Principles for Thinking - Part 2/3 of Organizing a Military Dental Clinic
Below is a list of concepts, ideas, thinking principles, thought experiments, mental models, or whatever else you want to call them. I do not claim to be the originator of any of these concepts, but all of the following are some synthesis of the many ideas I've gleaned from the books I've read and the experiences I've had.
They are "how to think" about certain types of problems, without delving into any specific issues. Hopefully these can be useful ways for you to think about problems as you work to come up with solutions.
Would they choose to come here? (for military clinics)
If your patients had a choice, would they choose your clinic? In the military, they don't have a choice! This question is the best way to think about the entire patient experience, and will ultimately lead to a more streamlined and efficient clinic all around.
Build it for the new person
You should do your best to *
never* build a system just to accommodate a person. You build it to accommodate a position and fulfill the purpose of that role. Now, having said that, you may have to tweak it for a certain person but the resulting outcome should not change.
Example: some people prefer digital lists of supplies while others prefer written lists. The resulting outcome should still be identical.
When creating a system, imagine yourself as a new person walking into the clinic for the first time and as yourself the following question.
How quickly could we train a new person to be proficient enough to run this system alone?
This question is the measuring stick for every system you create. The quicker the training to sufficient proficiency such that you trust them by themselves, the better the system.
The poisoned river problem
Imagine a village living on the edge of a river. One day, the water in the river starts making people sick. What is the best way to solve this problem?
1. Build a water filter
2. Remove the contamination upstream
Most people will answer #2 but actually do #1 in their life, because #1 simpler. Don't give in. Solve the
real problem! Stop building filters. Filters are for emergencies, they are not solutions.
Ask "why?" several times
I can't remember specifically where I learned this, but "why" is the most powerful tool you have to get to the root of any problem. It should be asked several times before settling for the answer.
This is a summary of a real conversation I had a few months ago.
Me: "
Why are we out of XYZ forms?"
Person A: "Well, Person B isn't here"
Me: "
Why does B need to be here?"
A: "She prints them" // *
(MOST PEOPLE STOP HERE!)*
Me: "
Why can't you print them?"
A: "I don't have access to the forms"
Me: "
Why not?"
A: "I don't know, they tried to give me access but it didn't work"
Me: "
Why didn't you follow up?"
A: "Person C was working on it but I haven't heard anything"
Me (talking to C): "
Why doesn't A have access to the forms?"
C: "Person D is in charge of that, and I tried for a while to get A access but they couldn't do it"
Me: "What is D's email address?"
...
In 2 hours, person A had access to the forms via an email and phone call I had with person D. Most people would stop at the first question and just accept the problem. No more!
Pay attention to your shoulders
Shrugging your shoulders is admitting defeat. I do this too, usually without thinking. But don't let the shrug be the final response. You know you're making things more efficient and simpler when the shoulders of people around you are being shrugged less and less.
A shoulder shrug says "I don't know, I don't want to put in the effort to find out, and I give up".
It's ok to not know, but it's not ok to not know who DOES know or how to find out. A shrug is an indication that people are too far removed from the solution to take any action at all. A shoulder shrug is an indication to make things easier or more accessible!
When someone shrugs their shoulders, this is a silent request for a better system.
Remove redundancies
If there's 3 versions of the same thing, but only 1 is the real version, hunt the other 2 down and get rid of them. Bonding agent, rubber dams, paper forms, whatever.
Having more than 1 version of something, especially if it's no longer used, adds confusion to the supply chain and your clinic at every level.
Organize relentlessly
This sort of plays off the previous comment, but be relentless in your pursuit of organization. Do not accept clutter. A cluttered work space (unless a project is in progress, obviously) means the mind is cluttered. Our mind is a powerful tool, don't waste its energy on clutter.
Don't let other people dictate your programs
Put your foot down, standardize the process, write down how to implement it, enforce the rules you set, and watch the chaos subside. This often takes lots of up front work (although sometimes it just takes making a decision to stop tolerating something), but the ultimate result is a better process for everyone, and a happier work-life for you.
Don't ever rely on verbal transfer of information alone, except in emergency situations
Every important verbal exchange should be followed by an email or a note, and every interaction you have with those you work with that involve one-way exchange of information should involve as little verbal communication as possible because this is where things get either confused or forgotten. Exceptions are very routine items that require very short instructions, like "please check XYZ before you leave today". An email would defeat the purpose here.
Sometimes conversations must be had in person, and they are more efficient that way, but summarize the conversation with a note or an email, especially if action will not be taken on that item immediately.
Example: If you're running logistics, don't let people come
tell you an item is low. Have them mark the low item bin itself or write it down on an order form (more on that in part 3). Asking them to verbally tell you something is begging for trouble. Some day, you will forget or hear them wrong, or they will get used to telling you and filling up your brain instead of putting the information somewhere simple for you to access.
Think into the future
The clinic needs enough supplies to last through a shortage, and enough notice to get an item before it runs out. If you know that product X takes 30 days to come in from the day you order it, you better have some way to know when you are getting close to a 30 day supply. Stop waiting for the product to dwindle down and then panicking that it's low. This also touches on the previous point. If you run into this problem once, design a better way to communicate.
If the same problem happens again, that's on you. You're not thinking into the future. This is a key mistake I see people make very often.
Have projects ready for down time
Sometimes things break. Sometimes patients cancel. Have some projects ready that can be handed off and worked on during this down time. Stop just working "in" the clinic and start working "on" the clinic.
Everything can be simpler, better, or faster. Everything. Make it so.
Your clinic is a machine. Build a better machine.
Could you imagine the hilarity of watching a family push a Flintstones-style car down the highway? It would be absurd.
But we do this ALL THE TIME! How often have you watched a coworker (you and I aren't exempt here) complain about a process but fail to actually do anything about it? They keep pushing their Flintstones car down the highway, complaining about how slow it is, and never really thinking it might be time for a new car.
The car is a symbol of the system you've created. If you're not getting the result you want, build a better system!
Put instructions at the point of contact
If you want someone to do something when they encounter an particular object, make it obvious.
Example: If you want people to know where they can print new forms, post an address to the computer drive on the wall above the paper forms! Tada!
The good system you'll actually do is better than the perfect system you won't
I don't care how good a system is. If it's too complicated or burdensome to actually use, it's no good. Make something that's good enough but simple enough that people will actually follow it. Then you can gradually improve the system from there.
Start now, but make things editable
There's two problems that occur when you make a system too hard to modify:
1. You have your ego tied up into the time it took to make it perfect
2. You're more reluctant to change it because it will take a lot of effort
Example: At my first base, I typed labels for all our supplies. It looked nice, but it took forever and was a pain to change. At my new base, I made blank cards that we can just handwrite. It doesn't look as nice, but it's been much easier to make changes and it works functionally just as well as the typed versions. Besides, once we are stable for a while, I can always go back and type the labels.
Get started, but be prepared to change course. It doesn't have to be perfect before you begin. In fact, it shouldn't be.
Be thankful
Give people specific thanks and praise for what they do. Every. Single. Day.
People are far more motivated to continue doing good things than being constantly told to fix bad things.
Write it down, and take a picture
If you want something TO GET DONE a certain way,
write it down. Checklists, how-to guides, easily accessible Powerpoint presentations... it doesn't matter. Don't rely on mouth-to-ear transfer of knowledge.
If you want something to LOOK a certain way (a standardized room, for example) then you MUST take
photographs and make them easily accessible. Photos are the gold standard for standardizing anything visual.
Bonus: Add pictures or computer screenshots, where applicable, to whatever written process you want people to follow for added clarity.
If you want it to fail, fix it and walk away
This sort of piggybacks off of the previous point, but you must have a process for duplicating your solutions.
Here's the progression, applied to treatment rooms:
1. Create the standard (develop a standard treatment room)
*(MOST PEOPLE STOP HERE)*
2. Make the standard reproducible (take photos of a perfect room setup)
3. Give people time to hold the standard, and then enforce the standard (the photographs, not a person's opinion, is the ultimate authority, so use them to enforce the standard)
4. Develop repercussions the failing the standard (what happens if the standard is not met?)
A car uses more energy than a spaceship (how to create a system)
Ok, sort of. A spaceship uses WAY more energy to get off the ground and into space. But once it's in space, it's aided around the Earth by the force of gravity and does very little work to propel itself in orbit. Eventually, it travels farther than a car could ever go.
A car is under the same gravitational influences, but it must have constant energy input because it deals with FRICTION. It takes way less work to move a car on a road than a spaceship from a launchpad, but the car takes the same amount of work every single day, and ultimately, the car can't go that far.
Look for
friction in your clinic. Where are people complaining? Where are people bumping up against the same problem over an over? Where are things harder than they need to be? Where are things taking 5 steps when they could take 3? Where are efforts being duplicated for no reason?
Can you be a spaceship and put in a lot of energy up front right now to make the friction go away forever?
This is how you create a good system.
(Amazon's "One-click ordering" is an example of reducing friction)
A system is a 3-part answer to "how do we... ?"
The answer to this question must be:
1. Obvious ("here's an
obvious location to find clear, documented directions on how to handle certain patients")
2. Clear ("here it is, documented in
easy-to-understand and follow language")
3. Documented ("here it is, documented completely, so that
you could do what I do if I'm not here")
If you don't have these three components, you don't have a complete system.
People plug the holes of incomplete systems. An incomplete system is going to collapse when the person (or people) that is running it eventually leaves.
If you have someone just manhandling the Class 3 program, answering all the questions, doing all the work, but none of what they do is obvious, clear, and documented for someone else, you are asking for problems.
Tip: ask people to document their own jobs! Most are happy to do so.
Create decision ladders
For my Class 3 program, I have a file on the computer that is basically a "how-to" guide called "Class 3 Operations Manual".
Open that document and you'll find only 3 main points. What do do daily, what to do weekly, and what to do monthly.
Each section has references to other places on the network drive where there are directions on how to create certain forms, how to log our patients, and where the log is located.
In fact, once you navigate to the patient log, the log itself has instructions on how to use it!
Do you see what I've done? I hand over the starting point (the "Class 3 Operations Manual") and it points the reader--
Where go to
When to go there
What to do when they get there
Boom. All they have to do is open that first document and "climb the decision ladder" to each step. Every rung is built for them. There's only one way to do it.
Systems fail when there is a gap in the ladder so wide that the climber has to find another path to keep climbing. That's where mistakes are made.
Don't let old problems disguise themselves as new problems
Sometimes we fix a process, but something that was created under the old process pops up and causes discouragement.
If you created a new process on 1 October, 2018, then give it some time! If a problem pops up that was created before 1 October, 2018, no sweat. That problem says absolutely nothing about your new system!
Now, if the problem popped up in November, then you may need to do some tweaking. But old problems will bubble up, just have your head wrapped around when the problem started and don't nuke your new system or add a bunch of new steps just because old problems are still out there.
The goal of the new system is to prevent new problems from arising.
Side note: It might also be good, when creating a new process, to have a sister-process that can go try to hunt down old problems that might exist. The sister-process can be shut down when everything is corrected. (Example: you have a new chart color system, so new charts get the new colors as the patients come in for treatment, but for a while, someone needs to go through the old charts and proactively update their colors, too.)
Don't enforce a standard that doesn't exist
"Have your rooms cleaned and looking nice by the end of the day" is 100% unfair.
Your definition of that statement may be different than the person who has to clean the room.
Who is right? You both are. And by default, neither of you are.
Have a checklist or photographs of every standard you wish to enforce. If the standard is unclear, make it clear and then
update the checklist/photos. You cannot rely on someone's opinion as a "standard". This allows the standard to change on the whim of the person enforcing it. Not good.
Ask "what's the most annoying thing you deal with?" and fix it ASAP
Learned helpless will drag someone down slowly over time, to the point that they may fail to realize that their situation is solvable or avoidable.
People typically either:
1. Fail to see the "real" underlying problem as something small and easily solvable
2. See the problem, but lack the experience or critical thinking skills to come up with a sustainable solution
Solving someones most annoying problem will accomplish and demonstrate a few things:
1. Helps them realize their problems are really not that big, usually just an accumulation of small issues
2. You're on their side, you are a team, and you want them to win
3. Being "busy" and "stressed out" does
not have to be the default operating mode
4. Paying attention to the little things and fixing those can lead to a spiral of success, instead of a spiral of destruction
5. Most of the things they don't like about their job are the accumulation of small loses, not just a few big problems
Automate your brain
With calendar alarms, reminders, and digital to-do lists, you should never ever forget a task or an event.
If you are, you're relying on your brain to be a calendar or a to-do list. This is secretary work for your brain, something it's notoriously bad at doing.
Write it down, make a calendar alert, whatever you have to do. There is no excuse for "forgetting" these things, because they should never try to be "remembered" in the first place.
Big goals, little steps
You can't complete big audacious goals in 1 day. Many will take months or years to fully realize. This can be hard in the military, but you can do it if you focus on the smaller pieces!
Set an intention to accomplish big things, but break the individual steps into small and manageable pieces that you can accomplish.
I even like to have daily goals that are very small (example: research 1 new item each day).
Here's why:
On your "off" days, when you're just too busy to really get anything done, you can still find time to do your one small step.
On days when a patient cancels or you have a ton of unexpected free time or energy, you can slay a weeks worth of work!
Double the time, halve the results
Anticipate that any change you want to make will take twice the time and be only half as effective as you hope it will be.
This isn't to discourage you from trying to make changes, but to keep in mind that difficulties are often impossible to see, especially when the perfect end result is to clear in our minds.
Be prepared to work hard, long hours to get things done. Keep moving forward, and you will accomplish them.
