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

“Want to Turbo-Charge the Office?”

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

jpatsis@familyfirsthealth.org

“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