Working with the Clock: A Lesson in Scheduling
A couple of weeks later, Brian and Jen were sitting on their deck reading the morning paper and enjoying a few rare moments of relaxation. Occasionally, they would look up to watch their daughters playing on the swing set.
They were discussing the lessons of the past few weeks. Jen was curious about how Lean and Six Sigma were working for Brian’s practice. She had noticed a continuing improvement in cash flow but worried that if they moved their standard of living to a new level, they’d come crashing down if business fell off. After sharing her concerns with Brian, she relaxed back into her lounge chair and listened to Brian’s tale of the past few weeks.
“You know what’s really amazing?” Brian asked, excitedly. “In spite of her accident and months of rehabilitation, Sharon came back to the practice and immediately picked up on this task manager stuff. She’s ruthless. And Melody demanded that she be sent to some training classes, and she’s become our resident Lean and Six Sigma expert. She’s taken two courses and read a few books, but no one’s pushing her. She just seems to be a natural. Melody had always wanted to go to college but got sidetracked with family and responsibilities. Yesterday, she told me she feels that she no longer has just a job but more of a career.”
“So did you achieve anything tangible with ‘quality’ yet?” Jen wondered. “I thought Liz was supposed to be checking up on you last week.”
“She was supposed to do that last Friday, but she got the flu and postponed. She’s giving us till next week to show those tangible results you mentioned. But I think we did make some progress. It’s still a little early to tell because we haven’t tracked the outcomes long enough, but the trend looks really good. I took on lab errors. We deal with two labs, and as you know from working in the office, we have ongoing problems with both of them. Melody did almost all of the work in defining the problem and measuring the results and the variables that are critical to the outcomes we want. Then she set up a meeting last week with both lab owners. I went with her, and I think it went pretty well, although in retrospect I have a feeling things could have gone a lot better if we weren’t so confrontational with them. It probably would have been enough to just share the data that she had been measuring, but there was definitely some finger-pointing that went on. They listened, though, and we worked something out that we’re trying now.”
“Wasn’t Liz going to give you some suggestions on dealing with people? What did she call it—‘the human side of a dental practice’?” Jen asked.
“She will, but her next topic is scheduling. She’s left human behavior for last.”
“Why? Do you think she did that on purpose?” Jen wondered.
Brian pondered the question for a few seconds and shrugged. “With Liz,” he answered, “there always seems to be an organized approach and a reason for attacking things in a certain sequence. You’d think there was some deep underlying psychologic structure, but her approach is based on common sense. Maybe human skills take a little more time to learn and practice and become good at. So she probably wanted us to be energized enough by other successes so we would be willing to invest the time in people. Anyhow, I’m really interested in hearing what she has to say about scheduling. We definitely have some problems there.”
Jen was well aware of the scheduling problems from previous discussions with Brian. He had tried different approaches over the years, but never came to a permanent solution for the scheduling issues he faced. “What are some specific things you want to address?”
Brian put his paper down and leaned forward in his chair. “You know, I just switched to the automated web-based scheduling and accounting software. It has all these great features like online charts, web-based patient interactive services, email reminders to patients, and daily reports, but it’s missing the holistic scheduling approach.”
“What could possibly be missing from that wonderful software that has all of those amazing features?” Jen asked sarcastically, her disdain for all things electronic showing.
“You’ve said before that ‘wonderful software’ is an oxymoron, and you’re right. The dental scheduling software we’re using is not very intelligent. It doesn’t know that we can’t do three fillings in a row!” They laughed, then Brian thought for a moment, struggling to verbalize the scheduling issues he was confronting in simple terms. He began by asking Jen, “What do you think should be the primary goal of a dental scheduling system?”
Jen responded, “Of course it’s got to keep you busy—not waste your time. You’re the highest paid, critical constraint, right?”
“Yep. So how do you think a typical scheduling system tries to do that?” Brian asked.
“By showing all of the available time and filling it in as much as possible.”
“Right,” Brian said. “Our software does even more than that. It gives you all kinds of sophisticated ways of calculating procedure times. I do various procedures that can take a long time or a very short time. Ideally, the software should coordinate patient appointments based on my pace. For example, if it takes an average of 20 minutes to have a patient ready for root canal treatment, the software should also warn the assistant to start 20 to 30 minutes before I finish the first procedure on a different patient. The software doesn’t do any of that, so my scheduler has to figure all of this out on her own. If you let the software take over completely, even let patients book whenever they want to on the web, it can quickly become a scheduling disaster.”
“Brian, you paid more than $5,000 for that scheduling module! What good is it?”
“It’s a tool. It’s really helpful to my scheduler, but the hard part is for her to be able to squeeze more out of my time as the constraint without rushing things and sacrificing quality. There’s a lot to consider. For example, patients need to be completely prepared for each procedure by the time I’m ready, and I should never be rushed during one procedure to get to another one. And every patient is different. Some cases require more of the assistants’ and hygienists’ time and very little of mine, whereas others are just the opposite.”
“All of this sounds so complicated. I thought Rich said you needed to simplify things to squeeze more throughput out of your practice.”
“You’re right. But to schedule so that my time isn’t wasted, we need spare capacity in the assisting staff. If one staff member is behind in her work or falls ill, other staff members need to be prepared and capable of filling in to protect my time.”
“Have you discussed that with your staff?” Jen wondered.
“I’m just starting to understand how much resistance there is to this change. I had my first meeting with them last week. I made the mistake of suggesting my solution before getting their agreement on the problem. I talked about cross-training and told them they had to start working together and sharing information more. Boy, did I ever get a negative reaction to that. I learned a good lesson about buy-in. It’s exactly the way Liz described the layers of resistance when she talked about sales.”
Jen winced and asked, “Do you think you can recover from your mistake?”
“Yeah,” Brian replied. “I apologized to them for pushing my solution and asked them to think more about the problem. We’re having another meeting this week. But the focus won’t just be on cross-training to protect my time. We’ve already started talking about the need for having enough examining rooms and making sure that they are freed up and ready very quickly so that the assistants can bring in more patients and start working on them before I see them. This will avoid my wasting time waiting for examining rooms to free up. However, if I’m short of assisting staff, it wouldn’t do any good to have more examining rooms. We also need to be careful about scheduling too many patients at once, which will make the office chaotic and increase the wait time.”
Brian paused to reflect on everything he had told Jen so far, then said, “So when I finalize my new office space in a few months, I’m thinking that for another $600 to $800 per month for an additional examining room for myself and the new dentist, together we can generate another $10,000 to $15,000 per month in additional throughput, maybe more. With one extra assistant between us, we can probably double that.”
Brian and Jen were both quiet for a few minutes, thinking through the logic of what Brian had just described. Brian continued, “I’ve also started to build some knowledge about scheduling logistics from Rich. He told me about a concept called buffering. Let me ask you something—if all my appointments are filled in for the week, does that mean I bill a full week?”
Jen answered, “Actually, if all the appointments were filled in, you would probably have a combination of chaos and downtime. I’ve worked in your office, remember? You have some emergencies almost every week. You also don’t take exactly the allotted time on some procedures—sometimes longer, occasionally shorter. And then you always have last-minute cancellations, especially on Mondays.”
“So what you’re saying is,” Brian summarized, “if I have all of my appointments filled in for a week, I never bill exactly a full week, and I never have time to premium bill emergencies, right?”
Jen started to nod, but then queried, “What do you mean by ‘premium bill’?”
“If you were out of town attending an important meeting with a client and you fractured or chipped a front tooth, what would you do?” Brian asked.
“Well, if it looked really bad,” Jen said, “I would probably cancel the meeting, come back home, and try to get the earliest appointment I could to get it fixed.”
“Do you know what that would cost you?”
“Well, there’s the stupid $150 change fee that the airlines charge. And I would have to reschedule my trip—so easily a few hundred dollars.”
“So if you were going to pay $150 to your own dentist, would you be angry if you were asked to pay $250 for a four-hour response from a qualified dentist in the area?”
“Honey, I wouldn’t be angry. I would be relieved. I’d still be saving at least a couple hundred dollars by not having to reschedule my trip.”
“Exactly. You’d be willing to pay more, and a dentist would be willing to leave some extra room in the schedule for such short-notice procedures if they would bring in a bit more than a regularly scheduled procedure. That’s what I mean by ‘premium billing.’” Brian continued, “I think that there are two main objectives of a buffer: Protect the patient, and protect the dentist. I haven’t seen one software system yet that includes a holistic way to meet those goals. Protecting the dentist means that the dentist must always have billable work to do, and a buffer of time must be built in to allow for emergencies and premium billing. For the patient, the outcome duration should be minimized, as should the waiting time per appointment.”
“What do you mean by ‘minimize the patient’s outcome duration’?”
Brian answered, “Well, say a patient needs a crown. It could take two weeks from start to finish or it could take three months. I’ve had both experiences. I think a scheduling system should help me complete all of the procedures in the minimum number of days or weeks. If the limiting factor is the patient’s schedule rather than mine, then the pati/>