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an overview of how lean can be applied at the dentist, a small book can also be bought on this topic
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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.
Webinar “Housekeeping” TipsUse the volume controls on your computer to adjust sound.j
Enlarge slides with the console button b th thbeneath them.
Use the "ask a question" button on theUse the ask a question button on theleft side to submit questions.
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
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
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
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
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
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
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
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
7.Pursue operational excellence, growth will follow: solid solutions, hard to imitatefollow: solid solutions, hard to imitate
Bahri Dental’s System of Leadership PrinciplesSystem of Leadership Principles
- Process -1.Be equal part learner, equal part teacher
Bahri Dental’s System of Leadership PrinciplesSystem of Leadership Principles
- Process -1.Be equal part learner, equal part teacher2.Build a problem solving culture p g
Bahri Dental’s System of Leadership PrinciplesSystem of Leadership Principles
- Process -1.Be equal part learner, equal part teacher2.Build a problem solving culture p g3.Train to meet the needs of the patient
Bahri Dental’s System of Leadership PrinciplesSystem of Leadership Principles
- 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
Bahri Dental’s System of Leadership PrinciplesSystem of Leadership Principles
- 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
Bahri Dental’s System of Leadership PrinciplesSystem of Leadership Principles
- Process -6.Standardize first, then improve
Bahri Dental’s System of Leadership PrinciplesSystem of Leadership Principles
- Process -6.Standardize first, then improve7.Gather decision-makers around the patientp
Bahri Dental’s System of Leadership PrinciplesSystem of Leadership Principles
- People -1 Show respect for people and their personal1. Show respect for people and their personal
lives
Bahri Dental’s System of Leadership PrinciplesSystem of Leadership Principles
- People -1 Show respect for people and their personal1. Show respect for people and their personal
lives2 Create an open business partnership2. Create an open business partnership
Bahri Dental’s System of Leadership PrinciplesSystem of Leadership Principles
- People -1 Show respect for people and their personal1. Show respect for people and their personal
lives2 Create an open business partnership2. Create an open business partnership3. Respect everyone’s time
Bahri Dental’s System of Leadership PrinciplesSystem of Leadership Principles
- People -1 Show respect for people and their personal1. Show respect for people and their personal
lives2 Create an open business partnership2. Create an open business partnership3. Respect everyone’s time 4. Balance competing interests
Bahri Dental’s System of Leadership PrinciplesSystem of Leadership Principles
- People -1 Show respect for people and their personal1. Show respect for people and their personal
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
Bahri Dental’s System of Leadership PrinciplesSystem of Leadership Principles
- People -1 Show respect for people and their personal1. Show respect for people and their personal
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
Bahri Dental’s System of Leadership PrinciplesSystem of Leadership Principles
- People -1 Show respect for people and their personal1. Show respect for people and their personal
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