Health care providers today are feeling significant pressure to work more efficiently and streamline procedures in their offices. The pressure can come from insurance companies, patients, or the government, but the message from all parties is to reduce costs and avoid waste. For dentists faced with the pressures of running their own practices, the push toward greater efficiency can be internal as well, based on a desire to minimize unnecessary costs and keep the practice running profitably.
Perhaps you have already tried to implement a procedure aimed at increasing efficiency, but factors like staff indifference and a lack of follow through have let these goals fall by the wayside. Or perhaps you have no idea where to start looking for added efficiency, with the daily flow of patients keeping your time full as it is.
The benefits of implementing a lasting and effective program to increase efficiency can be significant in helping you face the pressures outlined above, making your practice run more smoothly and delivering more value to you and your patients. Through these types of programs, A-dec and organizations it has worked with have seen numerous gains that you’ll learn about below and clinicians such as Dr. Sami Bahri have dramatically streamlined their practices to achieve up to 82 percent improvements, as well. In light of the potential gain from such an effort, added efficiency should be carefully examined in the dental practice.
Getting to a Place of “Lean”
The good news is that once you are serious about improving efficiency in your office and committed to putting a system in place, there is an outstanding roadmap to follow. Perhaps you have heard of “Lean manufacturing.” This production process has been put into place by some large scale manufacturers, but the truth is that it is not just for factories. The basic principles of “Lean” are highly adaptable, and can be put into place in any environment, from your home to your practice.
A-dec has been utilizing these principles since the early 1990s, and we have seen the dramatic effects they can have on a business. We have also witnessed some of the obstacles that are often encountered along the way. With experience putting Lean principles in place at our facility in Newberg, Ore., as well as in collaboration with Oregon Health & Science University (OHSU), we have observed the process of implementation for many different procedures and atmospheres.
The Lean Revolution
The terms “Lean principles” and “Lean manufacturing” were not coined until the 1980s, but this system of thinking actually had its origins much earlier than that. Many sources point to Henry Ford as one of the pioneers of Lean manufacturing, thanks to his development of the assembly line and his emphasis on waste reduction. Years later, it was another auto manufacturer, Toyota, that further developed these ideas into a form that was more widely popularized. The Toyota Production System was designed to facilitate continuity and process flow and also to accommodate a broader variety of product offerings than the highly standardized Ford Model T. Toyota’s system emphasized the flow of materials through the manufacturing process, seeking to smooth it out and remove obstacles or factors that slowed progress.
In 1990, “The Machine That Changed the World” was published, outlining the success of these systems for Toyota and other Japanese auto manufacturers. A later volume, “Lean Thinking” further explored this production process and outlined five core principles at the heart of Lean manufacturing (Figure 1):
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| Figure 1 |
- Specify the value desired by the customer
- Identify the value stream for each product or service and challenge all of the unnecessary steps currently taken to provide it
- Make the product flow continuously through the remaining value-added steps
- Introduce pull – identifying or creating a need – between all steps where continuous flow is possible
- Manage toward perfection so that the number of steps and the amount of time and information needed to serve the customer continually falls
This language is tailored toward the production of consumer products, but it’s easy to see how these steps can be applied to procedures in the dental office or any other environment.
Lean as a Way of Life at A-dec
At A-dec, our founders Ken and Joan Austin were intrigued by the idea of Lean manufacturing when it was popularized in the early ‘90s. The principles were appealing as a way to facilitate greater efficiency and because they were very compatible with “the A-dec way,” guidelines the company already had in place to encourage creativity, innovation, quality and conservation, among several other virtues.
While there is considerable meaning in each of the Lean steps outlined above, perhaps the most important for A-dec is the second step—identifying the value stream and any wasted steps. In the years since implementing Lean, A-dec has focused its efforts on examining all of our processes and looking for ways to improve each one. Very often this has led to cutting unnecessary steps or streamlining needlessly complicated processes (Figures 2 & 3).
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Caption: Supply management is a common area where processes can be improved. Figure 2 shows A-dec’s upholstery sample room prior to implementing Lean processes. In this state, photographers expended unnecessary time searching for the items needed for their product shoots, clearly not an easy task. Figure 3 shows how Lean processes have streamlined the storage space so each set of upholstery has a labeled “home” and it is a much easier and safer environment to navigate. |
To identify potential areas of improvement, we rely not just on management, but on every employee. We keep Lean principles top-of-mind and continually look for opportunities for improvement by posting “idea boards” throughout the facility, on which employees are invited to post ideas for productivity improvements. Additionally, when studying a process in one particular department, we include employees from a wide range of specialties within the company. These “outsiders” are sometimes better able to see things that aren’t as evident to people who work with the system every day. We know that each employee’s unique perspective has the potential to benefit the company.
Additionally, our departments have annual goals of three percent improvement, which they are expected to reach by examining their own processes and looking for areas to refine. While three percent may not seem like a significant amount, the virtue of Lean is that small improvements add up over time to dramatic changes. No one is expected to reinvent their systems overnight, but rather to come up with small, incremental changes.
You’ve seen how these processes have simplified our upholstery storage, another prime example of how Lean has made a difference in our facility is in our stocking of raw materials. Prior to implementing Lean principles, A-dec stocked dozens of different diameters of raw materials, each of which was cut to size in a lathe for its specific function. When we started looking for ways to improve the efficiency of this process, we realized that while the material cost was not a great concern, the time spent on changing the chucks for the lathe was significant. By standardizing with just a few diameters of materials, we’ve been able to achieve a dramatic reduction in the time needed to turn the machine around. We save not only in terms of time for the employee operating the machine, but in greater productivity by keeping the machine running more frequently.
Implementing Lean Beyond Our Walls
Often when employees hear management speak of “productivity improvement,” they fear layoffs. However, our implementation of Lean has not resulted in a loss of jobs, something we promised our employees would not happen. In fact, it has allowed us to create new jobs within the company for Lean coaches, who help organize our various Lean initiatives and keep the culture of Lean prominent. In addition to being a valuable resource internally, these staff members are able to coach our broader community on implementing the principles.
Most notably, our coaches have led our alliance with OHSU in helping the university put Lean principles in place as well. A-dec and OHSU have been longtime collaborators, thanks to our proximity and to mutual high regard between our leaders. After witnessing A-dec’s success with Lean, Jack Clinton, DMD, Dean of the School of Dentistry, invited our staff members to lead trainings on the process at OHSU.
One major initiative that the school has undertaken since the trainings has been an examination of its dispensary management. The university looked at its process from beginning to end, including steps for authorization, delivery, unloading, storing, dispensing and final use. Initially the school was buying its supplies just once per year, then expending considerable time and energy managing the storage of such large quantities. After appointing a committee to examine this process through a Lean lens, however, the university has been able to develop a system that significantly reduces the wasted time and space in supply management. The key has been careful analysis of each small increment of the process, from delivery at the dock door to use of the product. A-dec trainers remain ongoing resources for the school as it continues its work on Lean principles.
Making Lean Work for Your Practice
In any health care setting, there are rules and regulations that dictate how certain procedures are carried out. Some dentists may therefore read about Lean and think it can’t be applied within their own practices because of these strict rules. Fortunately, the flexibility of the system makes it adaptable to almost any situation, and it can easily be put into place in compliance with health care regulations.
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| Figure 4 |
Take a look at the processes in your practice. On a daily basis, you schedule and treat patients, utilize instruments and supplies, and manage staff and office upkeep. Opportunities to apply Lean principles exist within all of these procedures. By looking at a key tool used in Lean training, “Stop Waste” (Figure 4), you can easily identify areas within your practice that would benefit from process improvement, avoiding unproductive downtime.
For example, can your daily schedule present more information at a glance (i.e. – Non-use of Capabilities)? Or is it unnecessarily complicated (i.e. – Extra Processing)? Are supplies being maintained and stocked efficiently (i.e. – Inventory)? Are staff members paying attention to ergonomics (i.e. – Motion)? Something as simple as the way you sit may have an effect on your energy level and your ability to accomplish more in a day. Embracing Lean principles can help you spot these opportunities and obtain an improvement of at least 50 percent in each section of the wheel that is addressed.
Not all changes made with Lean practices are simple, and this is where it becomes important to ensure that staff members are on-board as well. At A-dec, it has taken several years for Lean to become embedded in our culture to the point that every employee understands the principles and actively participates. In the beginning, any organization that implements Lean processes will likely encounter skeptics internally. This is one of the reasons that it is encouraged to form committees and seek input from a well-rounded team of employees when looking for Lean projects. By giving team members a voice in the changes that affect them, and by negotiating with them to give each change a trial period, dentists can encourage greater staff participation and ownership of Lean projects. Once the first few successes are evident, employees’ enthusiasm for Lean principles often increases significantly. Additionally, if the benefits of the increased productivity are shared with staff members, then their incentive to participate and offer their own ideas is even greater.
Ongoing Improvements and Ongoing Engagement
An interesting thing about Lean enterprise is that it’s never finished. At A-dec, we have examined the same processes a number of times and made measurable improvements—up to 20 percent—repeatedly. By presenting the problem to different groups of people and trying different ideas, we have been able to grow more and more efficient, all by tapping into the knowledge and creativity of our existing team.
As we have learned at A-dec, Lean is a way of thinking that can give any organization—including a dental office—incredibly valuable tools for solving problems and growing more efficient. These changes come at the same time that employees are engaged in a process that challenges them, fosters creativity, and is ultimately highly rewarding. Many resources exist to help business leaders learn more about Lean principles and put them into place within their own organizations. Dentists who are interested in streamlining their practices would do very well to learn more about these principles. The benefits of improved productivity and less waste are valuable outcomes for any business.
The author would like to thank Dr. Jack Clinton for his participation in the development of this article.
Chet Marchwinski. Dentist Drills Down to the Root Causes of Office Waste. (Lean Enterprise Institute: 2007).
James P. Womack , Daniel T. Jones, and Daniel Roos. The Machine That Changed the World : The Story of Lean Production. (Harper Perennial: 1991).
James P. Womack and Daniel T. Jones. Lean Thinking: Banish Waste and Create Wealth in Your Corporation. (Simon & Schuster: 1996)
