Cross-Training Done Right: Maximize Efficiency and Profits

By Dr. Sami Bahri

At a lean management conference, I met a Toyota executive whose business card said “Jamie B…, Vice president of X.” He had another business card: “Jamie B…, President of Y”. I wondered why he occupied two different positions. “It is very usual for us to have several jobs at Toyota,” he said. I learned later that some Toyota employees go through four different jobs every day – they are cross trained for every one of them.

Imagine the difference between Jamie’s situation and the way my office functioned before we applied lean management. We had one assistant per room. If her patient showed up, she would work; if not, she would wait for the next one. She would help with the other assistant’s patient, only if we asked – and that was not considered part of her job. Assistants, hygienists and front desk personnel were three different groups that never mixed.

The situation was not that extreme all the time, but we certainly went through periods where functions were firmly separated. From an organizational standpoint, having a clear function separation certainly feels neatly organized. But it has a flaw that makes it very costly.

Why is the clear separation of functions very costly?
That separation makes equalizing the work load among employees almost impossible. Unless the workload is equalized, however, some people will be idle when others are busy. The busy ones feel that the rhythm is hectic; but if we can pass some of the load to the idle ones, everyone will be working slower.

However, passing some of the load is not a manager’s spontaneous reaction to overload. The natural reaction is usually to hire more assistants if the assistants are too busy, or more office employees if the front office is too busy. As we will see, hiring more people makes things worse.

How can hiring additional employees harm productivity?
Let’s say your assistants became overwhelmed. You hire a new assistant to alleviate the pressure, which in fact reduces the load on the rest of the assistants and they feel relieved. After some time, however, you find that the excess demand has been absorbed, and you are running out of work for the extra assistant. You also find that the increase in overall production was proportionately smaller than the amount you paid for her salary.

The new assistant has now some time on hand and all the team members start looking for a solution to her idleness. Fairness is on their mind! And to them, fairness means that her workload should not be smaller than theirs. We have experienced the following scenarios over time:

  • The newcomer tries to look busy in order to justify her presence at the office. She then starts doing unneeded work. She spends recourses that otherwise would have been available to treat patients.
  • The office manager gives everyone less work – she distributes the idle time. Everyone slows down and gets used to a slow pace. Then, when demand picks up again, it will be difficult to bring the team back up to the previous speed.
  • The “hide and seek” game: If you have one assistant and one task, she will manage it properly. However, when you have two assistants and one task, they will play “hide and seek” until one of them is caught. As soon as she starts to help a patient, the other assistant becomes more visible. Again, when work goes back to a normal pace, it will be difficult to bring the team back to speed.

As you see from those examples, an excessive number of employees can cause a large amount of process waste. As you added a new employee, the percentage of production devoted to salaries increases and you realize that giving salary raises will become more difficult. Consequently, keeping employees for a long time will become more challenging.

Therefore, it is in everyone’s interest to find solutions that improve efficiency by reducing the load on the actual team members. This is achieved through waste elimination. Such solutions will allow the current team to handle increased productivity without hiring new employees, and without having to work harder.

How to handle increased demand without hiring additional employees?
Two of the most effective solutions to absorb demand increase are leveling and cross training. Leveling was covered in a previous article, so let’s talk about cross training.

Not every employee needs to become an expert
First, let us make it clear that we are not trying to train every employee to the point where they are all experts at every job. In football, for example, we would not try to make every player a quarterback; that would be time consuming, unnecessary and even counterproductive. What we are trying to do can be explained by this example from Toyota.

Imagine a U-shaped cell when you plan the flow of an operation
One of the priorities in the Toyota Production System (TPS) and in Lean Management is flexible staffing – matching the fluctuations in demand by changing the number of employees involved.

As one way to attain that flexibility, Toyota’s engineers have arranged the workstations in U-shaped cells where machines are organized in the sequence of work. If demand is low, they use one employee to assemble the product by walking it from station to station until the product exits at the end of the cell. If demand increases, they will bring in additional employees from a different section to help with the load, until the production pressure is dissipated.

As you imagine a U-shaped cell, you can certainly see how the beginning and the end of the process are located in the same area. You can place one expert in that area, who will control the entire assembly process, from entrance to exit. That expert should have the knowledge and the skills to make decisions and execute them. The rest of the stations in the cell are filled with newer employees who are not able to make decisions by themselves, but have received enough training to carry out instructions given by the experts.

That is exactly what we try to achieve (it is also the main point of this article): We try to have one expert in each area of the operation, and train the rest of the staff until they can execute the solutions suggested to them by the experts.

How does that apply to dentistry?
The easiest example is probably how assistants in our office file insurance claims from the operatory. Sometimes they stumble on a complex case where they need help from the insurance coordinator. They just ask her for guidance; when she gives them the answer, they can apply it because they have received enough training in that field.

What is an easy way to cross train your employees?
Some cross-training techniques have worked for us. They will not necessarily work for you, but once you learn the following principles you will find your own way.

  1. Standardize to eliminate the need for cross training. While we advocate cross training, we advocate eliminating the need for it. That’s because cross training is a tool – a means – not a goal. The goal is cost reduction through waste elimination. Any effort, cross training included, not directly involved in patient treatment, is a candidate for elimination. Every time you plan a process, one of your main objectives should be to reduce the amount of labor it requires. The goal is to keep the staff available for value-added work. We standardized the room replenishment process, for example, until a person who received no training at all could replenish the supplies very quickly and accurately.
  2. Keep formal training to a minimum. Adults learn by doing. Classroom training has little effect and a small return on investment. In a classroom setting, we prefer to teach only the basics that allow for a common language.
  3. Intensify on-the-job training through coaching. You certainly know the difference between a teacher and a coach. A teacher gives you the information; a coach will make sure that you know how to apply it correctly. We need to become coaches, watching over people as they are performing their work, guiding them to avoid mistakes, helping them to develop their thinking and working habits. Are you worried that you might teach them and they might leave? Well, as my friend Orrest Fiume, author of “Real Numbers” said: “You shouldn’t worry if you teach them and they leave, you should worry if you don’t teach them and they stay!”
  4. Make every moment a coaching moment. As I am treating patients, I explain what I am doing and why to the assistant, and sometimes to the patient. Sometimes patients think that the assistant should already know what we are doing and they would lose trust if I explain it to her. In those cases, I give the patient a mirror and explain to them what I want the assistant to hear. This way, the assistant gets the training without the patient even noticing.
  5. Manage busy times differently than slow times.
    a. Busy times: When you are busy, you have less time for training. You want to give a task, to the most qualified employee.
    b. Slow demand times: When the schedule slows down a little, you can call your newest assistant to help you so you can train her. A good idea would be to have the experienced assistant stand behind her and coach her with every step to make sure she gets a quick and precise training.

The main goal from cross training is to equalize the workload among the team members. That equalization allows performing more procedures with the same number of people. This, in turn, guarantees that you won’t need to hire more people and that you will keep your current employees longer. If you like to research the subject of equalization, it is called Shojinka in Japanese, and the word was adopted by English speaking lean leader.

Shojinka is the equalization of the load that remains after leveling the schedule. While Shojinka means distributing the work evenly among people, leveling means distributing the work evenly over time. Leveling assumes that you have control over when to schedule an appointment.

However, no matter how hard you try to level – distribute the load evenly over time, you might find that the schedule gets uneven from time to time. That is when Shojinka – equalizing the workload among people – comes into play, allowing you to utilize your resources with flexibility. If you would like to research leveling for yourself, you could also research its Japanese name, Heijunka. Heijunka has also been adopted in English. The combination of Heijunka and Shojinka is very effective in boosting productivity.

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