Level the Schedule: Profit, quality, and less stress

By Dr. Sami Bahri

In a group practice, productivity is directly affected by the schedule. Many methods of schedule try to improve quality, increase productivity, lower stress and reduce cost. Although based on different philosophies, they are roughly divided into three parts: long-term planning, medium-term adjustments and execution.

In long-term planning, you create a scheduling template that reflects your management philosophy. For example, if you like to treat by procedure, performing veneers together in one appointment, and composite fillings in a different appointment, your template would reflect that philosophy. It would look different if you plan for quadrant dentistry, or for lean dentistry.

Medium-term adjustments take place around a week before the appointment. These templates are not personalized to accommodate the needs of individual patients, mainly those with special conditions – older patients, younger patients, patients with health conditions, etc. Providers are asked to review the schedule in advance and make any necessary scheduling adjustments.

Since the dentist and the assistant are busy treating patients, they are not available to check the schedule. At our practice, we created the position of “Patient Care Flow Manager” (“Flow Manager,” for short). This employee monitors and adjusts the schedule, allocates resources accordingly, and stays in contact with the providers to notify them of any changes.

“Lean management” approaches the three phases of schedule planning, adjustment and execution differently from the other philosophies.

Creation of a template
A template allows anyone in the office to make patient appointments if they know some basic information like planned treatment and its duration. The appointment might not be totally customized to the needs of the patient until it is reviewed by the provider, but the template provides a good starting point.

The Lean approach to creating a template differs from the traditional approach in that Lean starts from demand. Traditional scheduling starts from capacity – the number of treatment rooms, personnel, equipment etc. The thought process behind each philosophy is different as well.

Traditional thinking. If we have five rooms for example, we think that we can allocate two for hygiene, with one hygienist per room. If each hygienist can perform one cleaning per hour, we plan for seven cleanings in a seven-hour day. If we work 200 days a year, we plan for 1,400 cleanings (7 cleanings x 200 days). The same reasoning applies to fillings, crowns, etc.

The main flaw in this kind of thinking is that the number of planned procedures depends on the number of chairs, as if they were going to be always full. It does not take into consideration the patient demand for that particular practice, and does not calculate the number of needed employees. Lean thinking corrects these flaws.

Lean thinking. Although creating a template is speculative in any case, “Lean thinkers” try to get closer to the real situation of specific practices by starting from real data. In our practice, we base our template on the data from the previous year. We run a report that lists the different procedures, and an analysis that makes their frequency visible.

The more frequent a procedure, the more non value-added steps it will entail, especially if it requires setup changeovers. For example, every cleaning requires a changeover, while multiple X-ray exposures can be taken with the same setup. Consequently, the cleaning frequency entails more waste than that of X-rays.

Paying attention to trends is also important. If you see that for the past three or four years you have been performing around 4,000 cleanings yearly, you are more likely to perform the same number this year. On the other hand, if you see a steady 10 percent increase, you should plan for that increase in your template by making room for 4400 cleanings. The same goes for crowns or root canals or any procedures.

Based on the previous year’s data and your projected growth, you can speculate more precisely. But you still have some work to do before you can build the template. You need to know how many minutes you anticipate working this year, so you can calculate the Takt time of your procedures.

Time
Takt time
is the theoretical frequency of demand; it is calculated, not measured with a timer. Here is how you calculate the Takt time for a cleaning:

Takt time (in minutes) = number of minutes worked during a year/number of cleanings

Takt time is a theoretical assumption that answers the following question: If you placed all your cleanings back to back in a linear timeline, what is the time interval, in minutes, between two patients asking for a cleaning? Figure 2 shows that our patients are theoretically asking for a cleaning every 26 minutes. Now we need to know the cycle time –how long it really takes to complete a cleaning – to be able to determine how many hygienists are needed.

Cycle time is the actual time needed for an operation to be completed. Unlike Takt time, Cycle time is actual time; it is measured, not calculated.

You can determine a starting and ending point and have someone time a procedure 15 to 20 times. The common Lean practice is to take the most frequent low time as a standard cycle time.

You can compare Cycle time (CT) to Takt time (TT) and learn how many employees you need. If Cycle time is smaller, you need one hygienist; if larger, but not double, you need two hygienists. If it is between double and triple, you need three hygienists, and so forth.

In our case, Figure 3 shows that we only needed one hygienist even though we had three. To leave room for growth and unpredictable circumstances, two hygienists would be enough. As a consequence, when one hygienist went on maternity leave, we didn’t replace her and still did not struggle to meet our patient’s demand.

Takt time also tells you how many procedures are to be performed on a daily basis. If patients are asking for a cleaning every 26 minutes and you work seven hours a day, how many cleanings are they asking for per day?

Theoretical Number of cleanings per day = 7 hours x 60min / TT of 26 min = 420/26 = 16

Each of the two hygienists got a template for eight cleanings per day, at 30 minutes per cleaning. We also distributed the different periodontal therapies, but for the sake of clarity, I will mention only the simple cleanings.

That would not have been the case had we tried to fill the schedule with three hygienists instead of two. The actual demand in our practice is around 4,000 cleanings per year. No matter how we fill the schedule, by the end of the year, we would have performed around 4,000 cleanings. With three hygienists instead of two, filling the schedule will only guarantee unevenness – alternating periods of busy and slow days. To avoid unevenness, proper staffing is a prerequisite. This is determined by a simple calculation of Takt time and Cycle time.

The process of distributing the procedures evenly across the schedule is known as Leveling. This guarantees more contact time between providers and patients, a slower pace, better quality, and mainly a lot of room for walk-ins and flexibility in the schedule.

A long time ago, I asked a sales representative for advice on what would attract patients to my practice. “If you called every office in town to have a cleaning,” he said, “you would not find one that would take you immediately!”

After leveling our schedule, we can take an extra cleaning any day.

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 Aplying 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@baridental.com

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