Quality Time : Simplifying Six Sigma
Over the next few weeks, Liz spoke with Joe and Brian every Friday to check their progress with implementing the Lean approach in their practices. She enjoyed these hour-long webcam sessions because she got to hear about the improvements both of her friends were making by using the new strategies. By the end of the fourth week, Joe had increased the time he had available to work on billable procedures by 40 minutes per day. For Brian, the time recovered was a little more than 30 minutes. However, Liz was becoming concerned that Joe and Brian were focusing on learning everything about Lean methodology rather than on addressing their real constraint.
Joe had ordered two books on the Lean system and insisted that Brian do the same so that they could share their thoughts. They were spending a lot of time trying to apply Lean thinking everywhere—in the supply room, with the hygienist, in the reception area, dealing with insurance companies. Liz knew they were off track. It was time for a crucial conversation. So at their final Lean lesson, Liz asked, “Looking back over the four weeks, how much time did you free up each week?”
Joe thought about it, and answered, “From what I remember, the first week was 10 minutes per day; the second week, 15 minutes per day; the third week, 10 minutes per day; and this past week, about 5 minutes per day.”
Brian’s response was similar, but he added, “Except this week, we concentrated more on the supply room.”
Liz tried to hide her frustration. “Brian, if you got the best possible improvement out of this effort in the supply room, what would it be worth to your practice per year?”
Brian thought for a minute, then answered, “I think we have about 50 percent more inventory than we need, which is not always under our control. Some suppliers have minimum order quantities. We also probably throw some materials out because we’re not managing the expiry dates properly. I don’t know for sure. It’s probably a few thousand a year.”
“And how involved are you in this effort?” Liz asked.
“Right now, I’m pretty involved because I don’t have a Lean expert on staff, and everyone is looking to me for guidance.”
Liz felt that the time was right to challenge their current mode of operation. “Let’s go back to the Five Focusing Steps. Step 1 is to identify the system’s constraint—the biggest leverage point for improving your practice and reaching more of your goals. Do you think that the biggest leverage point is in the supply room, Brian?”
“No, of course not. But do I just leave this cost savings on the table and forget about it?” Brian wondered.
“Joe, what do you think?” Liz demanded, thinking it would be better if the right answer came from Joe rather than her. It was a real test of their ability to focus on the right thing and resolve conflicts in a win-win way.
Joe hesitated a moment, then said, “No, this is not where our focus should be; even if we could save some money here, the supply room is not the main point of leverage. Now that the processes are in place, we’re capturing data, and we have some books available for our staff, we should let the staff take over and move our focus toward identifying and squeezing more out of our biggest leverage point.”
Brian added, “I agree with Joe. But I’ve never been good at delegating to my staff. They either don’t pick up the ball or keep coming back to me with the details.”
Liz had similar experiences in the past, so she offered Brian some sage advice. “We’re talking here about the knowledge worker age, about the empowerment of people, and about management and leadership skills. Brian, if you don’t invest heavily in developing some of these skills, I can almost guarantee that you’ll always have a very small practice with significant frustration in dealing with staff. It might be a very successful practice, so please don’t think that you have to be a top manager to succeed. However, your practice will stagnate. There are enough books and courses out there to develop these skills and be able to grow your business with much less frustration and involvement in unnecessary details.”
“So what do we do now, professor?” Brian chuckled.
“Remember that step 1 of the Five Focusing Steps is ‘Identify the system’s constraint, that is, your biggest leverage point,’ which tells you that you must leave some cost reduction and improvement opportunities on the table. We aren’t just looking for weak links; we need to find the weakest link. In other words, our strategy is as much about not doing the wrong things as it is about doing the right things. We already agreed that your biggest leverage point is your time. To squeeze more throughput out of your existing time, I want to talk to you about three concepts: quality, scheduling, and human behavior. We’ll talk about quality today, then I’ll follow up with you on each of the other two during our next two weekly discussions. Just as with Lean thinking, I want to share only a few very basic ideas, so that you’ll have a more scientific approach to quickly address quality issues in your practices. Then, I’m ready to turn you loose again.”
Joe commented, “When we talked about the Five Focusing Steps with Rich a few weeks ago, he said if we thought we could wring only one or two percent more out of step 2, squeezing, we should move on to step 4 and increase capacity. But right now you’re suggesting that you want to spend three more weeks on squeezing more. Do you really think there’s that much more to get?”
“Remember,” Liz began, “both of you have contracted with that retired dentist to find new space and help you find another young dentist to enter your practice. So you’ve already started preparations for step 4, elevating capacity. Is there anything else in step 4 that you need to do right now?”
Both Brian and Joe said no, so Liz continued. “My thoughts on quality, which is our topic for today, go back to some of Dr Deming’s work. He said, and I’m paraphrasing, that before you improve a system, it must be under control to begin with. To Deming, under control meant predictable. I’ve had experiences where, for example, quality was so bad that every time you improved the sales of the company, the quality problems exploded, and the value of the improvements were lost or took more and more labor hours to maintain. I’ve seen situations where the communications between people were so poor that the right process improvements were never implemented correctly or they took much longer. People just didn’t care. So I’m intent on giving you the basics in the areas that I believe are essential to the performance of any system, and then you can decide for yourselves which steps to apply when. From my perspective, if it were my practice and I spent a little bit of time on quality or people management before a major transformation, it would not be a waste. It would be establishing the necessary conditions for the Five Focusing Steps to work at lightning speed.”
Joe commented to Liz that the danger he saw was in overprepara-tion or perfectionism—trying to get perfect quality or Lean fully implemented before doing the Five Focusing Steps. Liz agreed. Perfect quality was not an achievable goal. The key was to have enough knowledge to be able to decide what was good enough, and that was Liz’s objective in her focus on quality.
“Remember that whatever level you get your practice to in the next few months is the level you will expose a new dentist to when he or she joins your practice. You already know from experience that I do not believe in giving you knowledge unless you will apply it and benefit from it right away,” Liz said. “What I’m about to share with you is no exception. So the first thing I want you to do is think about how you will apply this knowledge next week and get something tangible out of it. In three weeks, we will come back to the Five Focusing Steps and fit all of this together in a way that makes sense.
“Here are some questions you can ask yourselves to select an issue to work on next week.” Liz brought up a slide on her computer and shared it with Joe and Brian through the webcast.
Guidelines for Selecting a Six Sigma Project
To help you select an appropriate Six Sigma project, ask the following questions:
- What do my patients complain about most frequently?
- Which process is always broken?
- Which process always takes too long?
- What does someone else do better?
- What gives me a headache?
- What do we seem to fix over and over again?
- Where do I take the path of least resistance rather than strive for a solution?
- Which process has a bandage instead of a permanent fix?
- Which process generates the most scrap, rework, or errors that need correction?
Brian wrinkled his forehead. “Liz, does everything we learn need to be wrapped up in jargon? I’ve heard the term ‘Six Sigma’ before, but can you tell me what it means without a big, long lecture?”