Q: Let me first say thank you for your interview with Dr. Bahri. It was most interesting and informative. My question has to do with managing production time of the dentists. Dr Bahri has stated that his core unit is the hygiene appointment. If you do not know what restorative needs your continuing care hygiene patient is bringing to your office, and her or his expectations are that your will resolve what ever needs that they have at that appointment how do your organize effectively the doctor’s production so that he is always productive and on time?

A: Dear Lawrence,

We focused on hygiene because we decided to shift our attention to making to patient’s time as the basis for our scheduling, instead of the doctor’s. Hygiene and general dentistry appointments became synchronized in the same chairs. If the hygiene department were still separate, we would have to analyze the hygiene process separately from the dental processes.

The dentist stays productive by treating one mouth at a time. For instance, I have worked all day today on one patient, in one chair, with one assistant. The patient took a few breaks where I did some hygiene exams, and simple procedures. The patient’s whole mouth is treated and he will come back for cleanings and checkups only.

So how can we stay productive and organized if we can’t anticipate the patient’s need after the hygiene exam?

Since we work in long appointments, several things could happen during the visit. The most frequent is finishing early. We need to give the patient breaks to rest, and some parts of the treatment can be delegated to the assistant. If the patient needs a cleaning, the hygienist will come to the room and clean their teeth. We also have cancellations, unfortunately, or patients deciding to have less work than previously planned. You would probably find more instances where unpredictable variation strikes. All the above allow the dentist to have some time away from the chair without interrupting the patient treatment.

To take advantage of that time we utilize three factors:

1. Short setup times based on the SMED principles of internal and external setups.
2. A Flow manager, rearranging the schedule constantly to meet the changes in demand
3. A Kanban pull system where the flow manager directs everyone, dentist included to the most useful processes.

It might sound complicated, but in practice it is much slower in pace than batch management and the dentist is much more productive.

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Q: From a patient perspective, if I have a cleaning, I know to carve out an hour from my day. Do your patients ever say, “No, I’ll have to come back a different day” because of work schedules, etc. if you find a cavity, etc. during an exam? I know your goal is to do it all in a single visit, if possible, but that’s mostly driven by patients who prefer to not come back, I assume?

A: The strength of Lean is that it makes it possible to offer same-vsit treatment to our patients. We do not try to force it upon them obviously.

Yes, some patients prefer to come back; we accommodate that too.

We also have cases where it is not indicated to do a lot of work at once:

1. Age: young or elderly.

2. Health conditions

3. Financial limitations

4. Just preferring a slower pace, etc.

But the majority of our patients, over 90%, prefer the same-visit treatment.

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(http://blog.kanban.com)

As the management of the practice is rarely a consideration in the education of medical professionals (I think she had one class on practice management), this is likely fertile ground for process improvement.

Neil

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