group practices, it may be helpful to cross-train so they do not need to wait on you or another entity to complete a task, which thus increases availability of labor
We can minimize waiting to enter information from the explanation of benefits by using the ERA with our EHR
Automation of tasks to continuously pull data from the explanation of benefits into the EHR and to automatically deposit funds using an EFT will significantly reduce waiting.
5. Overproduction occurs when we create more product than is necessary to meet the demands of our customers. It occurs when we make too much of a product or make it too early. It occurs when we create products for something the customer does not want and/or need. Overproduction may occur when we do not understand the needs of our customer. This may occur because the needs are not clear. This often occurs in our insurance contracts, since the expectations are frequently changing and insurance companies are notoriously poor at communicating what they want from us. It also occurs when we have not properly analyzed our markets.
Examples of Overproduction
We create reports that no one requires or asks for
Reviewing repetitive reports in our EHR or accounting software
Sending consents and assessments that are repetitive, unnecessary, or not required
Including myriad assessments that measure the same thing
including content in your consents that is not relevant
Documenting information that is irrelevant for medical necessity
Purchasing books that you will not read
Training in a modality that is not valued by the people you want to help
Printing excess materials
Writing blog posts that no one reads
Developing groups that no one is interested in.
Solutions to Overproduction
Use a standardized note template
You may also want to use Note Designer
Only print materials on demand
Use tools to set reminders for consents and treatment plans to ensure they are updated at the necessary frequency
Learn the requirements for insurance payers and licensing boards to minimize extraneous information in your documentation and consents
Send only consents that are necessary for your clients
Write blog posts, develop groups, and train with a target audience in mind
I exclusively write blog posts that I expect others will find meaningful or that I can use as a reference. Every post I make has a specific purpose in mind.
6. Overprocessing occurs when we add unnecessary resources to a product. Overprocessing occurs when we meticulously provide detail that does not add value. It is often difficult to identify overprocessing, as many of us attempt to justify our detail-oriented nature and conflate it with value-added processing. This is what makes it so important to understand value in our work. Overprocessing is typically a waste of labor that could be spent elsewhere.
Examples of Overprocessing
Providing signatures to documents/forms that were not required
Spending hours editing clinical notes
Including extraneous content in clinical notes that does not demonstrate medical necessity
Spending significant time composing emails to clients and/or other clinicians
Have you ever feverishly spent hours composing the perfect email to send to a client?
Solutions to Overprocessing
Overprocessing is resolved with simplification
Minimize total processes and tools
This also minimizes opportunities for errors
Clearly understand the board rules and insurance payer expectations
Use templates to keep you focused on what is required in your documentation
We might use checkboxes on our forms for frequently used statements in our clinical documentation, such as interventions and/or levels of risk.
Use scripts for generic emails that you expect to send
Turn on and use predictive texts
Reframe from “this needs to be perfect” to “this needs to be good enough.”
7. Defects occur when our work does not meet acceptable standards, typically meaning we need to rework, repair, replace, or reproduce to correct the error.
Examples of Defects
Telehealth platform is not working
Incorrect invoicing of clients leading to refunds
Insurance benefits check was inaccurate
Client met deductible and/or out-of-pocket maximum
Claw backs from insurance
Documentation does not meet medical necessity
Incorrect coding of session
Exact time of session not entered
Precertification not obtained
Member has secondary insurance
Member insurance expired and/or changed
Claims submission errors leading to rejections
Incorrect demographic information
Incorrect or outdated insurance information
Insurance that you don’t currently accept
Solutions to Defects
Make sure to properly verify insurance
Know the EDI numbers for the insurance providers
Check that insurance has been accurately entered
Don’t charge until you receive the explanation of benefits in order to avoid refunds
Have a backup HIPAA compliant telehealth platform
Establish a Pull System
We establish a pull system by ensuring that our customers’ needs dictate the flow of the work. We aim to limit inventory and work-in-progress (WIP) by performing Just-in-time work. “Just-in-Time” is simple - make only “what is needed, when it is needed, and in the amount needed.” We can establish a pull system by clearly identifying value and eliminating waste in our processes.
Continuous Improvement toward Perfection (Kaizen)
Once we have understood and applied the concepts of lean design engineering, we need to work on continuous optimization. We continuously assess and ensure that our focus is on value-added work. We work to identify and minimize waste. Focus on small, inexpensive changes, rather than large, sweeping changes.
It is important to effectively consult with employees, supervisees, team members, and peers in the field. We need to be mindful when we separate managerial and/or supervisory roles from the employees. We want to ensure employees are given more responsibility to be independent in their work. Empower employees to make changes. Get their feedback. All team members are part of the process of continuous improvement. All feedback is helpful. Listen to your team. Listen to your community. Solicit feedback from customers and employees. Consult. We want to solicit feedback on how to make improvements since everyone becomes an expert in the work they perform. My hope is that all therapists learn about lean design engineering and apply it to their practices, which should add value to our profession and minimize the unnecessary waste that’s become the status quo.
