The evolution of LEAN Six Sigma as a management philosophy has been rightly attributed to many companies, such as Toyota (Lean) and General Electric (Six Sigma). The genesis, however, can be found in the stark reality facing Japan immediately following World War II. With both human and material resources in extremely scarce supply, the Japanese began to understand that if their economy was to be rebuilt, resources could only be expended on activities that customers value and, therefore, are willing to pay for.
On the surface, this appears to be simplistic and self-evident. As we look closer, however, this hyperfocus on customer value, how it is created, and how resources are used uncovers underlying inefficiencies as well as significant opportunities for improvement in many facets of the enterprise. In my experience, it’s not uncommon to find that more than 50% of our resources are expended on non-value-added activities. The essence of a Lean Six Sigma initiative is finding these sources of waste and reducing or eliminating them, thereby freeing up existing resources and capacity to create more services and revenue.
In the health-care setting and with dental services in particular, a good way to get started is to examine current resources and capacity to see how much is dedicated to value-added direct care with patients versus other activities.
Measuring patient experience and resource efficiency: Direct care = customer value
The purpose of any health-care service organization is to bring together three key resources: a patient with a need, a provider, and the room needed to perform a direct care encounter. The percent of time each of these resources are actually in a direct care encounter is an important measure of how effectively they are being utilized.
Patients: The percentage of time spent in direct care (versus waiting) is a key factor in overall experience.
Providers: The percentage of time spent in direct care (versus other activities) is a key factor in capacity (patient access) and efficiency (cost).
What’s the ideal direct care percentage? For patients, generally, the target should be at least 50% to 70% direct care with 50% being an important threshold. For providers, the target should be between 60% and 80% direct care, depending on the provider specialty and the care model deployed within the practice. In a delegated care model with care extenders, it is difficult to achieve a provider direct care efficiency above 80%.
Here are a few things to look at if your practice is not meeting benchmarks:Scheduling
The arrival rate of patients is the key starting point for addressing any patient flow issues that could be negatively affecting patient experience or provider efficiency. By understanding provider work patterns and time duration for examinations and procedures, we can adjust and maintain the rate of patient arrivals to match the flow pattern of the provider.Time balance
If we have a good understanding of provider work pattern and time pace, and if patient arrival rate is in sync with that, the next step is to organize all of the activities upstream of the provider so that they can be accomplished within the same pace and rhythm. This can be tricky, as there are many factors that come into play, but with observation and study, we can effectively balance activities to stay on pace while maintaining the highest level of care.Room constraints
Does the practice have enough rooms to stay on pace with the provider? Delays in rooming patients causes stress and inefficiencies. Also, if not acknowledged accurately, spacing issues may be interpreted as a scheduling problem. Many practices will react to this situation by pulling back on the number of patients being scheduled. This only masks the room constraint problem and results in reduced provider direct-care time and, ultimately, reduced profitability. Staff constraints
The same idea applies to staff resource constraints. Similar to the room constraint scenario, when we do not have enough staff to stay on pace with the provider, we should acknowledge it and make adjustments to keep the practice operating at the optimal pace.No constraint, just waiting
This one comes with bad news and good news: The bad news is that while we tend to look for constraints to address, such as the number of rooms or the number of staff, all too often there is a patient waiting, a room available, and a staff member available, but no direct care happening. In this case, there is no constraint, just a slow response. This is, by definition, the worst and most expensive waste in the system. The good news is that this problem is easy to solve and doesn’t require additional investment. With improved workflow communications, team-based problem-solving, and management engagement, this type of avoidable wait can be minimized and throughput enhanced.
Applying these principles to your dental practice
Long wait times can have a disastrous effect on a dental practice. Research shows that not only do longer wait times severely impact patient satisfaction, but the longer patients wait, the lower their overall perception of their provider and quality of care. This can go on to have an impact on how patients perceive important instructions and information given by their provider.1
Add to this the current pandemic, in which patients congregated in waiting areas endanger the health of all people present in the clinical setting, and we should begin to see using lean principles to reduce wait times as more than just a matter of patient convenience. Improving patient flow is pivotal from every perspective.
1. Bleustein C, Rothschild DB, Valen A, Valatis E, Schweitzer L, Jones R. Wait times, patient satisfaction scores, and the perception of care. Am J Manag Care. 2014;20(5):393-400.
DENNIS MCCAFFERTY, MBA, is president of Visual Clinic. He is a Lean Six Sigma Black Belt professional with extensive training and experience in the deployment of Lean Six Sigma methods, such as the Toyota Production System.