Economics year-long "Quality Management" series.

Sept. 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.

Process improvement is dentistry`s remote control

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

Dr. Bruce Waterman

The cover of my Father`s Day card trumpeted this message: "We want to honor you with a statue in the front yard. We just have one question." Inside the card, it asked: "Which hand do you hold the remote control in?"

TV remote controls are a major improvement in the process of changing channels. Most American men can testify that remotes have made channel-surfing a breeze. It certainly is much easier.

We need to take this appreciation of process improvement and apply it to our practice-management mind-set. We all want to make our jobs easier, but it usually takes an improvement in a process to achieve this.

Consequently, if we want to improve the processes in our offices, we must first develop an understanding of the processes themselves. What are processes? Processes are the multiple steps or transactions that occur in the normal function of an activity. For example, the process of preparing and placing a filling requires multiple steps. A process improvement was the development of the tray and tub system. This made the filling process much easier than when all the instruments were in drawers. So, you can see, process improvement is not foreign to dentistry.

Fortune 500 companies around the world have utilized the tools of TQM (Total Quality Management) to achieve their process-improvement successes (reference GM and Saturn). In dentistry, we want tomake process improvement a functional part of our management. We need for it to be created by us routinely and purposely.

Three steps to process improvement

Step 1: Identify processes. Two types of basic processes are utilized in the dental office: 1) clinical and 2) informational.

Clinical processes: Each chairside procedure we provide has an associated series of steps to that particular process. The good news is that dentists are very active in trying to find easier ways to reduce the number of steps or improve the clinical materials and methods involved. Clinical-process improvement is created by dentists routinely and purposely.

Informational processes: The flow of information in the operation of our offices is the area of process improvement that has the most potential for progress. If we transfer the mind-set of our clinical inclination for process improvement to this area, we can increase our operational efficiency tremendously. Examples of information processes are the information flow from the initial telephone call or appointment until the final billing for new-patient exams, emergency patients, planned care, and hygiene appointments.

If you follow the flow of a chart, you usually can identify the major steps within that process. For example, consider the steps in the process of seeing an emergency patient:

(1) Phone call to receptionist and appointment;

(2) Dental assistant seats and checks patient;

(3) Doctor examines patient and treatment is rendered.

Any informational processes that have inherent unpredictability - such as seeing emergency patients - are prime candidates for process improvement.

Step 2: Understanding variability. Dr. Deming, the guru of the quality-management revolution (TQM), said that the ultimate goal of management is to optimize your system. To maximize your operations, you must minimize its variability. Some variabilities can be eliminated, while other variabilities only can be minimized.

To effectively deal with a minimized variability, your system must also establish guidelines of adaptability. Consider the variability that occurs in all offices with emergency patients. These patients` needs vary widely, and the time and treatment needed often can be guesswork and can destroy the best-scripted schedules. It would be nice to eliminate this variability or have systems to allow for easy adaptation.

Step 3: Process Flow Diagrams (PFD). Dr. Pete Dawson, in his seminar, "How To Put Your Practice in the Top 10%," often states: "If something is analyzed, it improves." TQM gives us tools of analysis, such as PFD, that our traditional management does not. Before you roll your eyes because a PFD looks too technical, let me point out that my fourth-grader advised me that they do PFDs all the time in school. A PFD is an easy tool of analysis, so it should not be intimidating.

Let`s go through an example of a PFD analysis from my office that illustrates the three steps to process improvement.

Reducing variability

In my office, the variability presented with emergency patients often would create scheduling conflicts and cause us to run behind. Utilizing TQM tools, we did the PFD shown in Figure 1 to analyze the system. The result was a reduction in average diagnosis time from 45 to 15 minutes.

The original PFD had 10 steps (not shown). The new PFD has five steps that reflect deletion or consolidation of redundant or ineffective steps.

The PFD yielded eight improvements explained below:

Phone Sheets: We found that a lot of valuable information given to the receptionist was not conveyed routinely to the treatment areas. The main format was verbal and the time or opportunity for information exchange frequently wasn`t available. We developed a form that specified needed information that could be easily filled in or circled.

Consequently, with better information, we could anticipate needs, know likely treatment set-up and time required, as well as make other scheduling decisions related to this emergency patient. For example, for a third-molar problem, we could copy the panarex and fill out referral forms before the patient was seen. This would enable the patient to be easily scheduled and referred. The telephone sheets are so handy, my wife and children can fill them out at home for those after-hours telephone calls.

Double X-ray: By routinely taking a double X-ray, we would have a radiograph ready for referral or for insurance use.

Handouts: We found we could standardize and improve information for patients by expanding our available educational handouts. Consequently, the dental assistant could begin the educational process early in the appointment when indicated. For example, if the patient has a possible TMJ problem, the TMJ handout is given to the patient. This begins his/her educational process and helps in the diagnosis.

Dental Assistant Notes: The dental assistant routinely supplements the telephone sheet information with subjective information from the patient and records this in the chart. We recently have added a rubber stamp that gives the assistant a format of symptoms to circle. This aids in standardizing data collection.

Quick Report Summary: The dental assistant provides the dentist with a verbal summary of findings and any health-history concerns, efficiently condensing pertinent data. This is similar to a report given by nurses during shift changes in hospitals.

Focused Data: This information allows the dentist to quickly determine the problem and not repeat previous data-collection steps. The data can be validated quickly.

Improved Financial System: Refinement of the system and verification of financial arrangements are performed before treatment is initiated.

New Referral Form: I created my own referral form that allows referral to multiple specialists and a summary of needs. For example, a patient may not be able to decide if he or she wants to see an oral surgeon or endodontist. We will attach my referral form to both specialists` forms to meet this need. My referral form also is helpful in a situation in which one of several endodontists may be utilized. Often, the endodontist the patient selects is determined by circumstances beyond my control, such as appointment availability, insurance, and/or office policies. Attaching my referral form to all of their forms covers this contingency. Instead of having to fill out all of the endodontists` forms, we just fill out mine and attach it to theirs. Of course, the duplicate X-ray is ready because of steps already taken.

From this analysis, you can see we addressed the three steps to process improvements:

1) Identify processes - We improved an information process by refining and focusing the flow of data.

2) Understanding variability - We eliminated considerable variability in each step of the process. We do not lose valuable data at the initial call and standardization of process flow eliminates operational uncertainty. For a variability that could not be eliminated, the systems created allow for adaptation as needed.

3) PFD - The PFD took 15 minutes to draw, and this time invested led to a minimum one-half hour of time-savings per day. Analysis often leads to innovation: The act of drawing the PFD sparked the ideas for the eight improvements detailed in this article. The lesson learned: as dentists, we should spend less time defending our inefficient ways and more time on analysis and improvement.

By improving our ability to see emergency patients, we eliminated wasted time and reduced variabilities in our system.

From a patient`s perspective, this allows us to see them easier, faster, and with more predictability. There also is less inconvenience to other patients. In terms of doctor and staff, we have created less stress, more efficiency, and better time management. Things are easier ... almost like a TV remote control in the right hand!

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