Smart Solutions for Dental Group Practices

Figure 1: The EyeSpecial C-II digital dental camera.

Informed and educated patients seek treatments that are aesthetic,
functional, and beneficial to their overall health. To address the growing needs
of patients, Shofu has developed a score of smart solutions, including the
world’s first digital dental camera, bioactive restorative materials, adhesive
systems, and minimally-invasive abrasives. These products are not only clini-
cal problem-solvers; they also have the ability to help the clinicians and team
members expand the range of treatment techniques in a simple and cost-ef-
fective manner, elevating the practice’s growth and profitability

The EyeSpecial C-II Digital Camera

Figure 2: Beautifil II LS (Low Shrink).

A third-time recipient of the prestigious BEST IN CLASS TECHNOLOGY AWARD by CELLERANT CONSULTING GROUP, the EyeSpecial C-II delivers predictable and consistent clinical photographs for case documentation, diagnosis and treatment planning, patient communication and education, insurance verification, legal documentation and dental laboratory collaboration.

Furnished with a 12 mega-pixel sensor and a proprietary system of ring and dual-point flashes, the EyeSpecial C-II demonstrates true-color reproduction with an exceptional depth-of-field range. The panoramic LCD screen of this camera is larger than displays and viewfinders of SLR and point-and-shoot cameras and can be operated with a gloved hand. It also employs gridlines that facilitate a proper image alignment, thus reducing the risk of photographing objects at an incorrect angle. Designed to provide predictability and functionality, the heavy-duty yet extremely ultralight (weighing ca. 1lb) EyeSpecial C-II complies with stringent infection control protocols. The camera is OSHA-compliant, water-, chemical and scratch-resistant, and can be swiftly disinfected with a disinfecting towelette.

One of the most notable advantages of the EyeSpecial C-II is its ability to efficiently achieve predictable and consistent images. Accomplishing photos with Shofu’s camera is virtually stress free and not dependent on the photographer’s technical knowledge or experience with photographic equipment. The camera features eight preset dental shooting modes (standard, surgery, mirror, face, low-glare, whitening, tele-macro and isolate shade) that are highly intuitive to navigate and do not require retrofitted equipment or software add-ons to function.

Giomer Chemistry
The Giomer chemistry is a proprietary component of Shofu’s restorative materials. It combines clinical benefits of bioactivity with superior physical, mechanical and aesthetic attributes. This innovative technology has been clinically vetted in 8- and 13-year recall studies and proven to sustainably release and recharge fluoride and other beneficial ions and to inhibit plaque formation to help establish a stable pH in the oral environment. 1,2 Inclusive of the Giomer chemistry is Beautifil II LS (Low Shrink), a universal direct restorative designed to minimize polymerization shrinkage and shrinkage stress, and Beautifil II Gingiva, a system of nanohybrid composites formulated to provide general practitioners with the means to optically improve gingival aesthetics. These versatile materials allow general practitioners to offer functional and aesthetic treatment options that are minimally invasive and cost effective.

1 Gordan V.V., et al. A clinical evaluation of a self-etching primer and a Giomer restorative material: Results at 8 years. JAM Dent. Assoc. 2007;138:621-627
2 Gordan V.V., et al. A clinical evaluation of a Giomer restorative system: 13-year recall. Presented at IADR General Session; March 23, 2013; Seattle, Washington

September/October 2017

 

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New Technology:
Sorting Through the Hype DSOs rely on careful evaluation to adopt technologies that maximize value for both patients and the practice.

From The Publisher
Raising the Level of Care

Building Relationships, Growing the Business
Dr. A.J. Acierno of DecisionOne Dental Partners addresses the value of a strong doctor-patient bond.

Creating Same-Day Opportunities in Hygiene

The QuickClean Ultrasonic Cleaner

What’s Eating Into Your Profits?

Smart Solutions for Dental Group Practices

Patient Safety: The value of protective eyewear

OSAP: Make it Happen

U.S. Healthcare at a Glance

Industry News

The Root of Productivity
A simple first step can significantly boost production

The QuickClean™ Ultrasonic Cleaner

SPONSORED: Midmark

Providing powerful, effective cleaning and consistent results, the QuickClean™ Ultrasonic Cleaner is a piece of equipment you can’t be without. The QuickClean’s cutting-edge technology can help clinicians create a safer, more efficient work environment by decreasing worker exposure to contaminants and potential sharps injuries while reducing the time and effort needed for cleaning.

Powerful technology
The QuickClean unit cleans thoroughly and consistently throughout the entire bath using Frequency-Leap technology. This advanced software helps ensure all instruments in the dental practice are fully cleaned the first time, every time, no matter where they are placed in the basket.

Simple to operate
The QuickClean is easy to use right out of the box, so you can get your offices up and running with minimal training time. Features like a digital LCD control panel that displays prompts, options for preset or customized settings, intelligent software that remembers the last cycle settings, and a fluid sensor that ensures the bath always has sufficient water levels help simplify processes and increase productivity.

Range of sizes and design options
The QuickClean comes in three tabletop sizes (1.2, 3.3 and 6.6 gal.) and two recessed options (3.3 and 6.6 gal.), so your clinicians can choose the option that best fits their configuration and workflow. And the stainless steel finish and attractive design coordinates well with any décor.

Important points to consider

Is now the right time to replace your old system? Ask yourself the following:

  • “What type of receiving, cleaning and decontamination processes are in place at my practice?”
  • “Am I having a hard time keeping up with instrument processing?”
  • “Am I looking to clean instruments faster?”
  • “Am I looking to run customized cycle times?”
  • “Am I considering a recessed or tabletop ultrasonic cleaner?”

The QuickClean is 150 percent more effective than the SoniClean unit and includes a full-size basket. Customized cycle times range from 1-99 minutes. QuickClean comes with a 3-year warranty. 

 

What’s Eating Into Your Profits?

Sponsored: A-dec

Analyzing the financial health of your practice is a good time to look beyond the obvious at the hidden costs that impact your profit margin. Here are some considerations that may be under the radar.

  1. Ongoing maintenance
    When your equipment isn’t working efficiently, neither is your team. Unreliable equipment that’s constantly breaking down or out of service not only cuts into the profit margin, but it frustrates doctors and dental teams – and it’s no secret that retaining top-notch doctors is an important factor in the success of group practices.
  2. Patient perception
    Growing your patient list is top of mind for increasing profits. But what about how patients (current or potential) feel when they visit your facility? If your practice is dated compared to the one down the street with the brand-new office and state-of-the-art equipment, it’s hard to compete. A calm, modern environment communicates a level of comfort and reassurance that your dentists are also high caliber. Environment drives perception. (That explains why patient treatment plans tend to be congruent with facilities.)
  3. Physical discomfort
    Ergonomics is a tough concept to grasp since it’s not a tangible concept: Yet the cost of a physical disability that originates from the dental occupation is quite real in terms of worker’s comp and downtime. The most common injuries in dentistry (tendonitis, pinched nerves, ruptured discs in the neck and lower back, or carpal tunnel) develop slowly over time, and if not addressed properly, become debilitating and career ending. The only way to prevent injury is by selecting the right equipment and practicing ergonomic positioning as much as possible. Equipment that places everything at the fingertips allows doctors to sit properly and work comfortably decreasing stress and fatigue, and increasing overall productivity.
  1. Ownership costs
    Distinguishing between products to make confident purchase decisions in the first place is challenging. But have you followed the total cost of the equipment beyond the acquisition phase? The major component that separates superior quality from low quality is what A-dec coined the Total Cost of Ownership. Because these costs are not always quantified, they are often overlooked. The cost of ownership concept is truly about value – not only the value of the product, but also the value of a customer’s time and productivity:
    Cost of acquisition
    Cost of operation
    + Cost of maintenance
    TOTAL COST OF OWNERSHIP

Whether it’s physical discomfort and exhaustion that have affected the dentist, or down equipment that’s out of service waiting for parts, all mean not having patients in the chair. And zero dollars from the treatment room, mean zero dollars in revenue. If you would like to talk about ways to remedy the hidden costs that are eating into your profits, feel free to reach out to the A-dec Special Markets team at 1.800.547.1883, or email DSOcustomerservice@a-dec.com.

Single-visit restorations

Large group dental practices today are privy to technology that surpasses past generations in terms of precision and efficiency, enabling them to offer more in-house services than ever before. Chairside Economical Restoration of Esthetic Ceramics – or CEREC – is one such example. While the technology has been available through Dentsply Sirona since the mid-1980s, refinements in imaging, including a move from 2D to 3D and expanded materials including zirconia, have made it possible for general dentists to offer high-end restorations in a single visit, as well as implant and orthodontic services.

Particularly for large group practices and DSOs, CEREC affords clinicians and staff at the practice complete control of the entire restorative process, leading to enhanced efficiency and effectiveness, according to Louis Vodopivec, director of marketing for clinical CAD/CAM, Dentsply Sirona. In addition, CEREC:

  • Enables practices to incorporate single-visit dentistry as a service to their patients.
  • Reduces outsourcing costs associated with restorations.
  • Eliminates second visits, permitting the practice to accept additional patient volume.
  • Permits guided implantology as well as custom abutments for implants, both possible in a single visit
  • Provides clinicians with complete control of the entire restorative process.

“Final restorations are delivered during the same visit, ensuring patients don’t need to take additional time off of work,” says Vodopivec. “And, dentists can evaluate esthetic results immediately, without having to request remakes from laboratories.” In most cases, implant and restorative outsourcing can also be avoided, he adds.

An impactful ROI
As with any technology, adding CEREC to a multiple-site dental practice requires an investment. To offset the initial cost, some clinicians opt to purchase only the scanning component. “However, an impactful return on investment is only realized by incorporating milling and providing single visit dentistry within a practice,” Vodopivec points out.

The good news is the system comes with a brief learning curve, and Dentsply Sirona offers “multiple tiers of support,” he notes. “CEREC requires about 1½ days of training on average for clinicians to understand the system and begin utilizing the technology,” he says. “As clinicians and staff members complete more cases, they naturally become much more efficient. Additionally, the launch of Omnicam has eliminated the need for powder and made scanning much easier to learn.

“There are multiple tiers of support available through our dealer and training partners, including online learning, training centers and on-site training,” Vodopivec continues. “With such a large community of professionals utilizing the technology, many study clubs also exist locally.”

It may be common for larger organizations to face multiple external obstacles to adding new equipment, such as an IT department’s requirement to onboard new technology, as well as purchasing protocols, committee evaluations, training curriculums, quality control, etc. But, “if organizations wait too long to begin implementing technology, they could be late to adopt what is quickly becoming routine care.”

Smart moves to grow a practice

Growing a dental practice has its share of challenges. Duplicating practice management efforts – and, in turn, eroding profitability – doesn’t have to be one of them. “A main reason to grow a practice to multiple sites is to increase efficiency and profitability by creating economies of scale,” says Nate Nelson, product manager, Henry Schein Practice Solutions. “One way to achieve economies of scale is by centralizing administrative functions, such as billing and scheduling, which increases efficiency and reduces costs as an organization grows.”

When dental offices within a group practice run disparate practice management systems or databases, they risk duplicating efforts and eroding profitability, Nelson continues. “In many cases, failure to centralize data can mean they actually spend more money on each practice as they grow.

The most efficient way to centralize administrative functions is to implement a single patient record for all offices within a group practice, Nelson explains. “And, a single patient record is not possible if a large group practice does not use the same software system across all of its locations,” he says. “If an organization uses many different software systems, staff is required to log into each one separately to perform each task. In addition, standardizing workflow is not possible since workflow can vary widely from system to system.”

When billing and scheduling for all locations take place in one location, “the centralized staff can specialize in a particular task and increase its efficiency in that task,” Nelson points out. “Staff in the individual offices can focus on activities that increase profitability, such as treatment plan acceptance.

“The key to taking advantage of a practice management software system for a large group practice is in centralizing the patient record to centralize administrative tasks,” Nelson continues. “And, strong reporting capabilities are essential to track the performance of each location, as well as the organization as a whole.”


Dentrix Ascend and Dentrix Enterprise

A comprehensive practice management solution typically includes clinical, scheduling, accounting and billing functionality and centralized data management according to Nate Nelson, product manager, Henry Schein Practice Solutions. For complete practice management, Henry Schein offers Dentrix Ascend and Dentrix Enterprise. Designed to integrate a dental practice’s business and front-office tools with its clinical tools, these group practice management solutions provide a single solution for improving patient care and practice profitability across multiple locations. The systems offer a path to a completely paperless office, including such features as:

  • Clinical efficiency, including periodontal measurements and 3D clinical charting.
  • Business management, including business operations and monthly goals.
  • Billing, collections, reimbursement and claims management.
  • Centralized control.
  • Training and education.
  • Technical support.

New Technology: Sorting Through the Hype

By Laura Thill

DSOs rely on careful evaluation to adopt technologies that maximize value for both patients and the practice.

Mark Blomquist

Dental providers today have no shortage of technologies and new equipment to choose from. But, sorting through the many clinical and non-clinical solutions – many of which are backed by positive testimonials – can be overwhelming, according to Mark Blomquist, chief technology officer, Benevis.

Not only is it impractical to latch on to every new solution, it’s unwise, he points out. “If a disruptive technology becomes available in dentistry that has positive, evidence-based impacts on patient outcomes and a positive business case, it behooves the dental group to invest in and provide this technology to their supported practices and patients,” he says.  “The evaluation of these two criteria is complex, and industry-supplied information is likely to have a significant proportion of hype included.”

“Adding technology for technology’s sake has the risk of creating poorer patient outcomes (such as overuse of CBCT) or increasing costs,” Blomquist continues. “For example, the lab savings and payer-approved incremental revenue from CAD/CAM-provided services may not offset the ongoing asset costs,” he points out. “A group of qualified clinical, business and technology professionals at the DSO should monitor the industry for developments and proactively perform these evaluations on an ongoing basis, in order to [ensure better outcomes] for the patients and [maximize revenues and minimize costs for] the business.

“To sort through the hype, we evaluate the technologies based on whether they positively or negatively impact patient outcomes or provide a positive business case for investment,” says Blomquist. “Patient outcomes can be evaluated by reviewing published, peer-reviewed studies and by using data analytics on longitudinal patient data in the practice management system. For example, we might evaluate using dental microscopes versus caries detection systems in the operatory setting for better outcomes. A positive business case for technology investment could be illustrated by team members’ productivity enhancements or ongoing cost reductions.” Converting from film x-rays to digital x-ray sensors, for instance, might reduce patient cycle time and supply costs, he says.

In Blomquist’s experience, the general dentistry offices that Benevis supports have not expressed a high interest in performing implants or same-day restorative procedures supported by CAD/CAM. “We would need to evaluate the restoration longevity, patient outcomes, cost effectiveness and ongoing demand for such services before considering investment,” he explains.  “Boutique dental offices are likely satisfying the premium demand for these services, but until the procedures become commonplace and frictionless with payers, [it’s difficult to make a] business case.”

For now, Benevis has focused on bringing several other technologies to its dental customers, including:

  • Electronic reminders and confirmations using email and SMS texting.
  • Online appointment setting and rescheduling.
  • Active management of online presence and online reviews.
  • Reliable and secure computing infrastructure to protect patient data and privacy.
  • Data analytics for finding outliers.

Standardization
It makes good business sense for large group dental practices to employ the same equipment, software and standard operating procedures throughout the organization, notes Blomquist. “There are significant benefits to [doing so], particularly if there is any level of best practices sharing or centralization of business functions and support,” he says. “There are cost and service advantages for both the DSO and the dental practice, [including greater] group leverage with equipment manufacturers, suppliers and service organizations to ensure the reliability and performance of a known set of equipment.

“The overall organization also has much better peer and DSO support, since [all of its] locations are running similar configurations and getting answers to questions on gear, equipment behavior or workflow issues,” he continues. “Supporting a standardized technology environment is much more efficient than attempting to support one-off configurations.”

Additional benefits of standardization include establishing:

  • A common set of known best-practice standard operating procedures using common software for appointment setting, recall management, appointment confirmations and reminders, and incomplete treatment plan recall.
  • The ability to compare effectiveness of different offices and find best practices that can enable some offices to improve their performance (i.e., using specific scripts or techniques to facilitate higher collections, higher payer rates or greater patient treatment plan acceptance).
  • The ability to leverage patient-engaging technologies, such as email and SMS text reminders and confirmations, using a common integrated eCRM provider.
  • More consistent adherence to HIPAA regulations and PCI compliance, based on common standard operating practices that have been developed and provided by the DSO.
  • Interchangeability of equipment between offices (i.e., fewer spares issues).
  • Faster ramp-up of personnel, given that common standard operating practices are in use and shared training materials can be leveraged (particularly for personnel transferring between offices).
  • Volume pricing with vendors and negotiating leverage (including that for new technology and releases).
  • An extended useful life for equipment (i.e., by passing to one office a piece of equipment that another office is removing).

DSO support
Dental service organizations can help ensure the success of their dental practices by playing a supporting role in evaluating emerging technologies and training clinicians and staff on new technology and standard operating procedures. “The DSO should [provide] a number of clinical, business and technology professionals [who are responsible for] evaluating emerging technologies for possible inclusion in ongoing operations,” says Blomquist. “This group should also have a forum to keep their dental customers informed and to field questions and recommendations for ongoing research.”

In addition, the DSO should offer its dental practices the necessary expertise, training and support required to integrate new technology with minimal disruption to workflow. “Centralized support with trained technology and workflow specialists is one of the key benefits of having a professional DSO for a partner,” he points out.  “These support professionals have detailed knowledge of all the standardized workflow standard operating procedures, technology integrations and knowledge of common problems and resolutions across the family of DSO-supported practices.”

U.S. Healthcare at a Glance

Health, United States, 2016 is the 40th report on the health status of the nation and is compiled by the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS).

The Health, United States series presents an annual overview of national trends in health statistics. The report contains a Chartbook that assesses the nation’s health by presenting trends and current information on selected measures of morbidity, mortality, healthcare utilization and access, health risk factors, prevention, health insurance, and personal healthcare expenditures. This year’s Chartbook focuses on long-term trends in health. The complete report and related data products are available on the Health, United States website at: http://www.cdc.gov/nchs/hus.htm.

Here are several charts from Health, United States, 2016.

news

Affordable Dentures & Implants opens practice in Kissimmee, FL
Affordable Dentures & Implants opened a new practice in Kissimmee, Florida. This practice opening marks Florida’s nineteenth practice in the Affordable Dentures & Implants affiliated network. The practice is led by Anthony Graham, DMD. The Kissimmee practice aims to increase local patient access to critically-needed tooth replacement services by offering free consultations and X-rays for new patients.


New DSO formed in Hawaii
A new dental service provider was established in Hawaii with the acquisition of four existing dentist offices on three islands, funded by Tradewind Capital Group (Honolulu, HI). Premier Dental Group Hawaii has offices in Aiea and Pearl City on Oahu, Kapaa on Kauai, and Hilo on the Big Island. Premier Dental allows the convenience of visiting one dental office for multiple services, such as routine exams and teeth cleanings to specialized dentistry such as oral surgery, endodontics, orthodontics, pediatric dentistry, implant surgery, cosmetic dentistry, and teeth whitening. The company plans to invest in state-of-the-art dental equipment, including three-dimensional digital imaging technology, computer-aided design and manufacturing technology for same day crowns and laser technology to give its clients the most advanced service package available.


Medicaid dentistry and the group practice
The merits of comprehensive dental healthcare – especially for the tens of millions of children covered by Medicaid – cannot be overstated. According to a 2016 Pew Charitable Trusts report, tooth decay is the most common chronic disease among U.S. children – five times more prevalent than asthma – and dental care is one of the nation’s greatest unmet health needs among children, especially in low-income, minority, and rural communities. In 2012, more than 4 million children did not receive needed dental care because their families could not afford it. Even when controlling for insurance status, low-income and minority children remain less likely than higher-income children to receive preventive dental care, according to the report. An article in the July-August 2017 issue of Efficiency explored the need for Medicaid dentistry, some of the access challenges that currently exist, and solutions that will help ensure dentists build upon the Medicaid dental access gains that are already demonstrating improved health outcomes and increased cost savings in a number of states. Visit https://www.dentalgrouppractice.com/is-medicaid-dentistry-sustainable.html


Crosstex International strategically strengthens marketing, sales teams
Crosstex International Inc (Hauppauge, NY), a subsidiary of Cantel Medical Corporation, strategically strengthened both its marketing and sales teams in anticipation of the retirement of SVP Andy Whitehead. This process was started nearly 4 years ago by adding additional talent to the top levels of sales and marketing with Whitehead transitioning to M&A/business development. Crosstex International’s sales department is headed up by Ken Plunkett, SVP of global sales. The marketing team is headed by Jackie Beltrani, VP of global marketing.


Zirc launches new color-code guide
Zirc (Buffalo, NY) launched its new and improved color-code guide. The new guide features simple, step-by-step recommendations to set up a color-code system for one, or all, of your procedures. According to the company, having a color-code system in place will allow users to save at least 5 minutes per procedure and minimize the time and stress of trying to find instruments and materials. You may request your own hard-copy of the Color Code Guide to achieve optimal efficiency and organization in your dental practice. To download Zirc’s Color Code Guide, visit zirc.com/colorcode


Kool Smiles donates $8,000 to Indiana University Dental Student Outreach Clinic
Kool Smiles recently donated $8,000 to the Indiana University School of Dentistry (IUSD) to expand service offerings at its Dental Student Outreach Clinic. The donation will help the clinic provide free root canals to local adults in need. Many of the clinic’s patients who required root canals were previously unable to receive them due to cost barriers. The IUSD Dental Student Outreach Clinic opened in 2009 and is run by volunteer dentists, faculty, and students from the dental school. The clinic helps an average of 20-25 patients every other Saturday and remains open for 11 months of the calendar year.


Aspen Dental to open new office in Alabama
Aspen Dental will open a new office in Mobile, Alabama. The new dental office is led by Dr. Harry Houston. Dr. Houston and his team will provide dental services ranging from dentures and denture repairs, to preventive care, general dentistry, and restoration. The new office is the one of 15 Aspen Dental practices in Alabama.


Air Techniques launches new shopping cart web platform
Air Techniques Inc (Melville, NY) announced a new shopping cart feature is available on the company’s website. The new “Shop” platform allows dental practitioners to place “order requests” with their preferred dealer via the Air Techniques website. Currently, the online order requests are limited to the following products: Monarch infection control products, chemistry, processor cleaners, CamX accessories and ScanX accessories. Dental practitioners will receive a complimentary Air Techniques shopping bag with their first order placed – while supplies last. For more information on Air Techniques, visit http://www.airtechniques.com.



Great Expressions Dental Centers makes donation to Transracial Journeys

Great Expressions Dental Centers (GEDC) (Southfield, MI) donated $14,000 to Transracial Journeys, an educational and social organization designed to support multicultural families. The funds provided to Transracial Journeys were the result of individual GEDC employee donations with matching donations from GEDC and the family of Kurt Harvey, GEDC’s chief business development officer. https://www.greatexpressions.com/

The Root of Productivity

Dr. Sami Bahri, DDS. Dr. Sami Bahri is the author of “Follow the Learner: The Role of a Leader in Creating a Lean Culture,” and of the DVD “Single Patient Flow: Applying Lean Principles to Heathcare”. The book won the 2010 Shingo Prize for Research and Professional Publication and the video won the same award for 2013. The Shingo Prize Conference also recognized Bahri as the “World’s First Lean Dentist.” He is a soughtafter speaker and lecturer nationally and internationally on implementing Lean management in dentistry. Dr. Bahri can be reached at Sami@bahridental.com

By Dr. Sami Bahri

A simple first step can significantly boost production

When looking to improving productivity, we often think about low-hanging fruit, like selling more accessory treatments or choosing the right service coding.

The approach is not wrong, but while it improves productivity, it also increases the workload on the staff. In the lean approach, we like to do the opposite. We want to reduce the non-value added work to create more free time for the staff to handle new tasks, like selling more whitening or selling more sealants. To that end, we use a variety of process analysis tools, like diagrams.

The Spaghetti diagram would be a good starting point. It is simple, doesn’t take a lot of effort, yet it will go beyond the low-hanging fruit to the root of productivity improvement.

Why the Spaghetti diagram is so important
At the beginning of the 20th century, dentistry started applying the division of labor created by Adam Smith, the time studies created by Frederick Taylor, and the motion studies created by Frank Gilbreth. That is when the different dental management functions were created – dentist, hygienists, assistant, etc.

Viewed from a productivity point, the division of labor allowed us to treat patients faster – shorter processing time, but created, among others, the problem of transportation. This mainly involves the transportation of patients between different areas in the practice: from the waiting room to the x-ray room, to the treatment room, to the hygiene room, to the treatment plan coordination room etc. There’s the challenge transporting materials to the storage area, then to the work area.

Treating faster makes money, but increased transportation spends it on unnecessary work. That is why in his book Fundamental Principles of Lean Manufacturing, Shigeo Shingo wrote “[I]f the benefits of the shorter processing time (meaning faster treatment) does not overcome the disadvantage of transportation, it is better not to introduce the division of labor.”

The Spaghetti diagram reduces transportation
Transportation is then the waste we need to remove. The easiest way is to visualize it. That is when the Spaghetti diagram become very important. It is simple, because all you need is a floor plan of your facility and color pencils. With the pencils you trace the movement of either providers, patients, or materials. The resulting tracings resemble what the name suggests, Spaghetti.

 

 
Figure 1: When the practice is organized by departments, transportation increases.

Figure 1 shows us our floor plan when we were still thinking departments. On the left wing of the office, we placed the department of dentistry where three dentists utilized two chairs each. On the right-wing, we had one chair dedicated to new patients and three chairs occupied by three hygienists.

To draw the Spaghetti diagram, we took a floor plan of the practice and followed the movement of the doctor working in Chair 1 when she was called for an exam in Chair 10. The red and the green line show she had a long walk — 110 feet to reach Chair 10 and another 110 feet to go back to Chair 1. This is the simplest form of the Spaghetti diagram because it traces one trip for the exam. Usually, to build a Spaghetti diagram, you trace the movement of a patient or a provider for a longer period of time (see Figure 2). You could trace it for two hours, half a day or even a whole day. It would be even more interesting to trace the movement of multiple employees or patients for a long period of time.

The diagram could look very chaotic, and the need for improvement would become more obvious. One manager in a manufacturing plant in Jacksonville traced the movement of all the employees for one year. “Cumulatively, we walked a full circle around the globe in one year” he commented. Can you imagine how much effort is lost in all that walking?


Figure 2: This is what the Spaghetti diagram looks like when the dentist has to examine one patient in each hygiene chair

Change the layout to reduce transportation
Our goal is to reduce the number and the length of the lines in the diagram in Figure 2. Ideally, we would change the layout of the office to bring Chair 10 closer to Chair 1, but that change would be too expensive. As a compromise, we moved the providers around as shown in Figure 3.


Figure 3: Dentists and hygienists were moved closer together in order to reduce transportation

As you can see in Figure 3, we have moved the providers around to where dentists and hygienists were using adjacent chairs. If you check the lines traced by hand, you would see that the dentist is now walking a total of 20 feet instead of the 220 feet she walked in the first diagram. The savings in walking efforts are remarkable, and they would be even more remarkable if we multiply them by the number of trips to do an exam in every treatment room, as seen in Figure 4. For four exams, the Flow-oriented layout allowed her to walk around 200 feet instead of nearly 800 feet imposed by the department-oriented layout.

Figure 4: When we trace a Spaghetti diagram for all the trips over a long period of time, the need for improvement becomes clear.

Add to that all the trips that could be saved for the rest of the staff, transform those efforts into treating patients instead of walking, and you would see how powerful the Spaghetti diagram can be in improving productivity

Controlling transportation
It is very important to be conscious of the advantages and the disadvantages of every management decision we make. Since we have adopted the division of labor, we need to be mindful that transportation of patients, materials and staff, if not controlled, can overcome the benefits of the shorter treatment times afforded by the division of labor. To control transportation, the easiest way is to make it visible. The Spaghetti diagram is a simple yet powerful tool that allows us to reach our goal. It can be drawn by anyone with very little training and tremendous results in productivity improvement.