The Lean Dentist Webinar Follow-Up Questions & Answers
Follow the Learner Webinar Follow-up Q and A
After reviewing all the questions that we couldn't get to during the webinar with Dr. Sami Bahri, several key themes emerged, such as lean leadership and how lean tools, such as one-piece flow (or in this case one-patient flow) were applied in a service company. What follows are the questions reflecting those themes and Dr. Bahri's replies.
Dr. Sami Bahri, DDS
- Founder, Bahri Dental Group, Jacksonville, FL, where he has implemented lean principles for over 15 years
- Author of Follow the Learner: The Role of a Leader in Creating a Lean Culture (Cambridge, MA: Lean Enterprise Institute, 2009)
- Recognized as the “World's First Lean Dentist” as a keynote speaker at the Shingo Prize Conference
- Lectures nationally and internationally on lean management
Q. What has lean done for your bottom line? Do you pass any savings to your customers in the form of reduced costs? Has it improved your competitiveness in the market? Are you seeing an increase in new patient intake?
A. The bottom line: we had taken a loan on the office in 1998 and half of it was paid off when the lean breakthrough happened in 2005. Less than a year later, we felt comfortable enough with our cash reserve that we paid the remaining half in a single payment.
We pass savings to customers because of our increased efficiency. We were able to join more insurance plans (PPOs) without reducing our level of profitability. Those plans require us to reduce our prices by as much as 20%, which had deterred us from joining them before lean. Actually, one of our fundamental principles, as described in Follow the Learner, is to pass on ALL the savings to the patient. Some patients say that our prices are the lowest of everyone they called, especially for orthodontics. That would have not been a cause for pride had we not been aiming at passing savings to the patient.
Regarding competitiveness and new patients, they go hand-in-hand. In my experience, lean has attracted two main groups of patients -- the busy ones who wish to spend less time at the dentist, and the ones who need immediate response such as emergencies and people going out of town. We see a large number of patients transfer to our office because they call their dentist for a toothache or a fractured front tooth, and their dentist cannot see them before a week or two. We offer to see them immediately, and usually treat them the same day. We have also seen a good number of our patients who had left our office before the lean transformation because of the wait length, return after we started applying lean.
Q. We started a lean program, where the CEO was fully supportive and the first year was great. Now we have a new CEO focused on cost reduction and he has reduced the headcount of the lean experts by 90%. On top of that, he is not supportive of the lean effort, hence the rest of the leaders are not helping anymore. As a team, what should we do? The CEO is not listening to us and the program is dying slowly.
A. We found that people get more resistant if you give a label to any program. Lean, TQM or any other name would cause people to feel boxed in. In our office, we never called our management system anything at all for over 15 years. We were just discussing problems and implementing improvements. Only after well-respected lean thought leaders visited the office did I feel the need to tell my staff that we were doing Lean Dentistry. The interest they saw from the experts helped me curb their anticipated resistance. My advice is to simply present improvements you learned from your lean experience and studies, without any label, and work on honing your "convince by providing proof" skills with the CEO and other leaders.
Q. What are some specific things you did to overcome the doubt and hesitation in staff?
A. Doubt and hesitation generate resistance. The entire social section in Follow the Learner deals with this subject. It is divided in three parts according to the three P’s of leadership: purpose, process, and people. In the process section we defined our organizational values and "rules of the road" by which decisions are made at all levels of the organization, in the process section we defined our guiding principle to becoming a learning organization where staff can reach their full thinking potential and act on improving their environment to serve their patients and themselves better. In the people section we described the principles we follow to make sure every person feels appreciated and respected in their intelligence, time, experience, knowledge, and integrity.
Your question is very important and it is at the heart of a lean implementation. To overcome doubt and hesitation, we have to deal honestly with people, without any gimmicks to artificially motivate them. We need to deal scientifically with problems and countermeasures, and use experiments to provide proof that new countermeasures are good to adopt. If after experimenting they don’t like the results, they need to feel safe to revert to the old way of doing their job.
Q. Would you agree that deciding to become a leader does not equal "declaring" yourself to be a leader; that you are a leader when people decide to follow you and that happens when they believe you have their best interests at heart?
A. Absolutely. Leadership is a human relations game, based on absolute respect for life in general, and for people in every aspect. I would like to add that team members are not watching out for their own interests only, but also for the interest of anyone you deal with. My assistants are watching, I believe, to see if I am honest with patients, suppliers, lab technicians, and anyone else. Failing at any of these interactions would cause me to lose their trust.
Q. As the leader did you find yourself concentrating on the big system or one lean aspect at a time? How did you balance both?
A. The only aspect that is specific to lean is one-piece flow. Every other aspect, including just-in-time, could serve any management system. In a batch and queue or theory of constraint or reengineering environment, is it possible to do 5S, continuous improvement, leveling, respect for people, mistake proofing, reducing setup times, sacrificing short-term interests in favor of long-term ones, going to see for yourself (genchi genbutsu), reducing waste, you name it? All are possible without shifting to lean production. Is it possible to do one-piece flow and not call it lean? It is not.
What is my point from all of that questioning? I have worked one aspect (i.e. reducing setup times, cross-training staff, adopting visual systems etc.) at a time for a long time. It resulted in some marginal improvements. But, when we eliminated the functional barrier between dentist and hygienist, the major value-adding operations, the one-patient flow system forced us to accelerate its own implementation. The old batch and queue system and the one-patient flow system were not able to coexist at all. How did I balance both systems? By accelerating the implementation of the latter. But that is not what I would recommend, now that I learned from that experience.
I recommend balancing both aspects by implementing one-piece flow in a small area, one dentist and one hygienist in our case, on a very simple repetitive one-piece flow task like combining a cleaning and a filling on the same patient. Implementing all the lean aspects in a small area provides a learning experience that would allow for an easier implementation throughout the organization. Convincing people by providing proof is easier when you have less people to convince and when you use a small area to show them faster results.
Q. Is it best to lead from the front or from the back?
A. Whichever will persuade them to go forward. As long as your true north is clear to everyone and you are learning together how to reach it, it doesn’t matter. It is interesting that you mention it in terms of relative position of leader and team. In Follow the Learner we say that when you take one-piece/patient flow as your true north, and determine the values by which decisions are made, you can walk next to your team members and learn with them where and how to go forward. Overall, I think that I have switched position, from front to back to side-by-side, according to the needs of the moment. Persuasion by providing proof is what determines a leader’s path.
Q. During the presentation, you mentioned something about 20% work and 80% results. Could you clarify that?
A. The 80/20 principle suggests that, symbolically, 80% of your results stem from 20% of your efforts. It also means that the remaining 80% of your efforts will give you little results. It applies to everything in life and business, including your improvement efforts. One important task of a leader would be to identify those critical few efforts that will yield great results. In our improvement experience, we found that the efforts that you spend seeking one-piece flow in your value streams represent those critical few efforts (20%) that will give you good results (80%). The efforts that you spend on improving your operations, without seeking one-piece flow in your value streams, will expend a lot of energy to yield small results.
Q. Can you describe your kanban system in more detail? Does it use cards, electronic signals, or other forms? Are there permanent cards in constant rotation or cards that are used once? Is there one queue for collecting the cards or are they collected at each dental chair?
A. In Follow the Learner a detailed description of the kanban system spreads over several pages. In summary, we use an A4 paper, color coded by provider. A cross-functional flow chart shows the progression of a patient’s treatment as the different providers come to the chair and perform their part of the treatment. We haven't found yet an electronic form that would track the flow of treatment as effectively as the paper form (but we're open to suggestions). At first, we used one sheet of paper for every patient, then moved to laminated, reusable paper with erasable writing -- just to save on paper. At the end of appointments, the cards are wiped with hospital grade disinfecting wipes and returned to the front desk, where they originated, to start a new cycle with a different patient.
A. We use both. However, we learned about kaizen around 1993 from the book with the simple title of kaizen and we used it extensively. In my opinion, applying kaizen indiscriminately, before you create flow in your value streams, was a very wasted effort. However, using it after flow, with the goal to improve one-piece flow is a great source of improvement. We learned about A3 reports recently; in John Shook's book Managing to Learn. A3 reports are an excellent tool to apply PDCA (Plan, Do, Check, Act) learning cycles.
Q. Can you give examples of how you used visual management?
A. One cannot create enough visual clues. We have them at many levels in the process, and I always think that we are far from having enough of them. Here are some: We have given almost every item a parking spot. We marked on the parking spot what belongs in it and on the item where it needs to be returned. We use color coded cards on top of the cabinets to indicate if work is flowing or if we need help in that room to stay on schedule. The dental supplies have a special color coded storage cart and bin system allowing anyone, with no previous experience, to restock the rooms precisely. Our reordering is visual, when some materials go below a certain point they need to be reordered. The schedule is color coded by provider, using the same colors as the kanban. [See the webinar slides or use the success story link at the end of this Q & A for examples of Dr. Bahri's use of visual management. -Ed.]
Q. Have you considered how the Theory of Constraints can apply to your practice?
A. We have. I personally was very interested in learning it and ended up with my own conclusion. If you have read Goldratt’s The Goal, at some point, the expert goes to the shop floor and looks for a bottleneck, where inventory has accumulated. He recommends eliminating that bottleneck and watching where the next one is going to form. The process is repeated over and over, continuously improving process efficiency. I tried to imagine: What would happen if I eliminated all the bottlenecks and arrived at a perfect process with no inventory waiting between the operations? Pieces would have to flow one at a time -- one-piece flow again! The only difference -- tell me if I’m wrong -- is that instead of starting close to the customer as in lean management, the Theory of Constraints starts at the bottlenecks, somewhere in an upstream operation. I think that starting close to the customer is a much more efficient starting point; it goes straight to heart of the process.
That is not to discount the value of the Theory of Constraints. We see bottlenecks at the front desk, the hygienist, the dentist, and the sterilization area. There is no harm in removing the bottlenecks at those levels in a cyclical way.
Q. How does your practice deal with variable demand? I suppose the number of patients varies by month, week, and day of the week.
A. We staff for what is normal demand. In hygiene high seasons, we hire temporary hygienists until things go back to normal. So far we’ve been able to hire a former employee who has retired except for when we need her. But lately, we had to interview for her position because she moved to live with her daughter in a different state. In the high season for general dentistry need, we have not had to hire outside help yet, since all the staff comes together, front desk, flow managers, assistants, hygienists, and dentists to figure out ways to meet the needs of the practice.
Q. How do you handle multiple, simultaneous no-shows?
A. If simultaneous no-shows get to the point where we have no patients in the office, there is nothing we can do but try to call someone on a waiting list, or utilize the time for improvement activities. If, however, we had no-shows in my schedule and we have a new patient or a hygiene patient needing treatment, we often end up treating those patients. Usually, when we start with an almost empty schedule, we end up working on emergencies, hygiene patients, and new patients as hard as when we start with a full schedule.
Q. Have you been able to apply lean successfully in the back office, specifically, working with insurance providers to improve speed of payment?
A. We have nearly eliminated the back office altogether. Departments are against the spirit of lean. Our insurance claims are filled and filed in the treatment room as the treatment is being performed. As you know, we have no influence on the processing speed of the insurance carrier. But we can minimize the time needed to set up the patient file and verify insurance coverage before the appointment, and minimize the number of mistakes that would delay insurance payment. For insurance verification, we studied the time it takes to verify all insurances and divided them in four categories, ranging from 30 second to 30 minutes. Insurances are verified, each according to the time needed.
To mistake proof the filed claims, we type any specifics on the appointment slot in the schedule. Then we provide the assistants with checklists allowing them to verify the information’s accuracy. The insurance manager reviews the claim, in the spirit of applying successive checks, before it is filed electronically. When the insurance manager read this question, she took out a claim and said, "This claim, for instance, has been paid in 16 days." That kind of time frame is probably usual for electronic claims. Our checklists and successive checks make it more consistent and minimize rework.
Q. How do you handle the unknown and unpredictable cycle times due to each patient having different needs? How do you balance this against a smooth takt time?
A. A smooth load is always a priority. If treating the patient immediately will strain the schedule, we try to find the first opening that allows the schedule to be leveled. But practitioners would give you the same answer whether they practice lean or a different system. So what is different in lean? You reduce the amount of time that your staff spends on secondary activities, like setups, to free them up for patient treatment. When team members and chairs are free more frequently, you would be able to treat patients sooner. If you can’t do it immediately, you’ll do it this afternoon or tomorrow. That is still very quick by today’s standards. Before lean, we used to make appointments a week later; and we still see some of our colleagues delay treatment by even more than a week or two. The problem is that when you think your schedule is full, it could be filled with preventable activities that lean teaches you how to avoid so you could make room for more patient treatment.
Q. How do you decide what [dental] chair to send patients to before examining them? Do ask questions at book-in?
A. All the chairs are equipped to receive patients. The assistant and the flow manager decide which chair is more convenient to the flow of the rest of the schedule. And, you're right, we ask as many questions, at the book-in, as needed to have a reasonably clear idea on what to expect. The more the people who answer the phone know about dentistry, the more precise the information we gather and the easier to evaluate in advance the patient's need.
Q. How do you get around needing time to let Novocain take affect?
A. We give priority to value-adding work. If the patient needs a cleaning, the hygienist will clean his or her teeth while the anesthesia is taking effect. If no value-added work can be done, I do a hygiene check while the assistant takes an x-ray or a preoperative impression, answers any questions the patient might have, etc. Again, decisions are being made on the spot on how to best utilize our time while balancing quick response, leveling the schedule and capacity.
Q. Can lean be applied to other service industries such as a law office where client contact is minimal but service production is similar to a continuous line flow?
A. Lean can be applied in any industry, including law offices. We actually have met with two law firms here in Jacksonville who are working on implementing lean. I wish I had some results to share with you, but it is still too early in the process.
Q. What are your future objectives for continuing to improve lead time?
A. Short lead times give your system the flexibility to respond quickly to market changes. Short lead times keep your resources free to serve any new, unexpected demand. We used to express our satisfaction with a management system by saying,"We are doing a good job keeping those chairs full," meaning that we always had someone to treat in those chairs. The other day I was giving a lean practitioner a tour of the office and caught myself saying for the first time: "We are doing a good job keeping the chairs empty," meaning that we are being able to treat patients fast, and still keep our resources free to receive unscheduled demand. So my objective is to make my systems more and more flexible and adaptive so I could treat my patients exactly when they want to be treated.
For More Information:
Follow the Learner: The Lean Dentist is the book by Dr. Sami Bahri that explores how to build a continuous improvement culture based on lean principles.
Dentist Drills Down to the Root Causes of Office wasteis the LEI success story about how Dr. Sami Bahri, driven by a gut feeling that the traditional method of managing a dental office could be improved dramatically, educated himself and his staff in lean concepts, validated the approach in pilot projects, then transformed his office.
Lean Enterprise Institute Webinar Library: To get first notice of free webinars and when follow-up answers are posted, make sure you are subscribed to our monthly e-letters. Using the Home tab drop-down menu, log in and check "Allow E-letters" near the bottom of the form.