When you hear about waste in health care these days, it seems often to be in the company of fraud and abuse, as in the FBI's warm invitation, “Anyone with information on health care fraud, waste or abuse may … call the HHS-OIG hotline, 1–800-HHS-TIPS.”¹ I'm not sure what the Inspector General would think if I turned you in for waste, but don't worry. Your secret is safe with me.

I know you're not committing fraud, and you're not trying to abuse the system (quite the contrary!). But that's not the point. The point is that your practice, no matter how big or small, is almost certainly wasting a truly astounding amount of money and other resources – money and resources that belong to you, your patients and your staff.

Routine waste

Your practice is reasonably efficient, you say? Let's see. Have any patients recently not kept their appointments? Every DNKA is a waste of capacity. Do you ever spend time looking for a chart – or waiting for one? You could be seeing more patients or spending more time with the ones you have. Do you ever wait for anything – maybe a chaperone, your nurse, a lab result, a patient, an interpreter, a large-arm blood pressure cuff, a consultant's report, a phone call or an instrument tray? How about waiting for a claim reimbursement? Time is money, and that's all money down the drain. And do your patients ever wait for you? Their time is money, too, of course. And don't forget, it's their money you earn.

Does anyone in your practice ever make mistakes? Do you ever have overexposed X-rays, dirty claims, uncollected co-pays, misread prescriptions, lost lab reports, missed diagnoses, transcription errors or drug interactions? More waste – wasted effort, wasted time, wasted opportunity, wasted health, wasted money.

Do you have any underutilized space, equipment or personnel? Do you have money tied up in a stock of supplies? More waste.

Questioning assumptions

I could go on. I haven't even asked you about unnecessary tests or treatments or about staff overtime necessitated by your running late, for instance. Or unnecessary paperwork! Anything that takes up space, time or effort without doing anyone any good is waste.

I can well imagine that all of this is frustrating. If it seems merely frustrating, something may be wrong. Perhaps you have given up the battle, conceding that a certain amount of waste is unavoidable even in the best run practices. Maybe so. On the other hand, it seems pretty clear that nobody currently knows how the “best run practice” should be run. There's no evidence that we've seen one yet. And even if it is true, the idea that some waste is inevitable has very little to do with any given example of waste. The question is whether that particular waste can be avoided, and the problem is that we're all too ready to conclude that it can't.

Pessimism seems justified by experience. If you look for them, you can find numerous examples of waste that persists despite attempts to do things better – to increase efficiency – even of waste created by attempts to do things better. But you can also find examples of waste that vanished when someone gave up trying to do it better and decided instead to do something different.

Try reading the articles in this issue on improving patient flow (page 45) and using walkie-talkies (page 55). I would be surprised if they don't make you think of ways to reduce waste in your practice. But they're still mostly about doing things better; what they can help you get rid of is minuscule compared to what's possible. For a real eye-opening experience, read Lean Thinking, which is mentioned in the reading list on page 50. While the book deals mostly with manufacturing, it's a good read and an excellent demonstration of the human propensity to ignore waste –mountains of waste – just because our preconceptions make it seem inevitable. Once you've digested the book and thought about how its insights might translate to health care, you'll be ready to go back to some of the articles FPM has published on quality improvement and the Idealized Design of Clinical Office Practice (for more information on IDCOP, see www.ihi.org/idealized/idcop/index.asp). And you'll be better equipped to start rooting out the hidden waste that's choking your practice and your income.