The Lean Practice Coach

Maybe the fundamental practice of Lean is eliminating waste. Whether you recognize it or not, waste is a part of all processes. Where do you look? Where do you start? First you should recognize that only a small fraction of the total time and effort in any organization actually adds value for the patient. By clearly defining Value for a specific product or service from the patient’s perspective, all the non value activities – or waste – can be targeted for removal step by step.  For most practice activities only 10% of activities add value, 40% are necessary non-value adding activities and 50% add no value at all. Eliminating this waste is the greatest potential source of improvement in practice performance and patient service. Processes are reorganized so that the service flows through all the value adding steps without interruption, using the toolbox of lean techniques to successively remove the obstacles to flow. Activities are synchronized by pulling the product or service from upstream steps, just when required to meet the demand from the patient. Synchronizing flow starts with reorganizing individual process steps, but the gains become truly significant as all the steps link together. As this happens, more and more layers of waste become visible and the process continues towards the theoretical end point of perfection, where every asset and every action adds value for the patient. In this way, Lean Thinking represents a path of sustained performance improvement – and not a one off process improvement.

Taiichi Ohno was the person who wrote “The Toyota Production System”. This book was the documentation of years of effort in analysis and development of the basic principles of Lean. He, of course, had applied those principles to manufacturing at Toyota. We abbreviate the Toyota Production System as TPS.

As Toyota grew, Ohno needed to train new people in TPS. One of the techniques he developed was called “standing in a circle”. This exercise was used by Ohno to train new members. This is part of the philosophy of “Actuals” which means go and see at the actual workers doing actual work at the actual place of work. No “desk studies”! The technique involves standing in a circle drawn on the floor and observing the activity all around. While in the circle, the person/student continuously asks the question, “Why?” Many times the student will have to go through the 5 Why’s (another post) to completely understand what is going on. The intent is to observe and understand. Analysis can come later.

If something has been done the same way for the last 1 or 2 or 20 years, don’t just accept it. Is it really the most efficient way? Is there any waste to eliminate? People often stand for 8 hours or more before they are satisfied that they have seriously understood the process(es) and seen the waste. During the circle exercise it may be best to simply acknowledge that the waste exists, without the need to explain it or try to figure out how to “fix” it. If the standing in a circle exercise is taken seriously, the amount of waste observed can be overwhelming. A common reaction is to immediately seek out solutions to remedy the situation. However, a thorough understanding of the situation is necessary prior to beginning corrective action. Standing in a circle for many hours will allow that thorough understanding.

I have used standing in a circle to great effect in the practices I’ve helped. When I’ve presented the results, the doctors have been amazed. Typically there is some amount of disbelief at the amount of waste in labor, facilities, and time. Once comprehension is achieved, improvements can be formulated, discussed, evaluated and implemented.

Every business, to some degree, takes on the personality of its owner or chief executive. I’m sure most private business owners wouldn’t have it any other way including professional dental/medical practitioners. After all, the business is “theirs”. They started it, they invested in it, and they grew it. Much of themselves is “in” the business.

One of the rewarding things about mid-life is that we can begin to see ourselves as we really are…we finally get to know ourselves. Unfortunately, we find out we’re not perfect and we all discover things about ourselves we wish would be different. Similarly, virtually every private business owner will come to see some aspect of their personality that has been reflected in their business they wish was different than it is. In the early years of a business’s existence that isn’t necessarily bad or a disadvantage. As the business grows, develops and matures, however, some of these personality aspects can become limiting. That is probably the primary reason entrepreneurs end up backing out of the operation of businesses they have created or selling them outright. The wise entrepreneur has the insight to understand their own limiting affect on the business (or simply want to get rich quick by cashing out).

This dynamic of personality overlapping into the business applies just as strongly to dental and medical practices except for the backing out or selling out part. That isn’t as readily available as an option to medical professionals because they themselves are, for the most part, the business. So the dental/medical professional’s dilemma becomes overcoming their own recognized limiting impact on the business without leaving it.

I have been really impressed by the desire, of every medical and dental professional I’ve met, to stay concentrated on providing the best medical care to the patient, so concentrated, in fact, that the practice can suffer. Recognizing that the “practice” is a business entity and dental/medical service is a professional calling seems to imply that focusing on one will necessarily take away from the other. But, it doesn’t have to be that way. The key is to make the practice business operating systems “unburdensome” to the delivery of medical and dental services.

Fortunately for the dental/medical professional, there are many well developed business operating principles that can be applied to private practices. Most of these principles have been developed in large industrial settings so it is not readily obvious that they may be relevant to smaller professional service types of businesses. These “world class” and “proven” business practices are not pie in the sky strategic directions or broad concepts. They are the “Lean” and “Total Quality Management (TQM)” methods.

Lean and TQM methods focus on how to get actual tasks done more efficiently and predictably. By putting these proven Lean and TQM methods in place, the day-to-day operation of a medical/dental practice can be structured, organized and predictable so the medical professionals don’t have to worry about them. The key aspects of the practice can be set up to provide visual indicators or cues to the staff and owner of the practice. Are we running out of a particular supply or not?….Are our overdue receivables in control or they growing?….Are our bookings 3 months and 6 months out stable, going up or going down?…etc., etc.

Structured, visual day-to-day operating systems can take these and hundreds of other concerns off the mind of the practice owner so nothing stands in the way of the dental/medical professional focusing on delivering quality patient care. On top of that, in every case, the application of Lean methods has a positive impact on the financial bottom line of the practice.

Written by Robert Angeli.

This morning had the privilege of taking my daughter to the oral surgeon to have her wisdom teeth removed. The intake process was pleasant enough, she went to the operatory, and I settled into the waiting room while the surgery was taking place. I opened my computer to work, and looked for a Wi-Fi connection. The office had wireless, but it required a security key to access. I went to the front desk to ask if wireless was available. The FD person looked up after a minute, said “no” and looked back down at her paperwork.

I found the interaction unsatisfactory.

On the one hand, I understand if the practice doesn’t want to offer Wi-Fi. On the other hand, the FD person could have been more sociable. The oral surgeon has a practice where return customers/patients are less important than at most practices, so maybe it doesn’t matter. If my daughter’s primary dentist asks “how was the experience at the oral surgeon’s office?”, the answer will not be as positive as it might have been.

The questions I would ask this oral surgeon include:

1. What is your standard for customer interaction?
2. Is the person who sits in the waiting room, and pays the bill a customer?
3. Have you thought about the customer experience of those who wait? (beyond the radio playing and magazines)

Customer Satisfaction is Lean Principle #5. In this and the next post we will explore customer satisfaction, and what it means to you and your practice.

First, what is a customer to your practice?

• Are customers the patients that walk in the door?
• Are customers those who receive services from the practice?
• How about you? Are you a customer of the practice?
• How about your staff? Are they customers of the practice?

I would use Webster’s definition as a logical starting point: 1) a person who buys, especially on a regular basis; 2) a person with whom one must deal. The U.S. GAO defines customer as groups or individuals who have a business relationship with the organization–those who receive and use or are directly affected by the products and services of the organization. Customers include direct recipients of products and services, internal customers who produce services and products for final recipients, and other organizations and entities that interact with an organization to produce products and services

Are patients the only customers of the practice? No, the dentists and staff are also customers of the practice. So are specialists, such as oral surgeons and so forth. I’m sure that your practice has many customers other than patients. A practice will have a number of customer types such as types of patients, types of staff (less position than temperament/motivation), types of specialists, and so forth.

What kind of customers do you want?

• Rich and famous?
• Elderly?
• Pediatric?
• Families?
• Industrial?
• Cosmetic?
• Restorative?
• Pleasant and competent coworkers?
• Entrepreneurial/self-motivated or “employee”?

As you have already noticed, we can’t begin to talk about customer satisfaction until we know who are customers are. Until we understand who the customers are by type, we cannot design processes to satisfy them. Another way to look at this is until we understand what kind of customers we want, we can’t design processes to attract and satisfy them.

Lean Principle #5 is Customer Satisfaction. There are a number of questions that could be asked about customer satisfaction; What is customer satisfaction? How do we measure it? How do we improve it? and etc. All of the other Lean Principles serve the principle (and goal) of Customer Satisfaction. We define the various dimensions of customer satisfaction as in the following table:

What are your goals for the patient experience? How do those goals translate into measureable outcomes for your practice? Should you have a set of standard practices for… greeting patients? …for seating patients? …for taking payment? …for taking x-rays? … for answering the phone? and etc.