The intermission is over...

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.

The curtain rises as Dr. Deming and our beleaguered dentist take center stage for...

Act II

The second act is by

Drs. Lowell Dawson and

Steve Cheek

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" is below, and the last segment will combine "Act III: The Treatment Plan" and "Act IV: The Prognosis" in the February 1998 issue.

In the first act, Dr. Deming took the management health history of the client. In the second act, we present Dr. Deming`s own management examination. Next month, 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.

In the December issue, Dr. Deming had concluded many things about his client by the end of Act One, during his Pre-Examination (Patient or Client Registration). The four aims of Deming`s Pre-Examination were synergistic:

- Determine how much his client/patient understood about management, (nothing less than we do with a new patient).

- Determine if his patient was willing to spend time "in study" to improve (patient education).

- Determine if the patient was willing to change through the acquisition of new knowledge (behavior modification toward home care).

- Since the doctor was, after all, top management - CEO, CFO and Chairman of the Board - determine if he would give his personal commitment to change (the patient`s commitment)?

When Dr. Deming departed after Act I, he left his list of his questions along with a copy of his CD-ROM/book, Deming: Best Efforts Are Not Enough. The resources are a form of providing leadership and instituting his own rigorous educational program).

Dr. Deming has firmly placed the decision to improve upon the doctor`s shoulders. The doctor must begin his own transformation. Was the client serious enough to spend time every day in study? Just like us, the doctor has had no prior exposure to Deming`s operational management terms, so the learning curve is steep. (But our doctor remembers pulling all-night marathons!) Deming understood he was helping his client to prepare for their next meeting, but to what degree rested upon the doctor`s response.

Act II:The Clinical Examination

(The second act opens with Dr. Deming wondering if they share any common management language at all. The aim of the doctor is to simply let Deming know he has been studying. The master and the pupil quickly realize both are true.)

Dr. Deming: "What is your aim?"

Dentist: "Do you mean what is my constancy of purpose, Dr. Deming?" (When Deming nods approvingly, the doctor continues. His voice takes on a slight questioning tone, for he hopes he is using the right words.) "It is to learn how to manage and improve continuously the quality of my practice. In some cases, this is in products and services that my patients pay for and, in other cases, the lives of my staff and my own family."

Dr. Deming: "The reduction in waste toward improving the bottom line without jeopardizing quality would have been sufficient for now. Until profound knowledge has been acquired, too big of an aim, or too many unmanageable aims, can increase variation in your system. This nonsense of things like the slogans `Be all you can be!` and `Reach high!` are deadly diseases, as we shall see."

Dentist: (smiles) "Walk before you run." (While he anticipates the good professor`s next question, he feels good that, so far, he seems to be holding his own. At the same time, Deming still is not suggesting any exact correctness to any answers.)

Dr. Deming: "What is your theory?"

Dentist: "My theory is that my practice can be stabilized and later managed toward optimization. That is, of course, if I can shrink variation in all of the sub-systems and, thus, the variation in my overall system is used to achieve my aim."

Dr. Deming: "Sounds about right - reduce variation. What does variation cause?"

Dentist: (struggling to guess) "Waste?"

Dr. Deming: "Is it measurable?"

Dentist: "I think it can be measured; at least, I have read that it can."

Dr. Deming: "So most managers believe I am told. Within any system, there exists a net lost value which is both knowable and unknowable. I am concerned not with the knowable. Anyone can find these. The unknowable cannot be measured in terms of actual costs to the company. Whatever they are, they are high, and they are caused by failure in management from under-optimization of the system."

Dentist: (uncertainly) "What was that again?"

Dr. Deming: "Lets come back to that later. What is your system?"

Dentist: (more confidently) "My system ... Well, it`s how I do things. You know, I use this and that, and do it this way and that way."

(Dr. Deming observes his client is proud about answering his questions so quickly, demonstrating that he has been studying, is prepared, and is smart like in the old days back in school. He is enjoying being tested under fire. Unimpressed, Dr. Deming will not directly humiliate this student.)

Dr. Deming: (staring, he ponders aloud as if it was just a passing thought) "How do you know if this system you are using is stable?"

Dentist: (answering softly, taken aback, remembering he had quickly clicked past this section on the CD because it appeared to be so self-evident) "I am not certain. I just sense when things are not going well. Is that what you mean by being unstable?"

Dr. Deming: "No. Learning the proper use of control charts and what the data means will help far more."

Dentist: (wearily) "Control charts, Dr. Deming? I`m too busy. By the end of the day, I`m simply too tired. I make a good living now. I would say my practice is stable."

(Dr. Deming notes the doctor`s frustration without expression and responds in a litany.)

Dr. Deming: "Are you too busy or too tired to fail to understand and diagnose when you are in a red bead or funnel situation then? Do you know why I always include these in my lectures? Control charts establish or document trends from the way the data points are disbursed. They can tell you if you have common or special causes occurring over time that you need to be concerned about. I do not use them for the exercise to prove otherwise. Look at your financial statements and tax returns for the past five years of your practice. These are forms of control charts. I do not mean you have to spend full time on documentation to determine if a system is stable or not. No! What the numbers mean is what is important! In order for any system to be stable, the information must be reliable enough to be predictable. I did not say stable means perfection, nor does it mean optimization. Total Quality Managers believe perfection is the aim from the beginning. TQM sounds good, but I don`t know what the words mean? One has to assume it means total, it means absolute. Numbers are relative measurements."

(Briefly, Dr. Deming stares at his client.)

Dr. Deming: "I just read that there are over 257 different measurements of the speed of light. If you ask me to define the speed of light as being an absolute, I could not. But I`d say, `Whatever it was, it`s damn fast.` (He roars with his trademark deep, jerk-like laugh.) Ha! Ha! Ha!" (The doctor chuckles, not expecting such a sense of humor from the crusty old consultant.)

Dr. Deming: "You know, doctor, once, while getting into a taxi, I was stabbed in my side after leaving a convenience store."

(The doctor`s smile is replaced with a stunned expression)

Dr. Deming: "Good thing I already had a ride to the hospital. While I was recovering, I studied how medicine could become better managed. That`s another subject; still, it applies here. Each of the elements of your system - your people, equipment, environment, materials and methods - must share in the overall aim of the system with which they are associated at that time. But most managers mistake a method for a system. Some may think equipment implies a system. By themselves, these will not produce quality."

Dr. Deming: (after a brief pause) "It is the system you are using that is being asked to prove your theory and achieve its aim. Appreciation of a system is vital to managing. Otherwise, how do you know if your system is stable? Without this appreciation, how will you know if things impacting your practice are common or special causes and how to react or manage them? How do you know if your practice is reaching or has reached optimization? Do you know what the seven deadly diseases really are?"

Dentist: "I guess what you are saying is that the time has passed when all you needed to do was put your shingle on the door?"

Dr. Deming: "Frankly, doctor, business means predication. Every business takes risks. There are statistically the same or greater number of patients today than ever before. Markets change and will always vary over time. This means more markets and more variation in the consumer. Do you listen to the voice of the customer as you listen to the voice of your process? I am saying that, in any business, it`s easier to date an earthquake than an economic decline. Yes, it`s even simpler and easier to manage during an incline. You have the money to cover your mistakes. With no warning, the good times will come to an end. They always do. By the way, what is quality and who determines it?"

(Dr. Deming awaits a response. The doctor doesn`t have an answer, and he is awed by the passion within Deming`s eyes.

Dr. Deming: (continuing) "You need customers who are more than happy. You need customers who boast about your product. The repeat customer - there`s the gravy. The repeat customer is the best part of any business. He`s the one you don`t have to argue with. He comes back ... your fixed costs are all paid. Most managers believe quality to be a method. What do you think?

Dentist: (thinking that is what his practice does) "Seems logical."

Dr. Deming: "You can pull a rabbit out of a hat, but you can`t pull quality out of a hat! Best efforts are not enough! Everyone is doing their best. A company cannot buy its way into quality either. A company must be led into quality by top management. You don`t install quality. Quality is something that takes root; you have to seed it; it has to take root; you nourish it, study it, and it is a very interesting study. The more you study it, the more you wish to study. You can talk about quality. But if you don`t know what to do about it, or how to bring it about, quality is an empty word. You can`t argue with a chain reaction. It will work."

Dr. Deming: (suddenly speaking softly) "Quality is not a method but an output of the system."

Dr. Deming: (pausing to catch his wind) "The last time I was here you were so kind as to offer me a drink. Care to do the same now? Don`t worry, I haven`t been charging you for my memories."

(The doctor hands Deming bottled water. The professor studies the bottle momentarily.)

Dr. Deming: "Thank you. You are so kind. Who would believe one could sell water other than in a desert environment. Certainly, a market has been created for this product. Someone has educated the customer to its value."

Dr. Deming: (after taking a drink, continues) "So, in your practice, are you creating markets for goods and services customers may or may not realize today they want or would like, as all other businesses are doing? Are you educating them about the benefits that can be derived utilizing your profession and yourself? After all, marketing is a subsystem of your overall system. How would you know if the market is changing if you were not educating them. How would you make predictions that will affect how you might want to manage your system next? There is a voice out there, you realize?"

Dentist: "Certainly. Cosmetic dentistry, implant dentistry, soft tissue programs ..."

Dr. Deming: (interrupting) "So you educate the customer; that`s good. Customers never know what they want until they begin the education process, and then they tell you what they want and you listen and try to satisfy them."

Dentist: "What do you mean by, `they don`t know what they want?`"

Dr. Deming: "Who ordered a phone before it was invented? Nobody! A businessman had an idea, thought he could make money at it - if it worked, if people liked it and were willing to pay his price. Then he found out, once he educated his customers on how to use it, that they wanted it in black, not red. More importantly, it was not the technical quality, but the service quality they sought. It meant that customers no longer had to walk across town on a cold day to talk to mom. Over time, this convenience was replaced with an increased demand for higher audio quality. Then came new designs, and the rest is history. Do you agree?"

Dentist: "Yes!"

Dr. Deming: "Then the practice of dentistry is nothing less than, as is the aim of every business, being capable of quickly responding as markets change, delivering the goods and services of quality these customers seek at a price they are willing to pay, and at a profit to you. Can you improve the voice of the process as it relates to the voice of the customer?"

Dentist: "Yes. Using the four ways to improve and the PDSA cycle?"

Dr. Deming: "You know, I took to Japan the thought of a system, a good start on what I call profound knowledge. Anyone can learn it. I taught them about the Shewhart Cycle - Plan, Do, Check and Act. Because `Check` denotes a holding back, or stopping, I preferred using the term, `study,` psychologically suggesting not to hold back but to learn and move forward. Today, it is called the PDSA Cycle. Can the PDSA Cycle be applied to services such as dentistry?"

Dentist: "I suppose we do it almost naturally and don`t realize we are."

(Deming appears pleased with the dentist`s response.)

Dr. Deming: "Without a theory, there are no questions. Without questions, there is no learning. It is so simple a schoolboy can understand it. Your plan is your theory. Doing is your test of the theory. Studying is your learning because of the new questions raised, if only to change your theory. Acting is taking action based upon new knowledge gained as the output of the cycle. Introducing a new material in your office should be done using the PDSA cycle for management quality."

Dentist: (frustrated) "But, if knowledge is all it takes, how come I can never seem to get my practice optimized and stable? I`ve attended management seminars when I can. Certainly, that is part of your 14 principles?"

Dr. Deming: "Yes. Instilling a vigorous education and training program certainly is. It demonstrates a form of leadership as well. I do not recall what number the principle is because I never numbered them. Somebody else did and it stuck."

Dr. Deming: (pausing briefly) "It takes an understanding of profound knowledge not to look for instant-pudding answers. First, understand that most learn how to do things through advice. These forms are actually methods, processes or techniques."

Dentist: (firmly) "They deliver results."

Dr. Deming: "Certainly, they can deliver instant results! That is, until the system stabilizes or until markets change. The marketing of your office depends on the aim of your overall management system, and how marketing as a subsystem contributes to the common aim of it. Your methods must support the whole system or they will not work until you change the aim or theory of your system. The tail does not wag the dog here. You must understand what profound knowledge is before you begin to change your system. Change for the sake of change is not enough. We need to know in what direction to change first and, then, how to continually improve. Management by numbers can be misleading. It implies that markets are incapable of changing. Managing by setting goals is demeaning to the human spirit, creating internal competition in people. It creates suspicion and distrust to help another. You lose, I win!"

Dentist: (softly) "Sounds like the way it was in school."

Dr. Deming: "What was that? Speak up."

Dentist: "I said that I have always competed."

Dr. Deming: "My management system is a thinking man`s system. One can spend a lot of money on everything else in search of the answer to quality. You should learn to work with your competition. Forty years ago, I called it co-competition. No doctor can see all the patients. If so, his system would become quickly unstable. All the doctors in an area or market should learn how to work together, sharing the common aim of increasing the market so more patients seek the same goods and services."

Dr. Deming: (changing the subject) "Do you understand the difference between what is common compared to a special cause?"

Dentist: "Common causes occur within an acceptable tolerance and special causes occur outside those limits?"

Dr. Deming: "Who imposes the limits?

Dentist: "I do."

Dr. Deming: "What happens when one tries to make a special cause a common cause?"

Dentist: "It`s an example of the Funnel Experiment. You get tampering?"

Dr. Deming: "And what happens?"

Dentist: "Eventually, even if people are trying their best, it is this trying that causes the chaos. The system was already stable."

Dr. Deming: "It`s good you realize that action without knowledge is costly. Now, what action, then, would you consider?"

Dentist: "I would have to determine if my aim, theory and system is correct for the task."

Dr. Deming: "Does optimization mean perfect, like the perfect practice or business we read about in all those business journals?"

Dentist: "I would like to think so; but, realistically, using common sense, no."

Dr. Deming: (checking his watch) "I can see you have been studying. Your commitment to change is growing. So, the aim of the next meeting is: I want you to think about the direction we should take next. Are not the words, `treatment plan,` frequently used in the profession?"

Dentist: "Yes."

Dr. Deming: "I will come with my own treatment plan to compare with yours. Just remember that it takes time. By taking this direction, you`ll never be the same again. But you now understand why there has to be transformation in your management. You`ve learned something about the roadmap - profound knowledge. Now we have to see some motion; the next step is obligation."

Dentist: "Dr. Deming, I am not sure that I can develop my own treatment plan."

Dr. Deming: "Then this is where we will begin together."

Dentist: "Where?"

Dr. Deming: "At the beginning. After all, where is quality made? I asked you. `Why are we here? By what method? What is your aim? What are your theory and system?`"

(Dr. Deming sees the frustration in his client`s eyes, knowing that it all sounds like jabberwocky. With a nod, Deming excuses himself and departs.) (The doctor knows full well that they have just touched the surface of what is to come. Slipping his CD into the computer, the doctor begins to search for an answer. Moments later, realizing an insight, he begins to make notes on a notepad.)

Dr. Deming: (Looking through the office window glass) "I`ve made a difference today. We`ve both learned something. I hope he has had as much fun as I did. I meet such wonderful people."

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