lean at the dentist 2009

Dr. Sami Bahri DDSFounder, Bahri Dental GroupJacksonville Florida

Dr Sami Bahri DDS runs a Jacksonville FL private dental practice that

Jacksonville, Florida

Dr. Sami Bahri DDS, runs a Jacksonville, FL, private dental practice that includes three general dentists, one orthodontist, 10 chairs for generaldentistry, and seven chairs for orthodontics.

D B h i h b l i d l i l t hi d t l ti fDr. Bahri has been exploring and applying lean to his dental practice for over 15 years. In 2007, he presented his work as a keynote speaker at the Shingo Prize Conference where he was recognized as the “World's First Lean Dentist ” He lectures nationally and internationally on implementingLean Dentist. He lectures nationally and internationally on implementing lean management in dentistry. Dr. Bahri is the author of the upcoming book, Follow the Learner: The Role of a Leader in Creating a Lean Culture (2009), published by the Lean Enterprise Institute Incpublished by the Lean Enterprise Institute, Inc.

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Why Change at All?The first job of a lean leader: Understand and believe that lean principles directly address core business problems.

•Without this there is no business case for lean. •Without a business case, there is no compelling reason for a leader (and the

i ti ) t horganization) to change

Problems with the Old System

Uneven work loadRelying on one front office personRelying on one front office personExcessive load on the front officePersonal problems halt office workMistakes when passing information

What Type of Change?

The second job of a lean leader: Determine the nature of the changeDetermine the nature of the change

• Scope• Direction• Direction

Why Change Radically?

The BIG Question

Is one piece/patient flow achievable?Is one-piece/patient flow achievable?

How to Change?The third job of a lean leader: BalanceThe third job of a lean leader: Balance the technical and social dimensions of lean

Concept & graphic used with permission, John Shook, 2009

The Technical Dimension

How did we pursue one-piece/patientHow did we pursue one-piece/patient flow?

Application in Dentistry

DA B C E

33 44 55 66 77 88 99 1010 1111 1212 1313 14142211 1515

One-Piece Flow

Application in Dentistry

DC EA B DC EC1C1 C2C2 C3C3 C4C4 E1E1 E2E2 E3E3 E4E4A2A2A1A1 E5E5

A B

B1B1 B2B2 B3B3 D1D1

Application in DentistryApplication in Dentistry

A BA B

B1B1 B2B2 B3B3A2A2A1A1 SS S SS SSAll in One Visit All in One Visit

Leveling, Synchronization, One-Piece Flow Smaller Lot SizeFlow, Smaller Lot Size

Lead 500 SMEDLead Time

500

Times!Treat=Time Treatto

DemandShingoPgs.37,101

Demand

Defining Leveling

Balancing Load and Capacity

Distributing Procedures:

• According to Takt time• According to Takt time

• Throughout the schedule

Defining “Flow” in Dentistry

• One appointment - all providers

• Continuous treatment

• No gaps between providers

Defining:Defining:One-Piece Flow – One Lot

• Procedure (Root Canal?)• Tooth=One Piece 4

876

54

9 1011

1213Tooth One Piece

• Quadrant? • Arch? UR UL

32

1

4

UR UL

LLLR

32

1

414

1516

13

1732

UR UL

LLLRArch?• Side?• Mouth=One Lot

UR UL

LLLR

LLLR

2322

2120

191817

2627

2829

3031

32 LLLR

24 232526

Ohno:Ohno:Shortening Lead Time

First Call HealthOne-visit Treatment

Lead Time

Order Cash

Lead Time

Order Cash

Implementing Flow

1. Grouping Activities by Complexity and PredictabilityPredictability

2. Switching to Flow Scheduling

3. Crossing Functional Barriers

Flow: 1 – Grouping ActivitiesG i t t t i t t i b dGrouping treatments in separate categories based upon their degree of difficulty (simple vs. complex), and their cycle time (stable/predictable vs. unstable/unpredictable) y ( p p )allowed us to create a consistent scheduling approach.

1.Simple and stable: Treated on the exam day

2.Complex and stable: Might need one additional visit

3.Complex and unstable: Unpredictable, but we try to3.Complex and unstable: Unpredictable, but we try to condense treatment in as few visits as possible.

Lean Solutions Pg.89

Flow: 2 – Batch Scheduling-Focused on Provider Efficiencyon Provider EfficiencyDentist 1 Dentist 1 Dentist 1 Hygienist 1 Hygienist 2

Chair 1 Chair 2 Chair 3 Chair 4 Chair 5Chair 1 Chair 2 Chair 3 Chair 4 Chair 5Crn Preps Amalgams Seats Prophy Prophy

Pbu Composites Ex1 Debridment DebridmentPbu Composites Ex1 Debridment Debridment

Inlays Extractions Ex3 RP&S RP&SBridge prep Pulpotomy FMX

RCTs ChPx

Veneers Checks

DeliversImpressions

SealsSeals

Flow: 2 – Flow Scheduling-Focused on Patient NeedPatient Need

D1 D1 D2 D2 D1,2,HChair 1 Chair 2 Chair 3 Chair 4Chair 1 Chair 2 Chair 3 Chair 4 Chair 5

P1 H P1 H

P2 P 2 Overflow

P 3 H P 3 HLunch Lunch Lunch Lunch Lunch

P 1 H P 1 H

P 2 P 2 Overflow

P 3 H P 3 H

Fl 3 C i F ti lFlow: 3 – Crossing Functional Boundaries1. Hygienist treating the dentist’s patients2 Dentist treating the hygienist’s patients2. Dentist treating the hygienist s patients3. All chairs becoming common to both:

“P ti t Ch i ”“Patient Chairs”

Defining Synchronization

1. Scheduling: Precise and Flexible2 Pulling JIT Services : No breaks in2. Pulling JIT Services : No breaks in

treatment

Synchronization:Synchronization: 1 – Schedule Control 1. Yearly Template: Leveling

Takt time from last year’s dataTakt time from last year s data

2. Biweekly Schedule: PrecisionProviders adjust their own schedulesProviders adjust their own schedules

3. Daily Schedule: FlexibilityFlow Managers and Providers adjust to shortFlow Managers and Providers adjust to short notice changes

Synchronization:Synchronization: 2 – JIT Service

1. Patient care flow manager2 Kanban2. Kanban

1 – Patient Care Flow Manager• Supervises the flow of treatment

• Secures JIT service for the next step through• Secures JIT service for the next step through a “Service Kanban”

• Enters the line when needed

C ti ll li i t t• Continually eliminates waste

2 – KanbanDirecting ProvidersDirecting Providers

towards

“V l Add d“Value Added Work”

Away fromAway from

“Waste”

L Thi ki R ltLean Thinking: Results“In short, lean thinking is lean because itprovides a way to do more with less :

• less human effortless human effort• less time less equipment• less equipment

• less space while coming closer and closer to providing customers with exactly what they want.”

Source: ”Lean Thinking”Source: Lean Thinking

Lead Time ReductionLead Time Reduction

Survey QuestionsSurvey Questions101

99

100 100%

es

97

9898% 98%

rcen

tag

95

96 96%

Per

94

95

PromptScheduling

One-VisitTreatment

QuestionsAddressed

WouldRefer Friends

Completely

Our Service RatingsOur Service Ratings100

89

708090

es

405060

Perc

enta

ge

11 0 0102030P

11 0 00

Excellent Good Average Poor

Doing More (with less): 2006 vs 2005Doing More (with less): 2006 vs. 2005Production Per Visit

IncreaseIncrease

35%35%40%

29%35%

20%25%30%

18%

5%10%15%

0%5%

Dr 1 Dr 2 Dr 3

L H Eff tLess Human Effort

55

6

3 3

5

3 33

42005200633%

40%

3 332

3

1

22006

0Dentists Hygienists Assistants

L TiLess TimeNumber of patient visitsNumber of patient visits

for the same amount of work 8000its

500060007000

atie

nt V

isi 24%

7,5195,723

200030004000

mbe

r of P

a

1,7960

1000

2005 2006 Difference

Num

S d i O YSaved in One Year1. Making appointment2. Confirming appointment3. Typing notes in computer4 Receiving patient4. Receiving patient5. Preparing the room6. Walking patient out X1,7967. Cleaning and sterilizing instruments8. Collecting fees9 Explaining treatment9. Explaining treatment10.Double checking treatment plan11.Writing kanban, etc…

L E i t d SLess Equipment and SpaceTreatment Rooms

10

12

Roo

ms

6

8

reat

men

t R 40%

106

2

4

mbe

r of T

r

0

2

2005 2006

Nu

2005 2006

C it I tCapacity Improvement

Dentist Hours-Weekly

140160

ekly

14080100120

ours

-Wee

82%63h

35+21+2177

140204060

Den

tist H

02005 2006

D

Fundamental Lessons:Fundamental Lessons:Technical Dimensions

P k d ll• Peaks and valleys:

• View from the valleyView from the valley

• View from the peak

• Value Stream vs. Operations:

Whi h t i fi t?• Which to improve first?

• Where to improve first?

Trying One-Visit Treatment

Countermeasure Barrier

Too Many Setups SMED:

Treatment Room Changeoverg

Extra Capacity Flow:

Dentist Part of Treatment e t st a t o eat e t

Hygiene Not Included

Leveling / Mixed Treatment

Coordination Problems

Flow Manager Position

Communication Problems

Kanban / Synchronization

Why 13 Years to Implement Lean M t?Management?

Fundamental Lessons:Fundamental Lessons: Social Dimensions

Jim Womack on Purpose, Process and People…• A clear and universally understood purpose

dedicated to solving customer problems, g p ,• supported by lean processes that are

designed, performed and improved g , p p• by engaged people with fulfilling work.

Bahri Dental’s System of Leadership PrinciplesSystem of Leadership Principles

- Purpose -1.Define “True North”: One-Piece Flow



2.Put the customer first: When they’re not lookingy g




3.Focus first on reliability and responsiveness: What they want mostWhat they want most




3.Focus first on reliability and responsiveness: What they want mostWhat they want most

4.Pursue quality & productivity with equal passion: Truthfulness in businesspassion: Truthfulness in business

Bahri Dental’s System of Leadership Principles

5 Minimize lead time and maximize flow to

System of Leadership Principles- Purpose -

5.Minimize lead time and maximize flow to increase capacity: Flexible systems, adaptable to changeg





6.Understand and treat the organization as a system: Follow the product, door to doorsystem: Follow the product, door to door





6.Understand and treat the organization as a system: Follow the product, door to doorsystem: Follow the product, door to door

7.Pursue operational excellence, growth will follow: solid solutions, hard to imitatefollow: solid solutions, hard to imitate


- Process -1.Be equal part learner, equal part teacher


- Process -1.Be equal part learner, equal part teacher2.Build a problem solving culture p g


- Process -1.Be equal part learner, equal part teacher2.Build a problem solving culture p g3.Train to meet the needs of the patient


- Process -1.Be equal part learner, equal part teacher2.Build a problem solving culture p g3.Train to meet the needs of the patient4 Create a learning environment safe for4.Create a learning environment safe for

experimentation


- Process -1.Be equal part learner, equal part teacher2.Build a problem solving culture p g3.Train to meet the needs of the patient4 Create a learning environment safe for4.Create a learning environment safe for

experimentation5 Communicate clearly and honestly with5.Communicate clearly and honestly with

patients


- Process -6.Standardize first, then improve


- Process -6.Standardize first, then improve7.Gather decision-makers around the patientp


- People -1 Show respect for people and their personal1. Show respect for people and their personal

lives



lives2 Create an open business partnership2. Create an open business partnership



lives2 Create an open business partnership2. Create an open business partnership3. Respect everyone’s time



lives2 Create an open business partnership2. Create an open business partnership3. Respect everyone’s time 4. Balance competing interests



lives2 Create an open business partnership2. Create an open business partnership3. Respect everyone’s time 4. Balance competing interests 5. Gain trust by providing proof



lives2 Create an open business partnership2. Create an open business partnership3. Respect everyone’s time 4. Balance competing interests 5. Gain trust by providing proof6. Build consensus rather than attempt to control



lives2 Create an open business partnership2. Create an open business partnership3. Respect everyone’s time 4. Balance competing interests 5. Gain trust by providing proof6. Build consensus rather than attempt to control7 Decide to become a leader7. Decide to become a leader

Summary of Advice• Improve processes before operations

R l ddi ti i i• Run your value-adding operations in a series, and the support functions in parallel S• Start improvements on a small scale

• Use small scale experiments to provide proof• Look for flexible people • Put the decision makers togetherPut the decision makers together

Now Available at Lean.org

Follow the LearnerThe Role of a Leader in

Creating Lean Culture

by Dr. Sami Bahri, DDSy ,

Continue the Learninggat LEI Workshops

June 2 – 4June 2 4

LEI Workshops In Dulles, VA (Washington, DC area)

• Creating a Sustainable Lean Culture

• Getting the Right Things Done

• Management Accounting for Business

• Key Concepts of Lean

• Value-Stream Mapping

• And more

Or Join Us in Minneapolis, MN July 14 - 16, 2009 Visit lean.org/workshops for workshop dates and locations!Visit lean.org/workshops for workshop dates and locations!

QuestionsQuestions& Answers& Answers

Follow the LearnerThe Role of a Leader in

Creating Lean Culture

by Dr. Sami Bahri, DDS

lean at the dentist 2009

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