The Lean Dentist: Book Review of Follow the Learner

Several months ago I finished Dr. Sami Bahri’s (The Lean Dentist) book Follow the Learner: The Role of a Leader in Creating a Lean Culture. I’m grateful to the Lean Enterprise Institute (LEI) for providing me with a free copy (as well as several other books they’ve sent me).

 

This post is my review of the book.

Leadership, Not Just Dentistry

Dr. Sami Bahri is a dentist, with a practice in Florida. His history goes back to the early 90’s where he quickly became frustrated with the current state of dental practice – for him, it seemed inefficient and patients deserved better. He quickly read all he could on the current management fads at the time, then in 1996, while listening to Lean Thinking on tape, he received the answers he needed to transform his dental practice into one that encouraged and supported flow and enabled him to create a better patient experience ¹.

In his words,

“When the patient gets in the chair, we don’t want to waste any time,” Bahri said. “I look at it from the patient point of view.”

Dentistry as Job Shop

In dentistry, conventional training told dental students to schedule patients by batching like procedures to avoid setups.

When I made your appointment I would see how many fillings you had and I scheduled them together. I had a different setup for crowns so the next time you came, I would do the crowns. Most of the time, dentists tried not to switch from one type of procedure to another in the same appointment because of the time that it takes to do setups.

He estimated the typical dental setup of preparing tools and materials takes about 15 to 20 minutes. Thus, a patient needing a root canal and crown even if they are for the same tooth will need a separate visit for each procedure.

The problem is that in your mouth, you need crowns, fillings, root canals, veneers, etc., Bahri said. So when you come to me, I should have the flexibility to go from one to the other nonstop. That puts the mouth at the center of the process.

Batching dental procedures avoids setups but leads to other wastes. For example, if you arrive for a dental appointment needing a procedure other than the one scheduled (like a root canal instead of a filling) the tools and materials for the scheduled procedure must be removed while tools and materials for the new procedure are set up.

Even if the appointment goes according to plan, traditional scheduling extends treatment time. For example, if you need a root canal, two fillings, and four veneers, you’ll need at least three appointments. That means three roundtrip drives to the dentist, three periods away from work or leisure, and three times the chance that at least one appointment will have to be rescheduled.

It was organized like mass production. I wanted to change that. I don’t think healthcare professionals realize how much their offices are influenced by mass production assembly lines. By removing these wasteful activities, a lean transformation gives healthcare professionals more time and resources to spend on personal patient care.

How Long to do a Cleaning?

Here is his explanation for what dental procedure was performed most often and how he arrived at a takt time for that specific procedure:

Bahri analyzed an annual history of procedures performed in his office to determine what was done most often. Cleanings at 3,985 were the runaway winner. Dividing by this number the available work time of 104,160 min., the time the office is open during a year, gave him a takt time of 26.13 minutes. Every 26.13 minutes we had a cleaning ordered, he said. Despite this stable average rate, the workload of hygienists varied greatly day-to-day. Some days the two office hygienists didn’t have enough work to keep them busy; other days Bahri had to bring in a third hygienists to help.

The next question was, “How long did it take to do a cleaning?  Bahri said. Using takt time and cycle time data, Bahri could calculate the number of hygienists actually needed to meet the rate of demand for cleanings (the takt time) instead of applying the traditional dental management formula of having one or two hygienists per dentist. He also would be able to distribute cleanings evenly throughout the schedule, eliminating the peaks and valleys of too much or too little work for hygienists to do.

Equipped with a stopwatch, pencil, and paper, Marisa Young, an office flow manager, studied hygienists working. She and Bahri discovered that a cleaning could be done in 20 minutes, six minutes less than the takt time, after nonvalue adding activities, such as walking to dentists’ cubicles and cleaning up between patients, were eliminated. Dental assistants and two flow managers took over the hygienists’ jobs of cleanups, collecting payments, presenting treatment plans, and making appointments.

Every 26 minutes a cleaning was ordered so hygienists had six minutes of free time in between cleanings, which is okay with me, Bahri said. It can’t follow the same drumbeat as an industrial process. And at that time, I was allocating an hour for cleanings, so I had cut it by half.

The Results – Applying Lean to Dentistry

Below are the results of his application of Lean Thinking to dentistry:

Mark Graban, at Leanblog, held a Q&A with Dr. Sami Bahri regarding his application of Lean for a dental practice. Please go there too to read more.

Below are two videos of Dr. Sami Bahri, the lean dentist – these videos are worth watching.