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The third act is by
Drs. Lowell Dawson and
Editor`s Note: This series about Dr. W. Edward Deming`s business philosophies, as applied to dentistry, is presented in three sequential sections. "Act I: Pre-Examination" was presented in the December 1997 issue. "Act II: The Clinical Examination" appeared in the January issue.
In the first act, Dr. Deming took the management health history of the client. In the second act, we presented Dr. Deming`s own management examination. Now we follow Dr. Deming`s road to continual improvement, per the treatment plan, as well as the "prognosis" in the finale.
The theatrical flair of this presentation is intentional, and it hopefully will offer insight into the methods espoused by Dr. Deming.
(At the end of Act II in the January 1998 issue, Dr. Deming asked his client to generate his own treatment plan. Dr. Deming indicated he would do the same. The client and Dr. Deming reconvene at the dentist`s office.)
Dr. Deming: "Management is a dynamic process at all times. It is important we understand that you not wait for one step to be completed before initiating another. Now, let`s study your treatment plan."
Dentist: (handing it over) "It`s direct and to the point."
(Deming studies the several sheets of paper carefully.)
Dr. Deming: "Isn`t any business in business to make as much profit as possible?"
Dr. Deming: "Isn`t any business in business to satisfy the financial desires of its owners?"
Dentist: (uncertainly) "Sure?"
Dr. Deming: "Isn`t any business in business to satisfy its customers by providing goods and services of quality?"
Dr. Deming: (holding the doctor`s plan high with his hand) "Then what does your theory/treatment plan have to do with how you are going to improve management to achieve these aims? How does it predict outcome, your prognosis?"
Dentist: "I`m not sure."
Dr. Deming: "Factored over time, no person is exactly sure of anything. Anyone who says otherwise is penny rich and pound foolish. But you need to be able to predict so you can manage!"
Dentist: "Dr. Deming, you asked me to come up with my treatment plan and then compare it with yours."
Dr. Deming: "Yes." (He appears to examine the doctor`s treatment plan again.) "Let`s see what I am thinking. We will discuss my reasoning as we proceed." (The dentist watches attentively as Dr. Deming skips back and forth through his treatment plan. Finally, Dr. Deming looks at the doctor.)"The first step is to beging to adopt the new philosophy about the role and responsibilities of management. That`s the second of my 14 principles. The day of just hanging out your shingle is over. The automobile companies learned this lesson years ago. You have to recognize the marketplace, which will always be ever- changing due to the continual rate of social and economic changes."
Dr. Deming: (pausing briefly)"The second step is to create constancy of purpose, which is my first principle. Ask yourself why you are here? Why is your staff here? And then collectively, why are all of you here? Manage the office as a system for optimization. Create a constancy of purpose that allows employees to take pride and joy in their work, irrespective of who might be the doctor, including you. My principle - breaking down barriers - allows for happy workers, who then will contribute to improved quality."
Dentist: (skeptically) "Dr. Deming, I`m not sure I agree with your idea about me being irrelevant or unimportant!"
Dr. Deming: "As a team member, you are important. But it depends to what degree, based upon your role at the time. When you enter the operatory, you become truly a different kind of manager. You manage the dental quality based upon that particular subsystem in existence. When you leave that environment ... when you go into your private office, for example, you put on a different hat. Now if you are managing your entire office under this constancy of purpose, isn`t it a possibility that someday you would bring in an associate and sell part of the system - your practice?"
Dentist: "Yes, I suppose so."
Dr. Deming: "Then it`s just as logical to project that your office could become an optimized system.
You perceive market changes ahead, which is good - you predict. Thus, your present system must also change. So you proceed to create or change the system and invite a new dentist to come into the area to provide clinical care. Competition is destructive to all systems, to human beings, and very wasteful. Imagine the quality that would come forth if companies spent more money on research and improving their systems rather than trying to beat up the other guy?"
Dr. Deming: (briefly pauses again) "Any dentist can go to the highest hill and shout about quality, but patients won`t agree until they find out for themselves. And their sense of quality could be nothing directly attributed to you as their dentist. I suppose, for most dentists, this concept may strike them as staggering. But market conditions are changing with managed care, as well as the consolidations that other industries have been facing daily for years. Top management must create options for themselves in order to survive - the only way to do this is improvement in goods and service quality or quit. On a smaller scale, you do this as a form of continual improvement by providing new services, adjusting to market changes demanded by the voice of the patient. May we move on to the third step?"
Dr. Deming: "The third step is to define your aim`s theory. You can change if you are committed to change through profound knowledge. Your office system can be improved and optimized with you and without you; it`s only a matter of variation in the process. You need to develop profound knowledge about managing the process and constantly shrink variation in the common causes found within your system, as your aim will improve the whole system."
Dentist: "What was that again, Dr. Deming?"
Dr. Deming: "Prepare a roadmap to where you are going."
Dentist: "Where am I going?"
Dr. Deming: "Toward your aim. Your aim would be to create such an office environment system through optimization in your management philosophy as a foundation. Optimally, it could function even without you being the dentist. Even your competition would want to practice here because, here, they do what they do best - and that is managing clinical dentistry."
(Dr. Deming reaches down into his briefcase and extracts a single sheet of paper.)
Dr. Deming: "The fourth step is to define your system and continually evaluate areas to improve. I refer to it by the acronym PEEMM, which stands for people, equipment, environment, materials and methods."
Dr. Deming: (reads aloud from the paper) People: patients, staff, doctors, and suppliers. Equipment: dental and office, computer workstations, laptop, Internet. Environment: physical, both home and office, as well as psychological. (He stops reading.) Then there are the educational materials. The methods refer to my some of my principles - the first, second, sixth, seventh, 13th and 14th - which are the starting guidelines and are followed by the others as time progresses. Continuing our discussion, we move on to the fifth step, which is to manage the process of management by first determining if your system is stable. What do I mean by stable?"
Dentist: "The present output of the system is reliable enough to be predictable, using some form of a control chart to assemble the data."
Dr. Deming: "You will try to recognize the differences between the internal voice of the process and the external voice of the customer. You will train everyone to learn to do the same."
Dr. Deming: (stands and stretches) "The sixth step is to use the PDCA Cycle (Plan, Do, Check, Act) on your original aim, theory and system. The aim of integrating and performing the PDCA Cycle is to establish a common management-test method for improvement. For example, you determine you are interested in a new material or change in office policy. Don`t just do it as a form of instant pudding, but integrate it through this approach so you can study its output, realizing further modifications may be needed. This cycle allows for time to understand where and how you might shrink variation in the new material or policy. In the attempt to reduce waste or to save money, one might, in fact, observe opposite outcomes, thus disproving the theory that a new material or office policy would save money or reduce waste, while retaining the common aim. However, in the hands of another doctor, the opposite may be true; the action taken may save money."
Dr. Deming: (seating himself comfortably again) The seventh step is to apply the same thinking approach to your personal lifestyle as a supplier to your professional life and vice versa. They serve as customers to each other. This is very important. They cannot be separated. If they are, both may become unstable. Costs go up; benefits go down. If one competes with the other, then one will lose and the other has a loser for a supplier and who wants that?"
(The doctor chuckles at Deming`s analogy.)
Dr. Deming: "The same can be said about a marriage. The eighth step continually seeks optimization between your personal and professional life while managing the common aim and constancy of purpose of both. As suppliers and customer of the other, they should - they must - help each other. Should you become handicapped, or die early, then irrespective of yourself, the probability that your systems will still be able to contribute does exist. This is what you should consider as your constancy of purpose, as your aim. Managers in other industries plan for this all the time, even simple retirement or job relocation. You can always re-evaluate later, but at least with profound knowledge improved decision-making as a process can be reached based upon new information. Can you give me an example of how you see that your customer can contribute?"
Dentist: (speaking slowly and carefully) "My aim is to survey the population to determine if the people are seeking newer types of services than we are presently providing within our market environment. Such a survey would also educate them on what we presently provide and what we are soon planning to make available. I could use this information. It may be as simple as expanding the quality of our practice by bringing in a specialist, rather than having our patients go across town."
Dr. Deming: "How did you come up with this?"
Dentist: (proudly) "Listening to the voice of the customer complaining about all the road construction and delays, especially in bad weather."
Dr. Deming: "Very good! It appears you are beginning to see why and how really important it is as a manager that you have an understanding of your marketing subsystem and the role of the customer in producing quality."
Dentist: "How should I advise others?"
Dr. Deming: "Dentistry has its own internal operational language. Although not a dentist, I still understand some of the language as a customer, as a patient. But you, as a dentist, must have a management language and understanding beyond clinical dentistry, a language of operational terms and definitions, equally capable of working internally as well as externally. Always remember that the theory of variation will show that there is no such thing as a perfect office. It`s sheer nonsense to have the goal of creating the perfect office without management. Nothing is perfect. There are just degrees in variation."
Editor`s Note: In future issues of Dental Economics, we will probe deeply into Dr. Deming`s 14 principles and how they can be applied to managing a dental practice. To order your copy of the CD-ROM Seminar, Deming: Best Efforts Are Not Enough!, call (800) 379-7911. Please use Reference Code "DE" or contact the website, immata.com for more information.