Friday, December 07, 2012

Who needs a waiting room?

Passing through Jacksonville, FL, I took the opportunity to catch up with "the Lean dentist," Sami Bahri, about whom I have written before.  Walking into his office, I was struck by this view of his waiting room.  This is a more or less typical situation.  Patients entering the clinic are immediately escorted into a treatment room.  Organizing a clinic's work flow to produce an efficient treatment of patient flows is a direct result of Lean process improvements.  I joked with Sami that he should find some other use for this space, like starting a book store or something!

One of the things I like about this clinic is the practice of treating a patient for all of his or her needs during one visit.  Most of us go to dentists who require us to come back for a second visit if we have a cavity that needs filling or some other procedure that emerges from the cleaning and examination.  Not here.  If they find a cavity, they fill it on the spot.  The result has been a 24% reduction in the number of appointments at the clinic (for the same number of patients.)  Besides making life more convenient for the patients, the office has eliminated the make-work associated with second or third visits: scheduling, confirmation, extra cleaning of each exam room, billing and collection.

Sami and his staff are very proud of customers' reviews on Angie's List--all "A" grades.  Comments reflect the perspectives of patients.  They don't know that this is a Lean clinic, but they do notice the aspects of customer service that result from the Lean philosophy:

This group is wonderful. Personnel are all low key.  I had a crown pop off.  No pain but they offered me a same day appointment if I wanted it.  Fixed tooth with the same crown.  None of this high-priced push for work you don't need.  I can really get intimidated at dental office and I didn't here.  My old dentist had retired and the new one was sell sell sell.

Thorough, professional and kind.  I was seen today and will be taking my children to this office also.

They are kind and compassionate.  They are all encompassing.  They will squeeze you in if you need them even if it is night.  You never seem to have to wait more than 10 minutes.  The staff is great and knows you by name.

There is not a single person there that I would not trust to provide 100% excellent service with skills, knowledge and compassion.


e-Patient Dave said...


And, now let's get two lists:

1. The reasons this isn't possible in medicine.

2. A parallel list from unsuspecting dentists (who haven't seen this post) about why this isn't possible in DENTISTRY. :-)

Compare & contrast lists. :)

Howard said...

How do they do it regarding scheduling? If they have scheduled a cleaning that is a certain amount of time. If they find a cavity and do it at that time, what about the timing of scheduling for those patients who follow? If they schedule time for something they might find and don't find it, what do they do with the dead time?

Paul Levy said...

The power of a Lean system is its ability to flex up and down as needed by the customer. It is a wonderful thing to watch, whether in a service or manufacturing setting.

Mark Graban said...

I've visited Dr. Bahri's office and I was very impressed with the spirit of everybody working there. It was very much a "can do" spirit where the team, under Sami's leadership, works together to figure out how to adjust when things run longer or shorter than expected, etc.

In a Lean environment, having a plan is great, but it also requires flexibility to have a gameplan of how to react and adapt... learning and improving as you go over time.

Some interviews I've done with him before:

Anonymous said...

Oh yes, it is possible in medicine. If I recall correctly it has been done at one or more clinics associated with Virginia Mason health system, as documented in Charles Kenney's book 'Transforming Health Care', about their Lean journey of over a decade. I have seen other references to it also - but, like everything in health care improvement these days, it is spotty and not widely known.


Unknown said...

There are a few ways to design a schedule that is flexible to accommodate the unexpected cavity. They probably have a good idea (through experience & data) how many cleanings they do before an 'extra' need comes up and also know how much time these various things take. One could build the schedule with the (safety) buffer times to address these unexpected occurrences. It won't be perfect but it does work to smooth out the schedule and allows you to take care of your patient in one visit instead of a separate visit. If the buffer times aren't used, you can use that time to improve the work.

Sami said...

Dear Howard,
Your question presents the fundamental problems we’ve tried to solve since the early 1980s. The answer, as I see it, is multifaceted.

Scheduling mechanics, although important, are merely a reflection of much deeper preparations in the way we organize our work, in the way we think about capacity, in the skills required from team members, and their willingness to learn, teach and help. Mark has given an effective summary in a couple of sentences; I’ll give a few more details.

Taiichi Ohno, the main creator of the Toyota Production System, said: “A man-hour is something that we can always count. But do not come to the conclusion that ‘we are short of people,’ or ‘we can’t do it.’ Manpower is something that is beyond measurement. Capabilities can be extended indefinitely when everyone begins to think.” The idea here is team thinking, team learning, team flexibility, team system building and team continuous improvement. This kind of collaboration has allowed us to increase our capacity as needed, although not indefinitely as Ohno expected.

Variation puts different levels of strain on our schedule. Here are some of what we did to offset its effects:
At a basic level, all team members are cross-trained to the full extent of laws and regulations. They are all willing to assist wherever they are needed; the assistant would answer the phone, the dentist would clean teeth, the hygienist would assist at the dental chair, etc. Cross training gives us a good amount of flexibility.

We have organized our work to treat the whole mouth in one sitting whenever possible (around 70% of the cases.) That practice reduced the number of appointments by almost 1800 in one year (24%, as Paul mentioned) multiply that by the number of make-work steps and you’ll find that we have plenty of time to treat more patients.
Alice is right about the buffer time. We keep our appointments loose. If we reduce three appointments to one, we can schedule that appointment a little longer than expected, and still save time. We use that buffer time to give patients a break if they need it within the appointment, or we might finish early and treat a patient who was added to the schedule. It also happens, as you said, that we have no patients to treat during that time; we use it for problem solving and continuous improvement, or to replenish the rooms. Sometimes a little rest won’t hurt either!

Sami said...

(part 2)

We’ve created a scheduling template based on our past rate of demand. It aims at leveling our schedule. A way to describe “leveling” would be to load the successive hours of the day with equal amounts of work.
For higher strain levels, we have a “Patient Care Flow Manager”—“Flow manger” for short –who constantly analyzes and reallocates human resources to allow for a smoother treatment flow.

As for the number of doctors in the office, I would like to say the following:
I have practiced solo for 15 years. The same ideas apply, with some adaptation, of course. My ideal schedule was one big case in the morning and one big case in the afternoon. Very similar to “one-patient flow!”

I feel that with Lean, Doctors in group practices work more like solo practitioners. In my case, out of 10 dental chairs I use only two.
The system was designed for offices with fewer resources. Ohno used to invite workers to use their ideas since Toyota had no money to expand its facilities or to hire more people.

To end I would like to clarify that it is impossible to finish every case in one appointment (one-patient flow.) Many obstacles can prevent it from happening. The need for lab work is one of them. Waiting for healing after a surgery is another. It is more realistic to say that “one-patient flow” is what Lean thinkers would call a “True North” goal. You’ll never reach it, but it shows you the right direction for your improvement efforts.

If this post raises more questions, please don’t hesitate to ask.

PS: I described some of the tools here, but one can find a more detailed description in my book “Follow the Learner” and the Video published by GBMP “Single Patient Flow: Applying Lean Principles in Healthcare”