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By Dr. Sami Bahri
Lean Management
Hygiene is undoubtedly the beating heart of a practice. When the hygiene department is busy we are, when it is not, we are not. Thankfully, hygiene is well organized in most practices, but as we like to constantly improve, we want to make it more and more productive.
What will make that possible? Systems thinking; more specifically lean thinking where one views hygiene not as a separate entity, but as a component of a larger managing system of a practice – or even multiple connected practices. Here are a few ideas on how to move closer to a unified management system where hygiene and dentistry are not two separate departments.
Organizing work
The element around which you organize work will determine how you run your hygiene department.
Organizing work simply means that, at the center of the organizing diagram, we place the most important element – the one element around which everything needs to revolve. Change that center element and you will change how you navigate the system efficiently. For a simple analogy, you would navigate the solar system differently if you thought that the planets revolved around the earth, instead of the sun.
In dentistry, we can put either the provider or the patient at the center. This choice will determine how we run the schedule and consequently, how efficient we are. So far we have placed the provider at the center of the dental universe. We have scheduled according to provider time and assistant time – in the hygiene case, according to hygienist’s time. Conversely, the new lean way puts the patient at the center, and organizes the schedule around how much work they wish to do and when. We like to perform all that work in one visit, if the patient conditions allow, and if it leads to patient satisfaction.
In the following paragraphs I will attempt to show the difference between the two schools of thought.
Organizing around the provider
Organizing work around provider tasks is the most widespread concept in business and dentistry today, but not the most productive.
Here, hygiene functions as a separate department. Some even call it a “Profit Center” and manage it as an independent business. Peter Drucker, the legendary management guru, originally coined the term profit center around 1945. He later recanted, calling it “One of the biggest mistakes I have made.” He then asserted that there are only cost centers within a business, and “The only profit center is a customer whose check hasn’t bounced.” 1
In this line of thought, you calculate the department’s production independently from its contribution to the profit of the entire practice. When you make changes or introduce new services, you try to increase the production of each hygienist independently, and when checking the results of that change, you look at the hygiene production report (As we will see later, Lean looks at a different report)
The biggest flaw in this system is that when you improve profit centers independently, they tend to grow at different rates and the whole system tends to become dysfunctional. It is like placing tires of different sizes on a car, or an excessively powerful engine.
Organizing around the patient
If you organize work around the patient experience, you will try to finish the patient’s treatment in one visit. Your schedule will revolve around their schedule.
In such an environment, hygiene cannot be viewed as a separate department anymore, but as one component of the patient’s treatment.
You will study the influence of hygiene on the profit of the whole practice, not only on the hygienist’s work.
If you introduce a change in hygiene, you will study its influence not in the hygiene production report, but in the practice profit and loss statement. The perspective here is more global than when you look at hygiene as a separate department.
You will seek to improve whole system metrics like patient satisfaction, treatment plan acceptance rate, lead time – the time it takes to complete the entire patient treatment.
The most profitable hygiene department is the one that does not exist separately unless the patient needs hygiene treatment only.
There is no problem thinking of hygiene as a separate department when only the hygienist is involved in the treatment – like when a patient needs a simple cleaning, for example.
Any other time, when more than one provider is involved, it would be more profitable to look at the hygiene department as an inseparable part of the entire dental practice managing system. The hygienist will come to clean a patient’s teeth during treatment, in the dentist chair. This becomes even more practical if you use CAD/CAM technology. While the crown is milling and while it is fired in the porcelain oven, the hygienist comes to do the cleaning. That saves an appointment and makes the treatment flow efficiently.
Combining functions in this manner is called “crossing the functional barriers.” It is not to be taken lightly. Talking from experience, I can assert that it is a very important factor in increasing productivity and most importantly, facilitating a smooth flow of treatment, which in turn reduces the level of stress dramatically.
1 (Drucker, Peter F. (2002). Managing in the Next Society. New York, New York 10010: St. Martin’s Griffin. p. 84. ISBN 0-312-32011-6.)
