process, elements, and the dental practice · process, elements, and the dental practice. ... table...
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Process, Elements, and the Dental PracticeDelivering Clinical Effectiveness and Efficiency
James Patsis, DDS MBA
One Sweet Nation…without a Dental Plan!
Annual sugar consumption per person
2003: 142 lbs
1967: 117 lbs 1901: 7 lbs
U.S. News and World Report, 2005
Waiting for a Fluoridated Solution in PA
a1.0 ppm = 1 mg/L and is the effective dose for drinking water From the American Dental Association from ADA Guide to Dental Therapeutics (2nd ed.).
York,PA
23% of the Municipal Water in York County is Fluoridated…the prevalence of decay for at risk populations is not located in fluoridated areas
York CountyPop. 350,000
60,000 MA and<200% below Poverty
Guidelines
Decay Price TagYork County, PA
$105,000,000
Commonwealth of PA$17,500,000,000
James Patsis, DDS MBA
From General Dental Practice to the Continuous Chemical Process World
Collaborative Manufacturing and Supply Chain Strategies
November 5-6, 2002 -
Düsseldorf, Germany
James Patsis, DDS MBA
(Family First Health, York PA, Jan 15, 2005)
…into Community Health Dentistry
The BasicsThe Basics
Elements and Process
Water
Air Fire
Earth
Dental Department
Dental Appointment
Preparing the Room
Cleaning the Chair
The Chair
….Become Systems
(Process)
(Element)
(Task)
(Activity)
(Sub-Processes)
(Macro-Processes) Community Health Center
Types of Process Flow
Volume
ProjectProcess
JobProcess
BatchProcess
LineProcess
ContinuousProcess
Cust
omiz
atio
nGeneral Private Practice Dentistry
Community-Based Dentistry
General Medical Practice
Characteristics of Processes
Flow -
Transformation of Inputs to Output
Effectiveness -
Expectations are Met
Efficiency -
Resources Used to Produce an Output
Cycle Time -
Time from Input to Output
Cost -
Expense of the Entire Process
The Eff---words
Efficiency
is ability to improve the amount of output generated without changing inputs, or in other words, the amount of “waste" is reduced or removed
“The amount of slide you get without adding any more glide to it.”
Effectiveness
producing or capable of producing a desired result.
“Did you arrive at the ENDPOINT?”
Streamlinethe
Process
All Dental Offices have Elements…
…Tasks, Activities and Processes
BillingScheduling
Charting
DischargingPatient
Dental Filling Procedure
PreparingOperatory
In-TakingPatient
Reception
(Clinical Value-Added)
(Non-Clinical Value) (Non-Clinical Value)
(Tooth #30-O Amalgam)
The Most Critical Dental Process…
Is the Dental Appointment
The Dental Appointment
PreparingOperatory
(Clinical ValueAdded)(Non-Clinical Value) (Non-Clinical Value)
(Tooth #30-O Amalgam)
PreparingOperatory
Process Steps
The Dental Appointment
1.
Wipe Dr’s Chair2.
Wipe
Dental Light3.
Wipe Patient Protective Glasses
4.
Wipe
Dental Chair5.
Wipe Assistant tray and Hoses (5a) Wipe
Back countertop and sink (5b)
6.
Gather
Instruments/Cassettes on metal tray
7.
Wipe the place where the metal tray was seated with dirty instruments
8.
Remove plastic wrap9.
Wipe metal tray in sterilization
10.
Remove Gloves11.
Place new plastic coverings
18 Elements are involved in this Activity11 Tasks are involved in this Activity 5 Activities are involved in this Process
(Tooth #30-O Amalgam)
18 Elements are involved in this Activity11 Tasks are involved in this Activity 5 Activities are involved in this Process
The Dental Appointment
1.
Wipe Dr’s Chair2.
Wipe
Dental Light3.
Wipe Patient Protective Glasses
4.
Wipe
Dental Chair5.
Wipe Assistant tray and Hoses (5a) Wipe
Back countertop and sink (5b)
6.
Gather
Instruments/Cassettes on metal tray
7.
Wipe the place where the metal tray was seated with dirty instruments
8.
Remove plastic wrap9.
Wipe metal tray in sterilization
10.
Remove Gloves11.
Place new plastic coverings
The Dental Appointment
BillingScheduling
Charting
DischargingPatient
Dental Filling Procedure
PreparingOperatory
In-takingPatient
Reception
Process Steps
(Clinical ValueAdded)
(Non-Clinical Value) (Non-Clinical Value)
JUST IN TIME EVENT
MOST CRITICAL CLINCAL VALUE
ACTIVITY
BATCH EVENT
MOST CRITICAL NON-CLINICAL
ACTIVITY
1
3
2
4
Taking it HigherTaking it Higher……..
Processes Improvement Can …
Organizing for
Improvement
Understandingthe
ProcessStreamlining
MeasurementsAnd
Control
Continuous Improvement
Maximize Organizational Resources
Eliminate Clinical Errors and Delays
Increase Overall Patient Flow
Challenge Organizational Differences
Clinicians
Do-ers
1:1 interactions
Reactive personalities
Require immediate gratifications
Clinical Decision Makers
Value autonomy
Independent
Advocate for the patient
Identify with the profession
Independent
Management
Planners-designers
1:n interactions
Proactive personalities
Accept delayed gratification
Delegators
Value Collaboration
Participatory
Advocate for the organization
Identify with the organization
InterdependentOrganizing
for Improvement
“Enhancing Oral Health Leadership and Management,”
Dec 2008, McFarland and Rosenstein
Manage the Process
Limited Size OperatoriesImproperly Positioned Dental ChairsLack of Storage SpaceDental Workflows don’t match Floor Plan
Equipment/Supplies Physical Space
Incomplete Charts andSuper Bills
Inefficient SchedulingNo Maintenance Protocols
Inconsistent Practiced PolicyOSHA
Hazard MatsInfection Control
Lack of MaintenanceImproperly Placed Equipment
Unsuitable EquipmentNon-Standardized SetupsLack of Inventory Controls
Policy/Procedures Personnel
Lack of Trained PersonnelImproperly Positioned, Placed, And Use of Personnel
Improved Dental Delivery
… Examine the Process
Organizing for
Improvement
http://www.isixsigma.com/library/downloads/fishbone_template.doc
And Deliver Lean Dental Care
Digitalization
OfficeLayout
Level Scheduling
Standardized Work
Containerization
Provider Capability
Reductionof Variation
WorkplaceOrganization
EquipmentMaintenance
Supplier Development
ErrorReporting
PullScheduling
Lean Healthcare Delivery Output Input
InventoryControls
Understandthe
Process
Limited Size OperatoriesImproperly Positioned Dental ChairsLack of Storage SpaceDental Workflows don’t match Floor Plan
… Start the Process
Equipment/Supplies Physical Space
Incomplete Charts andSuper Bills
Inefficient SchedulingNo Maintenance Protocols
Inconsistent Practiced PolicyOSHA
Hazard MatsInfection Control
Lack of MaintenanceImproperly Placed Equipment
Unsuitable EquipmentNon-Standardized Setups
Lack of Inventory Controls
Policy/Procedures Personnel
Lack of Trained PersonnelImproperly Positioned, Placed, And Use of Personnel
Improved Dental Delivery
Phase I
Organizing for
Improvement
Lack of Trained Personnel
Work Standardization and Simplification
WorkSimplification
Work Standardization
(Family First Health Dental , Jan 2005) (Family First Health Dental , Nov 2007)
Work Standardization Quick Set-upWorkplace
Organization
Standardize, Organize and Deliver
Streamlinethe
Process
Control by Peer Review
Table I -shows the percent compliance by site and by dental provider (dentist).
(89% 18 days)92% (13 days)81% (5 days)Overall Compliance %
(89%)Overall Compliance %(1stth Q ’07)
86%Dr. Yoon79% (2 days)Dr. Jang Yoon
84%Dr. LaJuan82% (3 days)Dr. LaJuan Mountain
93%Dr. MountainN/ADr. Joseph Mountain
95%Dr PatsisN/ADr. James Patsis
Provider Weighed Avg.
South George Street
Hannah PennProvider
(94%)Overall Compliance %(4th Q ’07)
81% (5 days)(1st Q ‘07)
93%Dr. Yoon87% (2 days)Dr. Jang Yoon
95%Dr. LaJuan94% (3 days)Dr. LaJuan Mountain
93%Dr. MountainN/ADr. Joseph Mountain
95%Dr PatsisN/ADr. James Patsis
Provider Weighed Avg.
South George Street
Hannah PennProvider
From 110 to 40 errors
MeasurementsAnd
Control
Providers Define the Schedule but Front Desk Drives It
Next Day Schedules must be Validated by Providers
Front Desk Checks, Controls and Monitors the Provider Scheduling Inputs
… Link to a ‘Standardized’
Schedule
MeasurementsAnd
Control
17 Scheduled Patients
Level Scheduling
PullScheduling
Reductionof Variation
Limited Size OperatoriesLimited Size OperatoriesImproperly Positioned Dental ChairsImproperly Positioned Dental ChairsLack of Storage SpaceDental Workflows donDental Workflows don’’t match Floor Plant match Floor Plan
… Move the Process
Equipment/Supplies Physical Space
Incomplete Charts andSuper Bills
Inefficient SchedulingNo Maintenance Protocols
Inconsistent Practiced PoliciesInconsistent Practiced PoliciesOSHAOSHA
Hazard MatsHazard MatsInfection ControlInfection Control
Lack of MaintenanceImproperly Placed EquipmentImproperly Placed Equipment
Unsuitable EquipmentUnsuitable EquipmentNon-Standardized Setups
Lack of Inventory Controls
Policy/Procedures Personnel
Lack of Trained PersonnelImproperly Positioned, Placed, And Use of Personnel
Improved Dental Delivery
Phase IPhase II
Organizing for
Improvement
FootballCoarse
(833G023)
FootballFine
(833F023)
Finishing Diamond(859F014)
ET Diamond(833G023)
(empty) (empty) ETDiamond850G012
#6 FG Round Carbide
(HM1-018)
(empty)
#8 Latch Round Carbide
(HM 1023)
556 SS()
245Rounded Straight
(HMUN245009)
#34 InvertedCone
(HM2008)
#37 Inverted Cone
(HM2014)
#6 Latch Round Carbide(HM 018)
Case Study: Dental Bur Blocks
Saved 24,000 minutes of Lost ProductivityReduced the Number of Blocks 5 to 3
Decreased the Variation in Burs 3 SetupsEquals $93,333 in RevenueDecreased Staff Frustration
Decreased Inventory From 45 Burs Types to 18
ReductionIn Variation
ContainerizationQuick Set-upWorkplaceOrganization
Work Standardization
Streamlinethe
Process
ErrorReporting
ReductionIn Variation
Deliver Lean Dental Care
Process time: 5 min
Quick Set-up
WorkplaceOrganization
Prepping theOperatory
Work Standardization
18 Elements are involved in this Activity11 Tasks are involved in this Activity 5 Activities are involved in this Process Streamline
theProcess
18 Elements are involved in this Activity11 Tasks are involved in this Activity 5 Activities are involved in this Process
Case Study: Operatory Set-Up
1
23
4
5a6
7
5b
89
1011
1.
Wipe Dr’s Chair2.
Wipe
Dental Light3.
Wipe Patient Protective Glasses
4.
Wipe
Dental Chair5.
Wipe Assistant tray and Hoses (5a) Wipe
Back countertop and sink (5b)
6.
Gather
Instruments/Cassettes on metal tray
7.
Wipe the place where the metal tray was seated with dirty instruments
8.
Remove plastic wrap9.
Wipe metal tray in sterilization
10.
Remove Gloves11.
Place new plastic coverings Streamline
theProcess
Balanced Clinical Spaces…
… to Patients, Providers and Clinical Activities
Hanover Dental-
5 OperatoriesModel Office for Implementing
• EFDA• Digitalization• No-Show Policy• New Patient Entry Strategies
Streamlinethe
Process
Non-ClinicalClinical
ClinicalSupport
Hanover Dental-
5 OperatoriesModel Office for Implementing
• EFDA• Digitalization• No-Show Policy• New Patient Entry Strategies Streamline
theProcess
Non-Clinical
ClinicalSupport
Non-ClinicalClinical
Clinical
Clinical
Streamlinethe
Process
ClinicalSupport
Limited Size OperatoriesImproperly Positioned Dental ChairsLack of Storage SpaceDental Workflows don’t match Floor Plan
… Complete the Process
Equipment/Supplies Physical Outlay
Incomplete Charts andSuper Bills
Inefficient SchedulingNo Maintenance Protocols
Inconsistent Practiced PoliciesOSHA
Hazard MatsInfection Control
Lack of MaintenanceImproperly Placed Equipment
Unsuitable EquipmentNon-Standardized SetupsLack of Inventory Controls
Policy/Procedures Personnell
Lack of Trained PersonnelImproperly Positioned, Placed, And Use of Personnel
Improved Dental Delivery
Phase IPhase IIPhase III
Organizing for
Improvement
Position, Place, and Use of Staff
Heather
Yasmin
Lidni
Tineesha
Brandy
Anne
Deb(Sterilization)
Dr. Joseph Inna
H YN LLab Endo DarkroomSupplies B Break Room
Date: Tuesday 6/17/08
Op3 Op4
Op1 Op 2
Op5 Op9
Op7
Op8
Op6
Dr. Patsis
Dr. Yoon(EFDA)
(Hygiene)
Hazel
Streamlinethe
Process
South George Street Center
Streamlinethe
Process
Improved Elements and Process Lead to …
Time Savings
Cost Efficiency
Improved Ergonomics
Inventory Reduction
= Increased Process Flows(Increased Patient Visits)
An Improved Patient Experience
Build New Practice ModelsBuild New Practice Models
Things Dental Must Be ...
MeasurementsAnd
Control
Dental Filling Procedure
the Most Critical ProcessPERFECTLY TIMED to ….
JUST IN TIME EVENT
MOST CRITICAL CLINICAL ACTIVITY
Provider Time15 min
Provider Time45 min
• Controllable
• Predictable
• Consistent
Regular Dental
Appointments
EFDA Dental
Appointments
Measure and Control
BillingScheduling
Charting
1
3
2
4
4
3
2
1
Process Waste• Corrections• Over Processing• Over-Production• Waiting • Motion• Inventory
MeasurementsAnd
Control
Error Reduction by Observation
MeasurementsAnd
Control
From 42 to 5 errors
Requires a Dedicated Team (Dentist, EFDA, and 2 Dental Ass’ts)
Works Best in 3 or More Operatories
An EFDA Specific Schedule is Needed
Performs Restorative Dentistry Only (fillings)
Facilitates Patient Flow and Billable Dental Visits
…Bring in an EFDA Program
27 Scheduled Patients
An EFDA Specific Schedule is Needed
Performs Restorative Dentistry Only (fillings)
Facilitates Patient Flow and Billable Dental Visits
Limited Appointments… …Lots of Patients
Managing Capacity and Demand
Managing Capacity and Demand
If Demand for Care is Greater then Capacity, If Demand for Care is Greater then Capacity, Patient Care Delivery will be Delayed Patient Care Delivery will be Delayed
If the Capacity is Greater than Demand, then If the Capacity is Greater than Demand, then Resources are Being Wasted Resources are Being Wasted
When Capacity and Demand are Matched, When Capacity and Demand are Matched, Patient Care Delivery Flows EvenlyPatient Care Delivery Flows Evenly
The “Dreaded”
No-Show Patient
The Rule of 72
No-Show Rate 10% 15% 20% 25% 30% 35% 40%
Years 7.2 4.8 3.6 2.9 2.4 2.1 1.8
Defines the Cost Impact of NoDefines the Cost Impact of No--ShowsShows
•• Method or Predicator of Loss due toMethod or Predicator of Loss due toNoNo--Show AppointmentsShow Appointments
•• Half of this YearHalf of this Year’’s Gross Revenues Gross Revenuewould be lost in 2.9 years due towould be lost in 2.9 years due toa 25% Noa 25% No--Show Rate Show Rate
Address Waiting and Wait Lists
Anxiety Increases with Patient Wait Time
Unexplained Waits Feel Longer to the Patient
Unfair Waits “are longer”
than Equitable Waits“The Psychology of Waiting Lines, Maister, D, Harvard Business Online, April 2004”
An Effective No-Show Policy …
Contains an “If-Then”
Statement and a Time Dependent Penalty
Has a Written and Signed Patient-Provider Contract
Is Constantly Reinforced Within the Organization and Documented at Patient Contact Points
Limitations to Care and Provisions for Return to Care
….is Only as Effective as Your Practice Model
The No-Show Predictive Productivity Model
A Consultant’s Formula to Address LostProductivity Due to No-Show Patients:
P = Σ
[Ps X S] + Pw
Where:P = ProductivityPs = Number of patients scheduledS = Show RatePw = Number of Walk-in Patients Seen by Provider
A Consultant’s Formula to Address LostProductivity Due to No-Show Patients:
P = Σ
[20 X 60%] + 5= 17
Where:P = Productivity
(17)Ps = Number of patients scheduled (20)S = Show Rate (60%)Pw = Number of Walk-in Patients Seen by Provider (5)
The No-Show Predictive Productivity Model
A Consultant’s Formula
to Address LostProductivity
Due to No-Show Patients:
P = Σ
[20 X 60%] + 5= 17
Where:P = Productivity
(17)Ps = Number of patients scheduled (20)S = Show Rate (60%)Pw = Number of Walk-in Patients Seen by Provider (5)
The No-Show
Predictive
Productivity
Model
No-Shows are About…
Patient Satisfaction
Patient ArrivalTime
(Inputs)
Patient FinishTime
(Outputs)
NewPatients(Inputs)
CompletedPatients
(Outputs)
= Perceptions –
Expectations= Timeliness plus Value Experience
minus Wait
Reach New HeightsReach New Heights……
Hannah Penn South George Street Hanover
Family First Health 2005/6 2006/7 2007/8 2008/9
Dental Patients 3,145 4,107 4,209 5,500
Dental Visits 4,811 9,022 13,017 26,500
Patient/Visit Ratio 1.5 : 1 2.5 : 1 4.5 : 1 5 : 1
# of Sites (Operatories) 2 (6) 2 (11) 3 (16) 4 (24)
…To Improved Dental Delivery
Perfect Days
July ‘07
Aug ‘07
Sept ‘07
Oct ‘07
Nov‘07
Dec ‘07
Total
Dr. Yoon 1 4 3 4 2 6 20
Dr. Mountain 1 2 3 6
Dr. Joseph 2 3 5 3 1 1 15
Dr. Patsis 1 5 2 3 2 13
Total # of Perfect Days 4 13 10 12 6 9 54
You can even have
The Perfect Practice Day
Improving the Delivery Model
FFH Dental Strategic Plan
Increase Dental Infrastructure to Access to Populations in Need
Continue Process Improvement Initiatives with their Resultant Practice Delivery Efficiencies and Effectiveness
Roll-out Push and Pull Community Based Prevention and Intervention Programs to At-risk Populations
Implement a Trans-disciplinary Approach to Oral Health DiseasePrevention
… Of Community Dentistry
HIV/AIDS Dental Access 2005/6 2006/7 2007/8 2008/9
Sharing Together Patients 56 106 126 160
Sharing Together Visits 196 386 488 610
City of YorkHead Start
2008
Total # of StudentsScreened
60
Total # of PatientsIn Treatment
48
# of Areas of Decay 240
Total CasesCompleted
11
SummerPrograms
InfantsToddlers(ECC)
SchoolBased
Sealants
HIV/AIDS
HeadStart
WIC
COMMUNITIESOF DENTAL
NEED
Reaching the SummitReaching the Summit
The Last Eff-word
Practice Efficacy
Is the Ability of a Community Health Center Practice to Deliver Capacity and a Dental Model that Produces Positive, Directed and Effective Results to the Communities it Serves
= Practice (Effectiveness + Efficiency)
Process and Elements
Basic Building Blocks of an Overall Systems
Can Reveal Constraints and Hidden Potential in Delivering Improved Patient Care
Facilitate and Align Patient Care Demand to Provider Delivery Capacity
Develop Replicable Processes that Become Lean Standardized Operating Procedures
Process and Elements
Ensure the Continuity of Patient Care not a Single Dental Provider or Delivery Center but The System of Delivery
Build a Process Improved Community-Based Practice that Staff Participates In and Improves Patient Care
Leaders are Readers
Lean Thinking for Healthcare
IHI National Forum, Dr. John Long, Dec 13, 2004
Lean Production Simplified
Pascal Dennis, Productivity Press
Mastering Patient Flow
Elizabeth W. Woodcock, MGMA Press
5 S for Operators
Hiroyuki Hirano, Productivity Press
Mastering the Management System
Kaplan and Norton, Harvard Business Journal, Jan, 2008
“It’s not that I’m so smart; it’s just that I stay with problems longer.” A. Einstein
James Patsis, DDS MBA Family First Health Suite 100116 S. George StreetYork, PA 17401
T: 717 801 4855F: 717 718 1317
“Less Becomes More When You Take the Waste Out of Less”
What’s Missing…..
An Electronic Dental Performance Dashboard
Dental Trends in Community Health
Increase Demand for Dental Care
Decrease in Dental Providers and Allocations for Dental Care and Prevention
Payment for Dental Services notAligned with Escalating Costs
Today’s Healthcare Delivery
Is Over-Engineered and Designed Upstream at the Bureaucratic or Policy level
Organizational Silos contain Resources and Delay the Process of Healthcare Delivery
Insufficient Resource Allocation at the Grassroots Level of Healthcare Products and Service Delivery