-Ideas to Improve the Dental Practice-

The Tale of Two Coronavirus Vaccinations

(with apologies to Charles Dickens)

Welcome back to Pt. 2 continued from last week and my! If you missed pt 1. Check it out HERE.

Now... on to the "worst of times"

Non-optimal patient flow. Not enough capacity.

First of all, let me say that I don’t have any info as to the experience of the volunteers. Or who created their workflow.  And please don’t see this as a criticism of folks who unselfishly volunteered their time to help their fellow humans.  I’m just commenting on the efficiency of the process.

Again, I was psyched to be finishing up my vaccination protocol.  Especially, since I was planning a ski trip for next month that I really wanted to go on.  Arriving, I saw a line out the front door of the building.  (Not a good sign).   Again, I was met by folks asking me if I had an appointment for that day and was it my first or second vaccination. Again, I was directed to the correct line.

There were about 5 people in front of me to get into the building.  Once inside, I realized that the line snaked back and forth like the lines at ticket check-in at the airport.  And like the airport, there seemed not to be enough workers to check people in.  To complicate things, occasionally they would stop checking people in because the line into the gym (where the vaccinations were being administered) had grown so long that there was no more space for people to line up.  So, not enough capacity at check-in.  But even if there had been, clearly the bottleneck was further down the line.  

Parkinson's Fourth Law: "The number of people in any working group tends to increase irrespective of the amount of work to be completed."

About halfway to the check-in station a volunteer was there handing out a “facts sheet” about the vaccine.  You know, “This is what the vaccine is, and this is what you can anticipate after getting it”.

At my first vaccination, this had been given to me as I left the “vaccination table” and headed for my 15-minute self-timed wait.  This eliminated the need for an additional volunteer.  Making the whole operation flow more smoothly with one less person involved.  Maybe they had too many volunteers.  Maybe they didn’t really have anything for him to do so they expanded the work a bit to fit the volunteers that they had. I’m not really sure but, it seemed an unnecessary expenditure of resources

Waste in the dental office

Most of us are much more familiar with Parkinson’s First Law “Work expands to fill the time allotted for its completion. Usually, without an improvement in results obtained” or words to that effect. That “expansion” can also apply to resources and personnel.  You can’t get the job done without “X”, until you have to.

As in, you get halfway through a procedure and your favorite instrument isn’t available and so you figure a way to accomplish it because you have to.  Or when your right-hand employee Jane quits and you have no idea how you will run the practice without her. But you figure it out.
So, just because we’ve always done something in a particular way doesn’t mean that another avenue that consumes less time, resources or personnel couldn’t be found.

How can we make our dental procedures more efficient?

Such was the case for me when I had to find a much more efficient way to do same-day surgical extractions. I had emergencies coming in the door in pain and I didn’t want to make them wait or send them down the street to my friendly oral surgeon who also might or might not have time to see them today.  By creating a different treatment flow (we prepped for plan A, B and C before I entered the room), I could complete almost any extraction in 10 minutes or so.  We even put all the instruments in their own cart to make the set up even smoother for the assistant.  Just roll the cart into the room.  As I gave the injection (between scheduled patients) I would dictate which instruments I wanted laid out and which of those I wanted opened.  (so, plan A, B and C, all ready to go) Now when I came back into the room to a numb patient, we were set for any contingency.  This way, the patient didn’t have to get referred down the road and they weren’t made to wait another day or two in pain.

But back to our story...

Finally, it was my turn at the check in station and I looked at my phone.  Almost an hour just to check-in.  Not good but, I had heard of folks in other states waiting multiple hours to go through the process. So, while annoying, I wasn’t going to spend my whole day here. I hoped.

I got a stamp on my hand indicating that I had been checked in and was pointed towards a line that was no more than 10 feet away.  There was another volunteer there who was checking to see that we all had “hand stamps”.  Two things here.  We were virtually in a continuous line from check-in to vaccination line, so I didn’t see the need for this extra step. (extra step, extra personnel, no advantages in outcome).  And is using the same stamp to touch every single person without any way to disinfect it or guarantee that no one was a symptomless carrier of the virus a good idea? (Sometimes we have processes that don’t really make sense. I try to be continually evaluating and upgrading on a regular basis to improve year over year)

Clinical dental office staffing 

Finally, I entered the gym and there I saw the problem.  While there were 12 stations, only about half of them were “manned”.  (Actually, womanned as most of the volunteers giving injections were female)  

Again, a capacity issue.  In a dental practice if you are working from multiple chairs, the optimal number of assistants is one per chair.  That way you are getting the maximum capacity out of each chair. Since your time in most procedures is less than that of your assistants, by having multiple assistants they are never the bottleneck and you are getting maximum through put.

Four-handed dentistry (again)

At last, it was my turn.  I handed my vaccination card to the first volunteer who handed it to the second volunteer who spent a few seconds inputting information into the computer.

Meanwhile the first volunteer asked which arm for the injection and swabbed it with alcohol. Now she opened the bandage and applied half of it to my arm leaving the other half dangling for after the injection.  She then looked me up and down and picked up a syringe, read the label and put it back down. Then she picked up another syringe read the label and put it back down. Now she picked up the first syringe again and put it back down. Finally, she picked up the second syringe again and opened it. So, I had to ask “what is the difference between the syringes?”  “Oh, some of the needles are long and some are short.  You’re kind of a bigger guy so, I need to use the longer one” she replied. She then asked me about allergies etc.  After I answered none, she finally drew up the vaccine and gave the injection.  Now back to the bandage to affix the other side. And I was done.

Let me say again, they were very nice folks and were volunteering their time, so I am grateful.  But the waste!

First, there seemed to be only two needle sizes. So why not put them in two piles or containers, long and short. This immediately eliminates “searching”.  She handled the bandage twice.  I don’t think that I would have bled out while waiting for her to open and apply the bandage.  And by handling it only once, time and possible contamination are both saved. With some of these decisions premade (which syringe is which, what the order of the procedure would be) she could have been asking me the required questions while attending to other duties further saving time.

Finally, the second volunteer could have been doing something (maybe opening the syringe and prepping the vaccine or prepping the bandage that was to be applied after the injection) rather than working for literally seconds and then just standing by for the rest of the procedure. Surely, she would have been less bored and more engaged.

So how does this play out for us?

In our practices, frequently we don’t have a standardized set up for each procedure.  Sure, everything is in the room. But it’s in drawers and cabinets and bins. It’s not sitting out on the delivery or counter top where it can just be picked up.  Or it hasn’t been opened and dispensed (if appropriate) ahead of time in anticipation of its role in the procedure. None of these things takes a lot of time but all taken together they slow progress.

How to increase production in the dental office

Also, we fail to train our assistants to the fullest extent of the law. So, they sit. And they watch us. Then when directed, they hand us instruments or materials.  Additionally, we haven’t trained them to work independently. So that while we producing in another room, they can be finishing part of the previous procedure without us. Think temporaries, impressions, initial fitting of crowns or denture deliveries. Obviously, adherence to “the fullest extent of the law” will make this different in different states.  I know that training is a pain but the payoff is huge. 

Dental assistant training 

It can be as simple as taking a video when you are working on staff members.  Get your best assistant to assist you and both of you talk to the camera explaining why and what you are doing as you go through the procedure. Now you have documented the set-up, order of procedure and materials for the procedure. This gives a good place to start a less experienced assistant’s training.

And you don’t have to be there explaining the same thing over and over again.

One of the things that really saddens me is seeing assistants with 20 years of experience that haven’t even been trained to pass instruments correctly.  I think we do ourselves and our staff a disservice if we aren’t constantly helping them to improve and grow in their jobs.

Conclusion

In both of my experiences, I got the vaccination. But if I had a choice of where to go back for another injection, I’m voting for the first place.  Patients come to us daily for something they need and aren’t necessarily looking forward to the experience. By making our offices run as smoothly as possible we minimize everyone’s discomfort, create a better work environment and maximize our profitability.

Remember, “Slow is Smooth and Smooth is Fast”