The Working Vacation : Learning to Be Lean
It was late February, and the three couples were sailing around the Caribbean. The first stop was Tortola, a town in the British Virgin Islands that was two days away. Joe and Brian had agreed to spend an hour each day in the ship’s conference room working on practice improvement with Liz, the Lean and Six Sigma expert. Meanwhile, Rich, Jen, and Barb kept themselves busy shopping and spending time in the casino on the cruise ship.
Liz knew she wouldn’t have enough time to transfer even a thin layer of her knowledge of Lean and Six Sigma to Joe and Brian. Her challenge was to give them enough to get started. For Liz, “enough” meant that Joe and Brian would be able to carry out her instructions and reap such significant benefits within a week that they would be excited to learn more.
As they sat down for their first meeting, Liz began, “Why do you think Rich and I waited until now to introduce you to a new methodology?”
Brian laughed and answered, “Geez, Liz, I knew this session with you would be challenging, but I never thought you would start off with such a tough question! I guess it’s because, for both of us, our constraint in the beginning was sales, so you wanted us to learn to use the Five Focusing Steps first, right?”
Liz nodded, saying, “Correct. Now both of your practices are limited by your availability. Your mission is to squeeze more out of the biggest constraint of your practice—your time—to improve net profit. By the end of four weeks, using a combination of the Lean and Six Sigma techniques, you should be able to find one hour per day of additional capacity. This means you will be carefully documenting all those times during your day when you are not actively working on a patient. Squeezing out this extra hour per day will not require anyone to work more hours or undergo more stress.”
Joe interrupted. “It seems like, with all the new business we’ve gotten in the past few months, I’m with patients all day long.”
Liz nodded, “You are spending a lot more time with your patients. But being with patients and treating patients are two different things. How much time do you spend waiting for something—a chart, an x-ray, an instrument, a computer? How often are you manually writing down notes rather than dictating them to an assistant? How many wasted steps are there in some of the procedures you commonly do?
“In Lean, these areas where you can gain more capacity are described as seven different forms of waste, called muda in Japanese. I’ll give you the complete list of these at the end. But I’m not trying to transform you guys into Lean experts. I just want you to take a very simple, common sense approach to this. Lean, Six Sigma, the Theory of Constraints—all of these methods are ways of thinking more holistically about your practice. I want you to go to your practice, document, and learn. If you benefit within a week, then that will drive you to more reading and learning.”
Liz wrote on the whiteboard:
Where to Apply Lean
- Inputs—Full kit (space, patient, instruments, equipment, supplies, insurance approvals, assistant, in formation)
- Nonproductive Activities—Gaps that waste dentist’s time (eg, breakdowns, defects, poor scheduling, unnecessary walking)
- Processes—Process improvement and delegation opportunities
- Outcomes—Doing things right
- Recording and Analysis
“Let’s start with inputs and the concept of full kit. The idea is that when you are starting your work with a patient, all necessary preparations are complete and 100 percent correct. If anything is missing and you have to wait or take time to go to another examining room and come back again, that is a waste of time. If you have to search for supplies in multiple places, that’s another waste of time.”
Liz showed Joe and Brian some photos she had taken of the organization of Rich’s supplies.
“One way to reduce errors and enable other staff to do full kit preparations is to have a labeled photo and a chart that lists all of the required items, with space next to each item for the person doing the preparation to initial. If you’ve ever been with a patient only to find at the last minute that the crowns you ordered from the lab are not the right material, you can appreciate the full kit concept for its ability to avoid such time wastage.”
Brian asked, “What do you mean by ‘space’ in step 1 there?” He pointed to the list on the board.
“Do you ever find yourself waiting for a room to free up in order for you to continue a procedure or start a procedure?” Liz asked.
Joe nodded, answering, “With our second hygienist, it happens to me occasionally—probably once or twice a day. But I just go to my office and catch up on paperwork and emails.”
“What kind of paperwork and emails?” Liz demanded.
“Usually I’m reading journal articles, sometimes looking at patient inquiries, investments—all kinds of stuff.”
“You see, most of your office time is not generating income, Joe, or moving a patient through an appointment. Even with patient inquiries, when you do them on the fly, grabbing a minute here and a minute there, it can take you 20 minutes to do 5 minutes of work. You concentrate for a couple of minutes on an inquiry, don’t finish it, get pulled away because the patient is now ready, come back to it, and have to take time to get back to where you were, at which point you might get pulled away again.”
Joe sighed, “What am I supposed to do about it?”
“Usually a little bit of forethought in scheduling and making sure your staff understands what you’re trying to accomplish will help immensely. Rich and I will address scheduling with you later. For now, remember that the goal of full kit is that everything is there and correct when you need it so that you and your patient are not waiting or having to do rework. So here are a few suggestions for full kit implementation.
“Make one person in your practice responsible for full kitting your work. Let’s call this person your flow manager. Have your flow manager prepare full kit checklists for each of the procedures you perform. You may want to use pictures for items that are easy to visually mistake for something else. The checklist will be used by whomever is responsible that day for the full kit. Each item will be checked and initialed by the full kit person.
“Allow the flow manager to ask you the hard questions, such as, ‘Dr Armstrong, why are you checking your emails instead of treating the patient? ’ ‘Dr Lerner, is that a personal call you’re taking on your cell phone?’ ‘Dr Small, why are you reading journals during prime business hours?’ You’ll see that you can have fun with this. And when you get this kind of question, respond with a smile and say, ‘You’re right!’
“Let the flow manager know a few minutes before you expect to finish a procedure so that he or she can make sure everything is ready for the next procedure. And have the flow manager note two pieces of information any time there is a delay: what you are waiting for and the duration of the delay. This should be captured in a spreadsheet for analysis.
“When you’re back in your office next Monday and you explain this to your staff, make it a game. Give them points or award a prize for any staff member who can find ways to reduce your wait times.”
Brian seemed puzzled. He said guiltily, “All these things on the board on full kitting seem fairly obvious. My assistant is aware of all this. />