The issues of practice management, as seen through Dr. Demings glasses

Dec. 1, 1997
Editor`s Note: Due to space considerations, this series about Dr. W. Edward Deming`s business philosophies, as applied to dentistry, will be presented in three sequential sections in upcoming issues. The article below is, "Act I: Pre-Examination." In the following issues, we will present "Act II: The Clinical Examination," and the last segment will combine "Act III: The Treatment Plan" and "Act IV: The Prognosis."

A four-act play by

Drs. Lowell Dawson and

Steve Cheek

Editor`s Note: Due to space considerations, this series about Dr. W. Edward Deming`s business philosophies, as applied to dentistry, will be presented in three sequential sections in upcoming issues. The article below is, "Act I: Pre-Examination." In the following issues, we will present "Act II: The Clinical Examination," and the last segment will combine "Act III: The Treatment Plan" and "Act IV: The Prognosis."

In the first act, Dr. Deming takes the management health history of the client. In the second act, we present Dr. Deming`s own management examination. The third act takes us down Deming`s road to continual improvement, per the treatment plan. The finale is the "prognosis" which, through examples, lends meaning to Dr. Deming`s questions.

The theatrical flair of this presentation is intentional, and it hopefully will offer insight into the methods espoused by Dr. Deming.

The aim of this article is not to judge anyone`s present management approach. Rather, it is to help make you, the reader, visualize a scenario. In our scenario, you have retained Dr. W. Edward Deming to help improve the management quality of your office. The article suggests a series of questions that would be asked.

The ground rules are rather simple. Unless you have studied Deming, it may be difficult to answer the questions that follow. So, simply relax and try anyway.

This exercise could later serve as the baseline for your management transformation. Hopefully, we can get you involved with a subject matter that management around the world has found so intellectually compelling and self-enlightening. Thus, over the course of time, as Dental Economics continues publishing Dr. Deming articles - covering each of the good professor`s lecture topics - the longer-term aim of mastering Dr. Deming "by putting on his glasses" will be accomplished. You better will understand why this particular article has been presented now.

It has been said, "Half the problem is in knowing the right questions to ask." As you discover what Dr. Deming felt were the real management issues, you are half way to understanding, "The Prophet of Quality." Thus, knowing the right questions to ask begins your own self-empowerment. A true education is based upon acquired knowledge and how to act upon this knowledge, not just retaining rote facts.

Deming management is a thinking individual`s approach to managing. It is not for those seeking cookbook solutions delivered in the form of instant-pudding results. Why? By their very nature, these instant-pudding methods are more like putting fires out rather than preventing fires in the first place. Corporations have used these "instant" concepts to present profitable short-term quarterly reports. In the long-term view, though, they can generate very misleading data as to what a market is really doing.

Dental markets and change

As with all markets, dental markets are continually undergoing change. These changes occur most of the time for reasons beyond the control of one`s personal influence and abilities. An example would be that of a huge, new industry developing or moving into your area. Certainly, it did not start because of the number of dentists or quality of care. Equally, when an industry leaves, it has nothing to do with the quality of dentistry being offered.

In comparison to other industries, dentistry is not a key economic driver. If anything, it is there to fulfill its role of a supplier serving the human health-care needs of the community, rather than being an impetus for the existence of the community.

The following questions are representative of Dr. Deming`s professional-management language in operational terms and their combined relevance to the whole management problem. Expect to not understand all of the terminology at first. Think of the time when you were first exposed to dental terminology, and you`ll get the picture. So, as you improve in ability to master his operational terms, you also will begin to see why we say that one only needs to put on a pair of Dr. Deming`s glasses to understand, as he did, that management is a process where the output is quality.

In time, you will attempt to integrate Dr. Deming`s principles into your practice because you will want to share what you are realizing with your staff. Why? Leadership and professional staff development are yet other responsibilities of management. More importantly, you will realize how members of your team also naturally desire to improve their lot in life. This improvement in their life can take the form of pride in their work and enjoyment in their work environment.

Educational failure

Finally, it will become painfully obvious that one of the greatest failures in our dental education (for that matter, beginning from the first day of college) has been that no professional management-language system (with the exception of dental-operational terms) was taught to us. And yet, the greatest challenge rests in the degree of risk inherent in managing a business like dentistry.

It makes one seriously consider the very question, "Are colleges really providing a quality education?" Four years of education (more in our case) and yet no mandatory requirement of basic management training. This occurs despite the fact that we spend our lives trying to understand how to manage, earn a living and live a quality life.

Getting Started

Please read Act I now. Later, at the end of Act II (January issue), Deming completes his "clinical examination" of his client and leaves the doctor with a list of his type of management questions, as well as the CD/book, Deming: Best Efforts are Not Enough! He does this as a means to further evaluate the doctor. That is, will he spend any time in study? It`s sort of like patient home care, right? They have to get involved in their own self-improvement.

Deming`s questions

Since audiences know what`s going to happen just before the characters do, we are going to provide you with a peek at Dr. Deming`s list of questions. As the acts unfold, we will look more in-depth at these questions. But don`t wait on us. See how you might answer them. Remember, the answer, "I have no idea," still serves as a baseline for continual improvement. We will even answer the first one, since this is Dr. Deming`s greatest concern as both a professor and adviser.

It`s up to you whether or not you begin to set aside the time to study Deming. It`s a matter of choice. No one can make you want to improve. You must make the decision to take the first steps The answers to Dr. Deming`s questions are there on the CD. Just imagine that Dr. Deming is personally asking you these questions. It`s just like when we try to evaluate a patient`s dental awareness. Communication is a two-way street.

Here is the list of Deming`s questions:

- What did I do to influence the Shewhart cycle, if anything?

- Where is quality made?

- What is quality?

- Who determines quality?

- What do I mean by Appreciation of a System?

- What do I mean by Theory of Knowledge?

- What do I mean by Theory of Psychology?

- What do I mean by Theory of Variation?

- Can you recognize the symptoms of a red-bead management situation or what it is?

- What does the Red Bead illustrate?

- Can you recognize the symptoms of a funnel-management condition or what it is?

- What does the Funnel Experiment illustrate?

- What is a common cause compared to a special cause?

- How do you recognize each?

- What are Deming`s 14 principles?

- And primarily where upon the system is their greater influence?

- What are his Seven Deadly Diseases?

- And primarily where upon the system is their greater influence?

- What are the four ways to improve and how do they work?

- What is quality and where does it come from?

- To achieve quality, how does the process of continual improvement become the responsibility of everyone?

- What is the concept behind a System of Profound Knowledge, its theories and what do they create?

- What is the aim of the continual improvement process?

- What is the role of the customer?

- Is there more than one customer?

- How does the voice of the customer compare to the voice of the process?

- How does the management system of your private life influence your professional life and vice versa?

Had enough? Most of us quickly do! It doesn`t take too many Deming questions before you begin to feel overwhelmed. Don`t you just pity the good doctor`s next meeting with Deming? But we will help him just a bit. We will answer the first question on the list provided by Dr. Deming.

Dr. Deming and Professor Shewhart were to become lifelong friends. After Deming`s post-graduate years, he worked directly under Dr. Shewhart at Western Electric in the late 1920s. The Shewhart Cycle had its origination in the scientific-approach model - theory (hypothesis), test or do, study results. The aim of Dr. Shewhart`s Cycle was to focus on uniformity in manufacturing processes for products such as the telephone. Unconcerned with style in terms of color or design, his goal was for products to be made with minimal errors and consistent uniformity.

Design and service

Dr. Deming`s contribution, on the other hand, was to focus this cycle on product design and service. How did he do this? He taught the Japanese to put the customer at the front of the production line - before and as the product is being created. This allows better prediction and risk management of the product in the market, since variations in markets can change well before production is achieved.

Let`s give you an example here in the form of a question. Can you remember when implants came of age and the customer base in your office began to ask for them? If you were unprepared to provide this service, even on a referral basis, then the quality perception of your office was placed at risk - that is, an image of not being up-to-date in the latest goods and services.

It was such a simple idea and Dr. Deming would say, "So simple, so stupid. A schoolboy could understand its importance, because without the customer, there is no business."

The Japanese began using the term, PDCA, which meant, "plan, do, check and act."Dr. Deming would further modify it to PDSA - "plan, do, study and act." He felt that to"check" meant to hold back or inspect. In Dr. Deming`s mind, this was a barrier to continual improvement, since it led one to a greater reliance on mass inspection.

Quality and value

These rich, historical perspectives breathe life into the concept that quality is another man-made concept transformed into a value. Most people would agree with the statement, "I can`t define quality, but I know it when I see it."

Ultimately, we say Dr. Deming is seeking an evaluation of his client in context to the most basic, clinical-management question and using this as a basis to proceed. We shall see in Act II if his client is "willing and how much time the doctor spends in study to improve?" If the doctor is prepared, the two will continue. If not, then Dr. Deming knows his best effort will not be enough! He understands very well his own principle - adopt the new philosophy - as a transformation away from the old to the new way. The new way, of course, is where quality really does begin.

Owners of very small businesses are in a game where the finish line is elusive. Only by taking the long-term management approach can you shorten the distance between aim and achievement - and that takes managing the process for quality!

Stay tuned for Act II!

To order your own copy of Deming: Best Efforts are Not Enough, call (800) 379-7911; fax: (307) 877-4149.

Act I: Pre-Examination

Dr. Deming takes the management health history

(Dr. Deming lays his client`s copy of Dental Ecomics magazine on the table. The dentist quickly changes from a smock to a shirt.)

Dr. Deming: "Why are we here?"

Dentist: "Why? Well, aren`t we are here to discuss management for dentists?"

Dr. Deming: "What is our aim?"

Dentist (replies uncertainly, as if perhaps Dr. Deming failed to hear his response.): "I thought I answered this?"

Dr. Deming (studying his client closely): "By what method?"

Dentist: "I don`t understand?" (brief pause) "I thought we were here to learn to use your method. But first, I need to see your contract."

Dr. Deming: "I don`t use contracts ... never have in my life. Contracts cannot guarantee quality or that clients will learn. That is up to them as we manage their future. They can do it! You can do it! It depends on how much time they are willing to spend in study. Can you guarantee me that you are disciplined and intelligent enough that you will study?"

Dentist (abruptly): "No, I cannot. But I need to know if I can afford your services. Please continue, sir." (As he replies, the doctor suddenly realizes that the tough-man business approach he had been taught is not going to work with Dr. Deming.)

Dr. Deming: "Don`t worry. I haven`t yet accepted you as a client. I know why I am here. I`m here to conduct an evaluation to determine if you are willing to commit to change. If not, our best efforts are not enough."

(The doctor does not respond. He begins to realize this old man is not someone to take lightly.)

Dr. Deming: "By what method do you plan to meet your management aim?" (He knows the client`s answer is not what he is trying to evaluate. He has seen it all before, as he looks for any understanding about management from his client.)

Dr. Deming (He continues to probe, noticing how uneasy and lost his client has become.): "What is our system for implementing this method to achieve our aim?" (pauses) "Let`s move on for now. We`ll come back to these questions later."

Dentist (He is relieved to change the subject and asks politely): "Would you like something to drink?"

Dr. Deming: "You`re so kind. Thank you, doctor."

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