When someone else messes up

May 1, 1998
3M Dental, winner of the 1997 Malcolm Baldrige National Quality Award, is proud to sponsor the Dental Economics year-long "Quality Management" series.

3M Dental, winner of the 1997 Malcolm Baldrige National Quality Award, is proud to sponsor the Dental Economics year-long "Quality Management" series.

If total quality management is our goal, then our reliance on other sources for referrals, supplies and payment must also evolve.

Dr. Bruce Waterman

While examining how successful quality-management models from business and industry can be translated into dental applications, the vital roles of our "suppliers" need to be analyzed. In previous Dental Economics articles, Japan`s economic revolution and America`s current quality transformation (GM and Saturn, for example) were attributed largely to the application of W. Edwards Deming`s philosophy. His philosophy is embodied in his "Fourteen points" (for a complete list of the points, see page 32, March 1998, Dental Economics).

The third point (titled, "Cease dependence on mass inspection") and the fourth point (titled, "End the practice of awarding business on price tag alone") sound great philosophically. To try to extrapolate these points to dentistry, it is best to examine how businesses in America have successfully applied them to their quality transformations.

But first, let`s review the full text of these two points, as written by Mary Walton in From the Deming Management Method:

- Point Three: "Cease dependence on mass inspection. American firms typically inspect a product as it comes off the line or at major stages. Defective products either are thrown out or reworked; both are unnecessarily expensive. In effect, a company is paying workers to make defects and then to correct them. Quality comes not from inspection, but from improvement of the process. With instruction, workers can be enlisted in this improvement."

- Point Four: "End the practice of awarding business on price tag alone. Purchasing departments customarily operate on orders to seek the lowest-price vendor. Frequently, this leads to supplies of low quality. Instead, they should seek the best quality and work to achieve it with a single supplier for any one item in a long-term relationship."

Automobile manufacturers use multiple suppliers to produce the parts vital to the quality of the final product. Within the manufacturing process, through mass inspection, defective parts are found. Of course, the amount of defects often could be related to the fourth point, which is choosing suppliers on price tag alone.

To try to reverse this trend of accepting defects as a large part of the manufacturing process, the automobile makers took Deming`s points to heart. First, they eliminated the lowest price as the primary determinate of the supplier and chose those they could work with constructively. Then, for example, in the manufacturing of doors, they noticed that one in every five metal doors was defective. By working with the supplier, they were able to identify the cause of the defects and greatly reduce costly waste. Before, they scrapped 20 in every 100 doors; now it`s only one in every 100. It definitely is cheaper to work with the supplier than to throw out these doors - not perfect, but tremendously improved.

Old `habits` with suppliers

How do we open the door to quality and apply this thinking to dentistry? The first step is to define who the suppliers are in dentistry. As a general dentist, I would identify referral offices, labs, dental suppliers and support services. Just like the automobile manufacturers, we must challenge old thinking that justifies doing things the old way just because it has always been done that way. I call this the HABIT syndrome (acronym for Has Always Been Instituted Thusly). Let`s look at a few examples and apply this to our "suppliers" in what I call "supplier enhancement." In this analysis, all successful applications revolve around improving communication.

- Referral offices. Examine the referral forms and the process of the referral with a renewed sense of constructive change. The "quality" of the referral to offices and their subsequent interoffice communication in both directions definitely can be improved.

If a patient is referred to another office and the appointment logistics, clinical information, records, etc. are fouled up even one in five times, we have an opportunity for improvement. There is nothing worse than a patient being referred to an office and then feeling that the referral office has no idea what is going on. Similarly, specialists will advise patients that they need to have their wisdom teeth removed. But that information is never communicated to the general dentist. I personally can relate to that "stupid" feeling of being uninformed.

Continuity of coordinated care is critical. Poor communication is not an acceptable excuse in this information age.

For example, have you ever noticed that when you refer patients to specialists, they usually will ask your receptionist multiple questions about them? Unfortunately, you may have only a few of the answers. I have found that most of the answers to these questions exist in the brochures that many of these specialists give the patients at their offices. Now I keep many of these brochures in my office to give the patient before the referral. The net result is compliance and treatment acceptance. It`s like eliminating that defective door.

- Labs. Challenge the communication and interactive aspects of the relationship in both directions. Forms that grade their products and yours, as well as personal meetings with technicians, should be routine, not reserved just for problems. Just like the automotive examples, the choice of labs may not be totally determined by the lowest lab fees. Instead, choose the ones that will work constructively with you to optimize quality. Money saved by reduced defects and adjustment time from improved and consistent quality can more than offset these costs.

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Dental suppliers. Identify defects in your billing, ordering and products. Then proactively seek mutual solutions. If dental suppliers become involved, the defects in the system that cause expense to the supplier and are passed on to the dentist can be reduced. For example, I am aware of one dental supplier who works closely with his dental accounts to determine and inventory the majority of their supply needs. By design, the dentist receives these products at a discount because the expense of waste from wrong orders and restocking has been eliminated. Supplier enhancement works when there is a win-win relationship.

- Support services. This would include insurance and other support services such as janitorial and maintenance. How defective is our insurance system? Certainly, there is a tremendous opportunity for improvement.

In Florida, I have been fortunate to be part of a group that has innovatively challenged the "defects" in direct reimbursement (DR) as the exclusive, self-funded offering in the marketplace. The new concept, called direct assignment (DA), has helped make Florida one of the top sellers of self-funded plans in less than a year. DR and DA complement each other in the marketplace by offering freedom of choice and fee-for-service dentistry. DA has some features and options that help in its marketability, but also seems to create more opportunities for DR. The astonishing part is that this concept was developed by dentists working with the insurance industry. The effectiveness of supplier enhancement is certainly evident in this successful application.

As you can see, Dr. Deming`s philosophy can be successfully applied to dentistry. The application is never "instant pudding," but a journey of continuous improvement that requires an activist mentality.

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