Wednesday, October 05, 2011

The Lean dentist

The next speaker I am hearing at the "Made Lean in America" conference is Sami Bahri, DDS, author of Follow the Learner: The Role of a Leader in Creating a Lean Culture.  The book describes how this organization, the Bahri Dental Group, transformed its work and thinking from a traditional batch-and-queue approach to one focused directly on the needs of the patient, not on the needs of the practitioners.

Sami related how his practice in Jacksonville, Florida was growing unsustainably.  His solution to complexity was to "hire more people," but he soon realized this was not the answer.  "I wanted to get rid of the problem.  I needed to find a theory.   With a theory, you can make quick decisions."  He then became aware of the Lean philosophy and the work of Jim Womack and others.  Reading a number of books, he figured out how to apply Lean manufacturing ideas to his practice.

Sami summarized that Lean was an evolution over time of our collective thinking.  We started as craftsmen; then moved to the division of labor; but then, with more complex processes, we had quality problems; then time and motion studies of people led to improvement of functions; and then we learned to follow the product to improve efficiency and improving quality.

Sami said, "I went back and started learning how Toyota did it.  How did Ohno start?  'The TPS started when I challenged the system.' "

Sami noted, "It took him five years to produce a high quality car.  It took me nine years in our practice."

His conclusion after all this time:  "The most important ingredient is people.  Are they learning every day?  If you want them to learn and sustain the system, you need your people."

Speaking of his practice, he noted, "Set-ups stand in the way of one piece flow.  We eliminated these."

Sami defining "leveling" as balancing load and capacity.  The idea was to distribute procedures, according to TAKT time, evenly throughout the schedule.

He had to define "flow" in dentistry.  This resulted in a system of one appointment to see all providers.  The end was continuous treatment, with no delay between providers (just-in-time treatment).

His goal was that the patient's stay time would be equal to the treatment time, eliminating waits, optimizing use of the patient's time but also the providers' time.

The treatment the patient receives changes during the appointment, but the patient location stays the same.  Providers move to where they are needed.  Crossing the functional barriers was key.  The hygienists, whose lives improved dramatically under this approach, ultimately said, "Please don't give me my own room.  I'll go to whichever room the patient is located."

Sami reported on patient satisfaction surveys, showing a remarkable uptick in their views about his office and his staff.

All in all, this was a marvelous presentation by a thoughtful entrepreneur applying the theories of Lean to a new setting.


Anonymous said...

Dr. Bahri's experience coupled with those detailed in Kenney's book "Transforming Health Care" certainly give impressive examples of how adopting Lean culture and principles can be indeed, transformative. And it appears that Lean is probably superior to other programs such as Six Sigma, etc. However, I continue to be struck by the inordinate length of time required to educate leaders and personnel, change culture, and truly make a difference. Don't get me wrong - I think this may ultimately prove to be the Holy Grail. However, health care is in such a deep quality, safety and efficiency hole that I fear taking 9, 10 or more years in each practice and institution to achieve significant change (and that's assuming everyone started tomorrow) is simply impractical.

I would like to ask the presenters the question; how can this system be adapted, or what else should be done, in order to bring about real and widespread change in a more reasonable time frame? As you phrase it, Paul, we continue killing and maiming people every day through our inefficiencies and errors.


Sami said...

Dear anonymous,

I wish someone had asked me that question at the conference, I would have corrected the impression I gave that everybody needs to take that long. It takes you 80% of the time to find the information you need to learn and 20% of the time to learn it. It’s the 80% of research that took us so long. That should not apply to people who decide to implement lean today because many experts can direct them to the right sources of knowledge.

As a live example, one internal medicine specialist, a good friend of mine, has applied our methods in his practice. In less than two years, he tripled the number of patients he could see per day. He estimated that short lead times are saving three patients a month from serious complications like strokes, heart problems, amputations, etc. On the financial side, he asserted many times that he multiplied his income by a factor of eight.

Anonymous said...


Thank you; that's much more reassuring. However, do you think your friend would have done as well without you around to teach him and give ongoing feedback? I just feel that many practitioners are out there not knowing where/how to start.

nonlocal MD

Sami Bahri said...

You’re right, having someone around helps; but more help is becoming available to practitioners every day. Many hospitals teach it. Many engineers, who learned lean in manufacturing, have transferred to healthcare. They are helping hospitals all around the country.
To help in non-hospital healthcare, with Underwriters Laboratories, we created a center to teach “Lean for Ambulatory Healthcare” in Jacksonville, FL.; it will open before the end of this year.
With Lean, you start improvements next to the customer; which gives you immediate results. We took many years because we didn’t know…
Where/how to start? Just think that you’re learning how to flow treatment. Take the simplest case, flow it through your system, learn from it how to flow a little more complex one, and so forth. In the mean time, treat the rest of the practice as usual. Every case you flow will save you resources. You’ll learn much faster than you think!
I’ll be happy to help, too. Just e-mail me, or comment on this blog, and I’ll tell you what I know.