Nuts and Bolts - Part 3/3 of Organizing a Military Dental Clinic

Nuts and Bolts - Part 3/3 of Organizing a Military Dental Clinic

Practical tips for making your clinic more efficient. These are actual, real world things you can do to help improve different areas of your clinic.

Post contents:
-Supplies
-Patient Records and Forms
-Meetings

Supplies:

1. Everything has a home

Make sure every single supply has a "home". Some bases have storage areas that can accommodate everything, but some don't. That's ok! Everything should still belong somewhere. NEVER order a supply and deliver it straight to the treatment rooms only and don't just throw the box on a shelf somewhere. You MUST have an area that the rooms are restocked from that itself is a holding area for the clinic. An assistant should never ever ever ever run out of an item and not know where to look for more. The process CANNOT be "tell me when you're low". The item must have a home!

With that being said, this "home" should have standardized labels! NEVER place a box on a shelf by itself unless it's a large box and the shelf itself has a label for that item. Always place the box, or the items in the box, into a standardized container with a label on the front that will allow ANYONE to find that item again later. See #2 for how to do this.


2. How to label item containers in supply areas

Every item must be labeled on a standard container with at least the following information:

-Item Name
-Manufacturer
-Manufacturer Number

These 3 pieces of information are all you need to reorder the correct item. Do NOT just rely on the name alone. Too many products sound similar to trust the name alone! We moved to this system at my previous base and one had 1 item ordered incorrectly in 2 years. At my new base? We accidentally ordered an extremely similar, but extremely wrong, version of the "right" product last month that has wasted money and time, not to mention we have to start over and order the right thing (which we are now out of).

We are working on it :)

3. Have a doctor supply huddle

Every time you get new doctors in the clinic, sit down and go over the supplies. There's no reason that the doctors in the clinic can't compromise on 1 or 2 types of bond. Every single doctor should not have a special bond for themselves. This is ludicrous and adds unnecessary work and strain on the supply chain. Bond is just one example, but it goes for everything.


4. Develop a simple system for alerting the person who does the ordering

Here are some ideas that have worked well --

• Place a sticky note on the low supply container. The Logistics person sees the sticky note and orders more. When they order more, they write the date the item was ordered on the sticky note and the sticky note stays on the item until it comes in, at which point the sticky is removed and the item is restocked.
• Pros
• Eliminates verbal communication 
• Eliminates Logistics person being notified multiple times about the same item
• Eliminates the assistants and doctors wondering when an item was ordered
• Good for clinics with 1 supply area
• Cons
• Stickies sometimes fall off
• Required Logistics person to visually scan supply area
• Not ideal for clinics with multiple "main" supply area

• Create a re-order clipboard. The logistics person keeps this clipboard in their area and techs and docs come write down items they need.
• Pros
• Centralizes all ordering information
• Good for clinics that hold supplies in multiple areas
• Cons
• Same item might get logged multiple times
• Handwriting might be an issue
• Often still required Logistics person to go look for the low item to decide how much to order

• Create order sheet binders or forms that can go in special areas. Many clinics have supplies that are exclusively held in an Endo cart or Surgery room. Hang a printed and laminated Excel sheet with the applicable information (name, manufacturer, manufacturer number) in the room or on the actual cart itself. 
• Pros
• Makes reordering very simple, because the item is identified as being low and the reorder information is right there
• Cons
• Make sure the sheet stays updated with new items or item changes

• BONUS: Same as the "order sheet binder" idea, but just place the info in a relevantly placed Excel document on a shared computer drive. Post the location of the document in the relevant location. This is the same concept as the binder, but more accessible for the person who likes their information digitized. Plus, when you modify it, there's no need to print it off.

5. Consider pre-sterilized burs

I love these so much. Individual burs, sterile from the factory, at practically the same cost as whatever burs you are currently using. 

• Pros
• No more nasty looking bur blocks!
• No more burs running through sterilizers 20 times (or more) before they get used
• No more "is this rust or blood"?
• Eliminates entire process for your sterilizer workers
• Safer for everyone (assistant, doctor, sterilizer techs) due to fewer burs needing to be handled (ie: decreased needle sticks)
• Cons
• Takes up more physical space in the treatment room and in the supply area
• Packages must be opened when needed, stalling your work slightly during the appointment vs having an open bur block with several types of burs

Brasseler and SS White make tons of these. There are other companies as well that should be easy to find with a Google search. Email me if you want some catalogs. I also recommend some magnetic bur holders from Dux Dental to act as temporary bur blocks.

6. Standardized treatment rooms

This is easier if your clinic was built so that all the rooms are the same. This is far harder if you have various types of room layouts in your clinic. Consider at least making all the basics (barriers, suction, etc) standardized. At my previous assignment, we had literally every room standardized, with the exception of the 3rd drawer in a rolling cart, so the doctor could add special things they wanted into that specific drawer.

This made room checks unbelievably simple. Doctors could move to other rooms in a breeze. Assistants knew where everything was in every room. It's a dream come true.

My new clinic was built within the last couple of years, but was actually designed very poorly with little foresight. We have 3 different types of room configurations in the clinic among our 12 treatment rooms (in addition to a severely dwarfed main supply area). I'm still scratching my head trying to figure out how best to serve our patients with these bizarre construction limitations. If I had it my way, we would demo the place and start over! Whoever designed Buckley would have been wise to recall this famous quote: "Begin with the end in mind" -Steven R Covey.

I put this step last on purpose. You must have the previous 5 things accomplished or the standard room will be a nightmare to try to create and enforce.

Note: In order to make this stick, you must have the room photographed so that binders with these photos can be made of what a "perfect" room looks like so the standard you create isn't lost! The binders are used by the techs to standardize the rooms, and used by the docs and NCOs to enforce the standard. 

Patient Records and Forms:

1. Have a weekly record scan program

I wish I thought of this one, because it's so simple. Basically, you have someone in charge of reviewing a set of records weekly.

You have a form on the wall where that person can log the date, the record range they checked, and how many errors they fixed.

Common errors to look for:
Duplicate records
Poor handwriting (rewrite the record)
Misfiled records
Records with missing or incorrect colored tags and papers

This would be in addition to the monthly records review, because that program doesn't hit every record. This does!


2. Put all the forms in the same place on the network drive

Nothing drives me crazier than having a medical history in this folder, the initial charting in that folder, etc.

Put them all in one spot! Here's why:

Makes it simple to train new people (the forms are here)
Makes it easier to update forms (this is the only version of the form, let's update it)
Eliminates redundancies (no more having 3 versions of the same form floating around)


3. Develop a naming system for the files so they are printed correctly

This is how we name our files:

"(BW, Yl, Double sided) Fly Cover Sheet, updated 31 Oct 18"

This naming scheme answers 5 questions:
1. Black and white, or color?
2. What color paper do I print it on? (In this example, Yl stands for "Yellow")
3. Do I print double or single sided?
4. What form is this?
5. When was this form last updated?

No more misprinted forms! Yay!


4. Put the date the form was updated on the form itself

In the example in #3, we would also have "updated 31 Oct 18" printed somewhere on the Fly Cover Sheet itself. This helps us know if a form we are holding in our hands is the most recent version or not.


5. Put physical forms in as few locations as possible

No more forms in treatment rooms. Period. This is where forms go to die and get resurrected 2 years later in a chart out of nowhere.

Find a centralized location, or two, that all the forms can be stocked. This is much easier to replace forms and make sure everyone is using the same version now that they aren't scattered to the 4 corners of the Earth.

6. If the form is part of a program, type the directions ON the form itself

Class 3 forms are standard in the Air Force, but we added a couple things to ours. We minimized some fonts to make room for these instructions:

"Putting a patient in Class 3
1. Have patient sign this form
2. Write up treatment note
3. Assemble completed chart and place chart in Class 3 box in records room
4. Class 3 NCOIC will take chart and... etc...

Taking a patient out of Class 3
1. When treatment is completed, write treatment note
2. Take the blue chart tag out of the chart
3. Take this form out of the chart and place the form in the Class 3 box in records room
etc..."

Now, it's extremely obvious what to do with a Class 3 record! Again, this forces the doctor or tech to go through the proper steps, get the chart to the right person so that person can run their OWN checklist for the Class 3 program. This ensures that all Class 3 charts are handled identically, and HOW to handle them is clear and obvious.

How easy would it be to train a new person on what do to with Class 3 charts using the above instructions? If they can read, pretty darn easy.



Meetings:

1. The length of a meeting is a maximum time limit

Don't feel obligated to stretch the meeting to fill the time allotted. Consider that a "maximum time". If the goal of the meeting is accomplished sooner, leave!


2. Have an agenda for every meeting

This is why people hate meetings. They turn into a circus of confusion and pointlessness. If the goal of the meeting is "let's brainstorm XYZ" then that's great! But set aside time for that type of work, don't make it the default. For everything else, plan it out in order and get to it. A powerpoint on the wall that helps guide the meeting is a great way to keep everyone on task.


3. Don't hate the meeting, hate the chaos

This sort of goes back to #2, but don't hate the meeting itself. If you are prepared with an agenda for the meeting, then implement it use this time to work ON the business/clinic. This is the time to build a better machine! If absolutely no one wants to attend the meeting, you should think very hard about why it exists at all, or how you can make it more efficient (or how you can convince the team that the meeting will result in better outcomes). To gauge interest in the meeting, don't ask a large group. Ask individuals one-on-one.

Don't eliminate the meeting just because you as the meeting leader don't see the purpose. There could be other people looking forward to that meeting for a variety of reasons and they deserve the chance to speak in that setting if they were expecting it.

Most meetings need to happen, but simply don't have an aim and end up running into chaos problems.


4. Be prepared and be decisive

Meeting chaos stems from a variety of places I've already mentioned, but the big one is indecisiveness. Make the decision and move on. "Let's talk about this later" is still a decision. Don't let a group of people spin on a topic forever unless the purpose is to get everyone to brainstorm ideas.

Actually, most decisions are made before the meeting beings (most meetings are a time to disseminate information), unless there is designated decision-making or brainstorming time. If you are prepared for the meeting, a lot of it should be delivering clear and concise decisions to the relevant group, or soliciting feedback from a group to finalize a decision. Once you get the feedback, finalize it. Start moving on it. You can adjust later.

Also, it shouldn't take an entire meeting to decide the theme for the summer picnic so don't let it. Most people won't care anyway, so have a separate conversation later with the group that cares... which brings me to point #5.


5. Don't waste everyone's time

If the decisions in the meeting, or outcomes of the meeting, are only relevant to 1 or 2 people there, consider having a discussion with those people only. The entire clinic doesn't need to hear a discussion about which bonding agent 3 doctors like the best.

Principles for Thinking - Part 2/3 of Organizing a Military Dental Clinic

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.