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By Dr. Sami Bahri, DDS
Creating systems, dividing appointments into doctor time / assistant time, and establishing arbitrary financial goals are three important concepts that have guided dental management for decades.
Inherently, there is nothing wrong with those three concepts. Nonetheless, advancements in management have led to better results in quality, efficiency, and financial outcomes.
In dental treatment, we easily replace older techniques, like silver points as root canal obturators, with newer ones, like gutta-percha, when we see better results. It is probably time to do the same with the three concepts.
Improving how we think about systems
Lean thinks about systems differently from the way we were taught. We grew used to creating many systems – hiring, training, scripting, scheduling, leadership, production, new patients, hygiene recall, overhead control, treatment presentation, marketing and customer service, etc. And, if they function as intended, we consider the practice optimized.
These systems orbit around the main provider, the dentist. We like to see the dentist always producing dentistry even when assistants, hygienists and patients are waiting, while salaries and rent are paid for wasted time and space.
In this management system, managers sets the rules; and although employees have little influence on making those rules fit the changing work environment, they are expected to follow them.
In lean thinking, we create one system – the entire business. The systems of the previous section become its subsystems. Practically, it means that if we make a change in our hygiene policies, for example, we measure how much the entire practice has improved as a result of that change, not only the hygiene department. That is very important, because you could worsen the global performance if you focus your resources on helping one department – hygiene in this case – at the detriment of others.
In lean thinking, even if our management works as intended, we know that 90 percent of our activities are wasted; they become the team’s target for relentless improvement efforts. In other words, a well-functioning system is only a start for improvement, not an end.
Why is the difference important? The way we measure performance is different. As we have seen above, in the multiple systems concept, each system tends to be improved separately. This will not necessarily improve the global performance of the practice. In the lean, we separate whole system metrics from subsystem metrics. We make sure that changes benefit the global performance first. The subsystem performance is always at the service of the global performance.
As a consequence, the allocation of responsibilities is different. Paradoxically in the multiple system methodology, employees are responsible for financial performance while they have no authority in changing the environment. In the lean methodology, we think that financial performance is the shadow of process quality. If you want to improve your financial results, you improve processes by removing waste. You relentlessly create consecutive “strategic target conditions,” continuously enhancing production conditions to improve cost, quality, safety and timely delivery. And, you constantly encourage your people improve their knowledge and skills.
Divide the appointment into doctor and assistant time
This is the second technique in our discussion. It utilizes the “time studies” created by Frederick Taylor and the “motion studies” created by Frank Gilbreth. It seems very efficient, but in reality, it consumes more resources than lean production techniques – more time, labor, space and cost of materials.
To increase productivity we need to understand the following: If we can perform all the patient’s treatment in one visit, any additional visit is waste. Excepting the treatment performed on the mouth, everything else is just a duplication of the previous appointment’s support functions – preparing the operatory, greeting patients, double checking the treatment plan, writing notes, prescribing medication, collecting, checking and filing insurance, making a new appointment, etc. When we apply doctor time / assistant time to those steps more than once, all we’re doing is producing waste efficiently. In fact, eliminating this redundancy in support functions is probably the main improvement that lean has offered over the current multiple appointment scheduling systems.
Establish arbitrary financial goals
This is the third technique in our discussion. We all agree that management needs to establish financial goals, but as W. Edwards Deming has thoroughly explained, it would be counterproductive to either force or incentivize team members to reach them. Deming said that every system is designed to produce a certain amount of treatment, regardless of goals or incentives. Unless we improve the system itself, it will not be capable of producing more.
Thankfully, dentistry offers many opportunities for improving systems. The main opportunity is to reduce the number of appointments needed to finish a treatment plan. We can also set what in his book “Toyota Kata”, Mike Rother calls “strategic target conditions.” For example, instead of asking the team to meet a financial goal, we can ask something like the following: “When the assistant is busy with a patient, I am not able to start a root canal treatment because the instruments are not available in the operatory. Where can we place them so I can start the root canal without help?”
This new condition improves the system and helps to increase productivity. With some discipline to place instruments and supplies in the new location, the improvement becomes permanent, with no need to constantly motivate people or artificially incentivize them.
Strategic target conditions
Lean management can help to improve all three techniques in the following manner:
- Creating systems is good practice, but we have to make them work together to serve the main system: the entire practice performance.
- Using the doctor’s time and assistant’s time is extremely productive as long as we are not performing more appointments than necessary. In that case, except for the direct treatment, the appointment itself becomes waste.
- Establishing financial goals is for upper management. As the responsivities trickle down to hygienists and assistants, they should focus more on improving “strategic target condition” than on financial goals.
I hope that you found this article useful. If you have any question,s please email me at: [email protected]
