Have you ever measured the length of a procedure enough times to know how long the procedure takes?

Is once enough to understand how long the procedure takes?

What is the range of time the procedure takes?

Lots of questions whose answers could help with scheduling.

I recommend that you:

• Measure a procedure 25 times to get a statistically valid measure. 25 is the “rule-of-thumb” for statistical validity.
• Average those times.
• Take the longest and shortest to get the range of time for the procedure.
• Have your assistant measure the time for restorative care, and the hygienist for their work.
• Have the assistant or hygienist note the total time in chair for the patient.
• Have the assistant or hygienist note the amount of time required to clean and set-up the opertory for the next patient.
• Have the assistant or hygienist note the total time the doctor was in the opertory.
• Have the assistant or hygienist note anything unusual about the procedure (good or bad).

Once you have collected and analyzed the data of 25 repetitions of the procedure you are in much better shape to make informed decisions about your schedule. Further you have established a baseline to which you can compare potential process improvements. You may also notice waste in your processes and procedures. If you eliminate that waste, you can re-measure the procedure to make sure you made an improvement.

The conclusions are two: variance causes waste, and variance is costing you money.

The question is whether you can do anything about the variance.

I know that many of you will say that variance is caused by the specific circumstances and physiology of the patient. I won’t argue. My experience “standing in a circle” has produced evidence that many practices induce variance into their processes through disorganization, inattention to detail, not taking the patient’s point of view, and so forth. So what did I see?

• I saw assistants going from opertory to opertory searching for needed items. This costs time and adds to variance.
• I saw staff not knowing what was required for the procedure. This costs time and adds to variance.
• I saw staff not planning for contingencies. This costs time and adds to variance.
• I saw staff waiting for the doctor who was on the telephone or computer. This costs time and adds to variance.
• I saw extra time necessary to explain post-procedure instructions to patients because the instructions were not delivered from the patient’s point of view, so the patient did not understand. This costs time and adds to variance.
• I saw assistants moving small inexpensive items from opertory to opertory because not all opertories were setup similarly and the patient was put in the “wrong” opertory. This costs time and adds to variance.
• I saw assistants searching through the drawers in the opertory looking for items, when they were in an opertory that wasn’t “theirs”. This costs time and adds to variance.

   

Not all variance can be eliminated. But much can be. You will have to involve your staff in the measurement of procedure time, and the identification and elimination of causes of variance.
 

You can be assured that the reduction of variance will pay long term dividends to your practice, to you and to your staff.

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.