Shifting to excellence

Feb. 1, 1997
Dental Quality Management (DQM) is a new method of management. It is new to dentistry and fairly new to management teachings and philosophies in general. DQM is derived from Total Quality Management (TQM), which is a way of running an organization so that it can better achieve its purpose. TQM was developed outside of health care. This should not be surprising, because current dental practice-management concepts were developed elsewhere.

Dental Quality Management hints at an overhaul.

Joan Forrest Eleazer

Dental Quality Management (DQM) is a new method of management. It is new to dentistry and fairly new to management teachings and philosophies in general. DQM is derived from Total Quality Management (TQM), which is a way of running an organization so that it can better achieve its purpose. TQM was developed outside of health care. This should not be surprising, because current dental practice-management concepts were developed elsewhere.

Traditional methods of practice management evolved from American industry. Industry has discovered, however, that its traditional methods of management are ineffective in today`s world and has discarded them in favor of newer concepts. The principles of TQM have revolutionized American business practices, and they can do the same for dentistry.

Almost 17 years ago, in June 1980, NBC-TV aired a special, "If Japan Can, Why Can`t We?" At the time, it had been 30 years since the end of World War II, and Japan had risen to economic gianthood. That year, the U.S. imported $30.7 billion in Japanese goods and exported $20.8 billion to Japan-mostly in raw goods. This ratio is typical of the relationship between a third-world country and a major industrial nation. What had happened?

A Historical Perspective

The television program held the answer. It featured a 79-year-old statistician, Dr. W. Edwards Deming. Dr. Deming taught the Japanese a philosophy of management called Total Quality Management. The TV special was the launching pad for an overhaul in American managerial theory and subsequent improvements in quality, productivity, and customer satisfaction-certainly three goals to strive for in every dental practice.

It is helpful to have a brief understanding of the circumstances surrounding Deming`s teachings to the Japanese. Japan had a population of about 90 million after World War II. The islands` small size permits her to grow enough food to feed about half of her people, requiring the importing of significant amounts of food. To pay for the food, Japan tried exporting manufactured goods, but the quality was miserable and resulted in a strong negative balance of trade.

In an attempt to put money into the economy, General MacArthur`s headquarters purchased as much as possible from local sources. MacArthur sent a team from his staff to determine what caused the poor quality.

The team reported that the problem was Japanese management methods. They described the methods as "feudal" in nature. The plant manager was the "overlord," while the rest of the plant employees were "serfs." The evaluation team concluded that these "antiquated" methods of running an organization were the primary causes of the poor quality. Thus, in the summer of 1950, Dr. Deming arrived to teach a brand new system.

But why did he teach the Japanese and not the Americans? Well, he tried to teach the Americans, but there was not much incentive to change. The old adage, "people don`t change until the pain of remaining the same is greater than the pain of change," certainly held true.

After World War II, America enjoyed tremendous prosperity. Goods from our factories were sold all over the world. Was it because our management theory was so good and effective? Our quality so outstanding? No! In reality, it was because we were the only country with factories still standing. The others had all been destroyed by the ravages of war. It wasn`t until 1980, when the reality of the superiority of the Japanese products could no longer be denied that American managers began listening to Dr. Deming and implementing his TQM teachings.

DQM`s Role in Dentistry

TQM can be defined as a business philosophy that is a customer-focused, information-driven management process through which the minds and talents of people at all levels are applied to the organization`s continuous improvement to meet customer needs.

TQM is an integrated, systematic, organization-wide strategy. TQM is not a program or a tool. It represents a shift in thinking and beliefs about quality, improvement, people, and customer satisfaction.

DQM is the result of the efforts of Dr. Bruce Waterman, a general dentist in Brandon, Fla., and his team of applying the principles taught by Dr. Deming to dentistry. As such, Dr. Waterman has defined DQM as a dental practice management philosophy that is a patient-focused, information-driven process through which the minds and talents of people at all levels are applied to the office`s continuous improvement to meet patient needs and expectations.

The four principles of Dental Quality Management are:

- Patient focused. Quality has two main components - content and delivery. Content quality is concerned with the clinical outcome that is achieved, and its evaluation is traditionally the province of the dentist and other dental professionals.

Delivery quality reflects a patient`s interaction with the practice. Was the practice clean? Was the staff caring and informative? Was the dentistry delivered in a timely manner, cheerfully, and with a demonstrated understanding of the patient`s individual needs and preferences?

DQM is concerned with the quality of content and delivery. In today`s competitive, managed-care environment, it is no longer enough just to provide content quality. The fee-for-service practice also must provide exceptional delivery quality.

- Information driven. The need to base decisions as much as possible on accurate and timely data-not on wishes, hunches, or experience-is a key component of DQM. Most managers, whether dentists or otherwise, traditionally have based major decisions on gut instinct. This would be like treating without diagnosing. DQM teaches us to identify the question before determining the answer, and this involves collecting data.

During a staff meeting, a team member responsible for hygiene-appointment scheduling lamented the high number of cancellations and rescheduled appointments.

When asked why, she said it was flu season and everyone was ill, necessitating the rescheduling. If the team had accepted that opinion, there would not have been a proactive initiative at their disposal. However, by deciding to track specific reasons for cancellations for two weeks, they were able to identify the true source of the problem, take action, and improve results. Dr. Deming taught that we must have real information before taking action.

- Continuously improvement directed. It is the leader`s responsibility to create an environment where every team member is focused on continuously improving every aspect of the practice and reducing waste. The concept of continuous improvement is like a race without a finish line. It is constant and ongoing. There is a popular phrase which sums up this point, "Even if you`re on the right track, if you`re not moving, you`ll get run over by a train." Improvement is not a one-time effort.

Putting out fires is not improvement. Improvement results from determining what caused the fire and eliminating that agent. This philosophy requires a leader to create an environment which eliminates blame (which is past-focused), and concentrate on improvement (which is future-focused).

Every action that every team member takes is part of a process or a system. Team members work within a system that-try as they might-is beyond their control. It is the system, not their individual skills, that determines how they perform.

Dr. Deming taught that when there is a performance problem, 85 to 90 percent of the time it is caused by a system problem, not by a people problem. Traditionally, we look at the person and take such managerial actions as direction, correction, discipline, termination, etc. These behaviors demotivate people, resulting in lower productivity, lower quality, and decreased customer satisfaction.

Integral to the successful adoption of DQM principles is a leadership-belief system which states that people want to be great. When their performance is not great, improvement occurs by determining what barrier is in the way and working to eliminate it.

- Teamwork dependent. Team-building is a means to an end, not an end in itself. Dental practice leadership needs to build strong teams. This purpose is not so everyone can like one another and get along. Instead, it`s because everyone on the team needs to apply his/her talents and abilities to continuously improving the systems of the organization.

The dental practice, like any organization, is a series of components strung together to form a process or a system. Scheduling, recare, financial arrangements, producing crowns for a patient-all of these are systems. Rarely does any one individual complete every step in a process or system. Thus, the only way the team can make improvements is to involve everyone, at each step in the system, in evaluating and improving the pieces of the process. This requires cooperation, communication, and a willingness to give and receive feedback.

The leadership role in a team-dependent organization is significantly different from that of traditional managerial theory. Traditional paradigms of leadership have come from the military model and revolve around a command and control mindset. In this model, staff perceives the doctor or manager as a police officer.

In DQM, the doctor (or manager) is perceived as coach and facilitator. The supervisor/subordinate relationship is no longer characterized by dependency, fear and control, but by interdependency, trust, and mutual commitment.

DQM is a philosophy of management. Implementing the concepts is a continuous process of learning about your practice and staff and journeying towards improvement. DQM must begin with the doctor. As the practice leader, the dentist must:

- Begin to look at process problems, not people problems.

- Foster a commitment to continuous improvement in a blame-free environment.

- Create an environment that encourages trust, participation, and creative problem solving.

Transformations do not happen overnight. Dr. Waterman began the DQM journey three years ago. He continues to learn more about Dr. Deming`s teachings and how to apply them to his practice. The result has been increased net production and happiness, and decreased overhead and stress. Results we`re all looking for.

Joan Forrest Eleazer is executive director of the Center for Advanced Dental Study in St. Petersburg, Fla., where she teaches courses on Dental Quality Management. She can be reached at (800) 952-2178.

DQM Tools in Dental Offices

* Problem diagnosis. Whenever a result is not within the desired range, the team can mobilize to make an improvement or solve the problem. Key to the principles of DQM is to make an accurate diagnosis prior to implementing treatment or the solution. This involves identifying the root cause of the problem. Just like in treatment planning, the cause of the problem must be identified if a lasting solution is to be found.

Prior to jumping to conclusions, ask, "What is the real problem? Why is it a problem? What could be causing the problem?" Involve everyone on the team in order to obtain all perspectives.

* Sources of variation. In order to do a complete diagnosis, the team should brainstorm all the possible sources of variation. In other words, what are all the possible causes of the particular problem. In the example of the canceled hygiene appointments, this would involve developing a list of all the possible reasons the patient might cancel the appointment, rather than jumping to the conclusion of the flu season.

* Data collection. Once all the possible sources of variation have been developed, data should be gathered to determine which, if any, of the possible sources of variation causes the most problems. This allows the team to create a solution, which will have maximum impact, rather than spending time and resources on a solution which will not make significant improvement.

Gathering information should not be difficult or time-consuming. Simple techniques, such as tally sheets to count the number of occurrences, are a good place to start. Once the information has been gathered, discontinue the collection of data. Don`t get trapped into developing monitors or counters after the requirement for information has been fulfilled.

Once a change to a system has been made, it is important to again collect data to be sure the change has produced the sought-after improvement. If it has not, develop an alternative improvement.

* Process flow diagrams. The first step a team often takes when looking for ways to improve a system is to draw a flow chart of that process as it currently works. A system cannot be improved unless everyone understands and agrees on what the process is. It is important that everyone involved in the system participate by putting his/her steps in the flow. The activity of creating a process flow diagram is a wonderful exercise in helping each person on the team realize how she fits into the steps as the patient experiences them.

Drawing a process flow diagram is simply a matter of doing a "connect the dots" puzzle. There is no need to be concerned with symbol types, etc. Simply start with the first step and continue asking, "What happens next?" Once the diagram is complete, the team frequently will see areas for improvement and elimination of redundancy, inefficiency, and misunderstandings.

Another useful step is to draw the ideal flow of the process and then determine how it differs from the actual. The team can then pinpoint actions to reach the ideal.

* Wastebusters. Turn every member of the team into a wastebuster and watch the improvements in productivity, profitability, and quality. Industry measures reveal that 40 percent of gross production is lost to waste. Of that amount, 54 percent is in wasted time, 21 percent is in wasted materials, 19 percent is in lost opportunities for sales, and 6 percent is in wasted capital expenditures.

Actual percentages have not yet been computed for a general practice, but Dr. Waterman and his team have had success focusing on wasted time. Process flow diagrams help identify areas where time savings can come into play.

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