1. Write down the problem. Grading down the specific problem helps you to describe it completely; it also helps the team to focus on the specific problem.
2. Asked why the problem happens, and write the answer down below the problem.
3. If you have not identified the root cause for the problem you specified in step one, ask why again. Write that answer down.
4. Repeat step three until you or you and your team agree that you have arrived at the root cause. This may take more or less than five why’s to accomplish.

Problem Statement: You are on your way home from work and your car stops in the middle of the road. (I borrowed this example…)

1. Why did your car stop?

– Because it ran out of gas.

2. Why did it run out of gas?

– Because I didn’t buy any gas on my way to work.

3. Why didn’t you buy any gas this morning?

– Because I didn’t have any money.

4. Why didn’t you have any money?

– Because I lost it all last night in a poker game.

5. Why did you lose your money in last night’s poker game?

– Because I’m not very good at “bluffing” when I don’t have a good hand.

As you can see from this example, using the five why’s has allowed the team to arrive at a root cause that can be acted upon. It is much easier to work on root causes than it is to work on symptoms.

Recently, I was in a doctor’s office where the treatment rooms are located in the corners of the office, as far away as possible from the front desk. This Doctor had the habit of walking each patient back to the front desk while talking to them. A quick back of the envelope calculation indicates that the Doctor walked about a mile every day escorting patients back to the front desk. This translates to 20 or 25 minutes of walk time. As it turns out, the office could be rearranged quite easily to reduce the walk time to nearly zero, thus saving the Doctor and the patients time and effort. This is an example of inefficiencies that are “built in” to a practice. If you look, these inefficiencies are everywhere.

To build and increase practice volume and production requires sustained effort which requires energy. I will assert that part, but certainly not all, of the problem in these offices was the atmosphere that the music helped create. We all know that colors in the office are important, as well as layout and furnishings. We also know that the demeanor of the doctor and staff also are important. I think that some practitioners have neglected to thing carefully through their music selection. Instead of the calm and relaxing atmosphere they may have wanted, they got depressing instead. In one of the offices, one of the patients commented negatively on the music while I was there.

If you do a Google search on “music atmosphere restaurant” you can find articles that have quantified the inclination of patrons to spend more when the right kind of music was on. Googling “music atmosphere dental office” gets some hits on the same subject, but without quantification. In short, the restaurant article found that “Classical, jazz and popular music were associated with patrons being prepared to spend the most on their main meal.” [http://pom.sagepub.com/cgi/content/abstract/31/1/93]

In the café I frequent, they play classical and jazz. Upbeat, not slow. Happy not sad. They are busy.

I have one client who manages and plays the music in his office from his computer, via playlists and music ripped to his computer. He wants to make sure the music is appropriate and wants no commercials. If you want the technical details, please contact me.

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.

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.