Delete the process model


These days are difficult to Portuguese. Portugal is under a bailout from the I.M.F. and the European Union. All my meetings with foreign people start or at some time of the conversation with the famous question: “How you are holding on?” or “How did you got into this situation?”.

Well, the bailout program is helping Portugal  to get again on track, I mean cut costs in order to release funds to pay the debt raised by former governments pharaonic investments. For those that have experience in cost cutting know that there is no such thing as process streamlining. Simply because there is no time for it. Is more effective to cut money, rather than reinvent the process (despite the fact it takes time to do it) cost cutting starts delivering benefits on the same day it commences.

One of the areas that is suffering from cost costing is medical care. Medical care in Portugal “was” or “is” (depends the country you are comparing with) universal. It means that most of the people can have access to a doctor or to a hospital without paying for it or paying around 10€ for exams and CT scans. But this is changing. Today you will pay much more (25% increase baseline, or even more your wage is above the country’s mean). Exams will be restricted (just the absolutely necessary).

The process problem:

Due the universal concept access, the population can see the doctor when they want to. In the biggest cities or in the east part of the country medial centers  have more patients that doctors. Some patients don’t even have a doctor. This creates pressure if you need to be seen by a doctor.

The process have to variants:

  1. You have a “family doctor” (means that you belong to a doctor circle, and you can schedule a visit);
  2. You don’t have a “family doctor” (means that you don’t belong to a doctor circle, and if you want be seen by one you drop by at the medical center and wait). This variant implicates if to many people flock by, the probability of go home without talking to the doctor is very high, unless you wait in the line from 4 a.m. (yes!).

The first variant have only a problem:

  • You need to wait around 6 months to have a slot on the doctor’s schedule!

The second variant have also, only a problem:

  • In some areas, you don’t have medical care.

The constraints of the process are:

  • Unbalanced doctors regarding the patients number (places outnumbered, others are more than the patients);
  • A doctor belongs to a particular medical center and is difficult to put them working where they are needed regarding union pressure;
  • Most of the doctors visits have the objective to get prescription for chronic diseases;
  • Only doctors can prescribe medicines (you can’t change this, it’s the law);
  • Doctors earn more on private sector;
  • Doctors schedule is poorly managed, meaning that it was possible to attend more patients.

Well, looks like the problem relies on the doctors, right? Wrong (don’t read the solution in the end yet).

What you you do to improve such a process? Basically the two main pains are:

  • Reduce the time to get an appointment (in a worst case it can takes 6 months);
  • Provide medical care for those that don’t have a “family doctor”.

I do not want to indicate any improvement opportunities, because all of them are ridiculous when we look to the solution. But you can share you thoughts.

The solution:

A doctor at the Santiago do Cacém medical center implemented this approach:

If you want medical care, drop at the medical center on the day that suits you better. I will provide everything you want. There is no more scheduling, there is no more process.


3 thoughts on “Delete the process model

  1. Alberto, government executed healthcare is not desirable. So that is the initial problem.

    In countries where people can choose their doctors and the insurance pays them it works a lot better. Not ideal but better. Unions are never a good thing in such situations. They complicate the work environment immensely.

    The solution to similar problems has been discussed at length and while it makes sense to just let people drop in on the doctor too when they have a problem, one should make them pay for this visit enough so that they don’t go the doctor unless they have a real need. Make them pay more if they only show up for a prescription. if you let people come when they want they will all show up at the same time causing long waiting times. Charge them by the length of the slot?

    The problem must be solved by Toyota’s Taichi Ono’s flow-of-goods concept. The process has to be ready to execute when the flow comes in. So the solution suggested to let people come in when they want is fine too, but then they should have the choice to go to the centers where there are shorter waiting times.

    Maybe a small online web app (mobile app?) that shows the number of people waiting in each center would do wonders. All patients coming that day must be treated! That will make doctors work faster to go home. Only those with real problems would wait a much longer time others will leave to come back when the queue is shorter. Tune the queuing concept over time. Maybe people can mark that they are going to a certain center online to avoid queuing oscillations. A center with a short time being suddenly swamped and people going there is a waste.

    The prescription issue must be solved by the law. Also in Austria only the doctor can do it, but I am in and out in 3 minutes.I need to pay for the prescription as well, but not the medication.

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