Ground Zero - Design Ergonomics Inc. · Ground Zero: Strengthening Your Practice From the Operatory Out! David J. Ahearn, DDS • Pacific Dental Conference, 2019 • Vancouver, BC

Ground Zero:Strengthening Your Practice From the Operatory Out!

David J. Ahearn, DDS • Pacific Dental Conference, 2019 • Vancouver, BC

The complexities of running a dental practice – capacity, revenue, staffing, patient retention – can be overwhelming. But as dentists, we’re manufacturers; the health of our practices depends on the efficiency of the “manufacturing cell” – the operatory. Creating a lean, productivity-oriented environment there gives us additional time and resources – making it easier to address system/process problems and larger business concerns.

In this course, we will discuss the following topics and provide solutions:

• Creating more ergonomically efficient delivery solutions• Making treatment rooms both highly productive and inviting to patients • Establishing the simplest and most effective sterilization & resupply system• Developing effective & replicable staff training tools

Understand the true pain points that restrict practice growth – and discover solutions for a better future.

Dr. David Ahearn is first and foremost a full time practicing dentist. Although located in a rural town, his office ranks among the nation’s most productive practices. Trained in prosthetics at the University of Michigan, Dr. Ahearn, like many of us, struggled to reconcile his desire for the highest quality possible with the requirements for practice success. His discovery of the principles found in the Toyota Production System in the early 90’s – and his subsequent application of them to dentistry – began a quality and productivity revolution that is at the heart of his design work.

He is the founder of Design/Ergonomics, the nation’s largest independent dental office design firm, as well as Ergonomic-Products,

a manufacturer of high-productivity, ergonomically sound dental equipment. Both companies work with doctors across North America to design and equip comfortable, productive and highly cost effective practices.

Dr. Ahearn has held faculty positions at both the University of Michigan and NYU’s College of Dentistry, and was a founding member of the ADA’s Ergonomics Subcommittee. He is a frequent lecturer and contributor to numerous dental publications, including multiple chapters in the current edition of the ADA’s Practical Guide to Dental Office Design.

Thank you for joining us in Vancouver! www.desergo.com www.ergonomic-products.com www.dental-reboot.com

Ground Zero Handout 3_1_19


© 2019 Dr. David J. Ahearn, Design Ergonomics | www.desergo.com | 800.275.2547

Three Tiers of Practice Problems

1. Tier Three - Delivery Problems• Efficiency/Productivity• Comfort• Quality

2. Tier Two - Process Problems• Inventory Control & Resupply• Sterilization• Room Turnaround• Scheduling

3. Tier One - Business Problems• Capacity• Training & Retaining Staff• The Patient Experience• Patient Retention• Obtaining New Patients• Revenue

333 Tiers of Practice IssuesGROUND ZERO

If you Þx these ÞrstÉ

BUSINESS PROBLEMS

DELIVERY PROBLEMS

PROCESS PROBLEMS

...THESE become much easier to solve.



Fixing Delivery Problems

You Can’t Use What You Can’t Reach• Range of Motion

Figure out what is essential for the majority of your procedures, and position it as close to you as you can.

Then minimize by removing the unnecessary back storage OUT of the room. (No side cabinets)

Consolidate Delivery Materials - in 4 Steps1. Empty your drawers and gather your stuff

• Convert to compact bins and tubs• Eliminate redundant storage• Move bulky gloves and bibs in or on wall

2. Use cassettes - no trays or bags.• Convert to compact bins and tubs• Eliminate redundant storage• Move bulky gloves and bibs in or on wall

3. Put everything where you can reach it.

4. Mobilize your high-tech and specialty procedures.• Convert to highly mobile carts with power supplies• Organize carts by use groups (i.e., Endo, OS etc.)• Clear pathways for access

42The Root Issue | YCUWYCRGROUND ZERO

2. Then minimize.The way to do that is to get all the unnecessary back storage OUT of the room.

Because - YOU CAN’T USE WHAT YOU CAN’T REACH.



Fixing Process Problems

Inventory Control & Resupply1. Find the best, and eliminate the rest.2. Put it all in one place.3. Make sure it’s easy to see.

Sterilization1. No Bags

©2017 CR Foundation®

Serv

ing Dentistry

42YEARS

A Publication of CR Foundation® • 3707 N. Canyon Rd, Bldg 7, Provo UT 84604 • 801-226-2121 • www.CliniciansReport.orgDecember 2017, Volume 10 Issue 12

ISSN 2380-0429

The BEST Products for 2018Gordon’s Clinical Observations: Every year Clinicians Report publishes an annual guide of many of the best products for the upcoming year based on evaluations from the previous twelve months. The products presented in this report have been through rigorous independent non-manufacturer sponsored evaluation and testing. CR conducts research at three levels: 1) product evaluations among 450 clinical evaluators worldwide in their own offices, 2) controlled long-term clinical research completed by TRAC Research, the human studies section of CR, and 3) Basic science laboratory testing. Classic products that have withstood the test of time and predictability are also listed in most of the categories.

Please read the following product category descriptions carefully. Products listed in this Buying Guide have been evaluated by the CR science team and CR Clinical Evaluators. Each product in this report is color-coded to identify why it has been included in this listing. • Proven classic products and updated classics are listed alphabetically and in red. These products have been determined by research

and long-term clinical use. They are often used for new product comparisons. Some categories do not have classics listed.• Highly rated new products were identified by in-house science evaluations and CR Evaluator use during 2017. Only products with an

overall grade of 3.0 or higher (4.0 highest) and an Evaluator recommendation of 70% or greater were included. Products that are not listed may not have been tested this year, may still be in testing, or were not among the highest rated. For many other excellent products not mentioned, please review previous CR Buying Guides and Clinicians Reports at www.CliniciansReport.org.

CR is the original and only independent dental product testing organization with funding only from dentists!

CR BUYING GUIDE

— THIS IS NOT AN ALL INCLUSIVE LIST OF SUCCESSFUL DENTAL PRODUCTS —

ANESTHETICS & ACCESSORIESTopical AnestheticsClassics:

• Benzocaine 20%, Various Companies• The Best Topical Ever, Nueva Vista Dental

GINGICaine, Gingi-Pak20% benzocaine gel formula. Syringe delivered with micro needle tip that has 7mm gauge mark and rounded end to eliminate poking or tearing the sulcus. Quick onset (15–20 seconds).$1.30/1.2mL syringe

77% of CR Evaluators would recommend this product.

DIAGNOSIS AND TREATMENT PLANNINGSee also Clinicians Report August 2017: “Can You Increase Acceptance of Treatment Plans?”

Cameras: Clinical and AccessoriesClassics: Single Lens Reflex and Point and Shoot

• Various Models– CliniPix – Lester A. Dine– Dental Learning Centers – PhotoMed

Cameras: Intraoral VideoClassics:

• Various Models– ACTEON North America – Digital DOC– Air Techniques – Schick by Sirona– Carestream Dental – Video Dental Concepts– DEXIS

MouthWatch, MouthWatch (also distributed by Lester A. Dine)Economical and easy-to-use intraoral camera with good image quality. Integrates directly to already present imaging software.$299/Camera kit

See also Clinicians Report February 2017

Oral Cancer ScreeningSee also Clinicians Report October 2017: “Is Your Oral Cancer Screening Adequate?”CR Note: Thorough systematic visual and tactile examination

of the entire oral cavity along with the head and neck remains the standard of care. Biopsy with histological examination remains the only tool for definitive diagnosis. Oral cancer screening devices may serve as an adjunct to a good clinical exam and represent an effort at earlier diagnosis of abnormal tissues.

CR Note: PhotoMed offers SLR camera adapters for Bio/Screen, VELscope Vx, and ViziLite Pro devices.

Classics (updated classics follow this list):• Fusion DOE SE, DentLight• Identafi, DentalEZ

The following four adjunct devices were featured in Clinicians Report October 2017.

Bio/Screen, AdDentOral mucosal fluorescent screening device. Viewing accomplished through handpiece with filter and light. Built-in rechargeable 65-minute battery.$1,995/Device

—P

leas

e R

ead

—

94Fix Sterilization | No BagsA Dozen Projects

Methods of Instrument Processing# Setup Method Pros Cons

1 Bags on bracket table (Storage in drawers)

• Dropped instruments easily replaced from drawer storage

• Accommodates varied setup

• The least efÞcient system• Requires the greatest labor to use• Maximal instrument handling• Least likely system to ensure

complete instrument set at chairside• More likely to get puncture wounds

when handling bags

2 Bags and trays(Storage on racks)

• Color contrast of trays and instruments makes instrument transfer easy

• Labor intensive• Added cost of sterilizing bags and

trays• Requires larger inventory of

instruments• More likely to get puncture wounds

when handling bags

3Cassettes(Storage in central resupply)

• Fast• No instrument handling• Lower cost for entire ofÞce setup• Less likely to get puncture wounds

than with bagged instruments

• Cassette cost• Visual access to instruments

somewhat reduced• Less ßexible for replacing dropped

instruments during treatment




Sterilization continued2. No ultrasonic - presoak3. Dishwasher • UC50e Washer - CMA Dishmachines4. Large, fast autoclave • RH Pro 11 - CPAC Environmental Solutions5. Flow

Room Turnaround1. Reduce surface areas - SEE 4 MINUTE ROOM TURNAROUND VIDEO HERE

bb

b

ss

s

r

rr

TrashMed. waste

Med. waste

MilkBath Soak

Rinse InstrumentWasher

Dry Heat

Autoclave

Storage

ResupplyRedeployment

To Treatment Rooms To Treatment Rooms

Efficient space/equipment design, based on sequential process. Poor space/equipment design, resulting in wasted movement.

ss ss

Trays stocked for movement to rooms

Trash Burs inTea Ball

Scrub Sink

UltrasonicDryAutoclave

Reset baggeditems into trays

bbb

r

Bagor Tray

vs

Scrub &Rinse

Processing Instruments Dancing

https://www.youtube.com/watch?v=6g7rASibdcY&list=PLdy8h3FzbwzKdnTsG_tnzSGv-CGO5PBXG



306

One crown is:,A X X X / / /

Let It Flow | SchedulingA Dozen Projects

307

Two crowns are:,A X X X X / / / /


308

Two crowns and two Þllings are:,

A X X X X X / / / /



Scheduling

148What Happens Upstream? | Process ProblemsGROUND ZERO

© 2015 Design/Ergonomics Westport, MA

Reference patient's occupation or other notes.

"Would a midday appointment work for you?"Some patients feel Saturday or Late Weekday

appointments are their ONLY option. We need to keepthese slots available for them as much as possible.

Procedure Codes Scheduling Time Procedure Protocols General Protocols

NP 12- older D0150 (/) 6 (add 2 units for pro) Required Data when making NP appt: 1 NP for every 1.5hrsNP 6-11 yrs old D0150 (/) 6 Referral Source Doctor $1200/hrNP 3-5 yrs old D0150 (/) 4 Email Hygiene $150/hr

NP Apprehensive D0150 (/) 4Any information that they voluntarily give us (ex. last dental appt, apprehension)

Any Appt needing prime time should be put on ASAP list

NP Limited/2nd Opinion D0140 (/) 4- Dr. Sch if poss. Pull from the Unscheduled/ASAP list to meet NP goals All Appt Notes should document preferred timeNP w/pro in Hygiene D0150 (X) 8- Hyg Sch. All NP scheduled out a week must be placed in ASAP listChild NP D0150 X (6) Rescheduled patients need to have status of appt reset to none

Adult Pro D1110 (X) 5 If rescheduling/ canc. put back with the same provider.Child Pro D1120 (X) 3 Rescheduled patients need to have status of appt reset to none

SRP (2 Quads) 1-4 D4341 (X) 6Breaks: (Providers must have alternating breaks between 11- 12:30 coordinate Huddles

SRP 1-3 D4242 (X) 6 40 mins under 8 hour shift, 1 hr over 8 hrs- staggered

Perio Maintenance D4910 (X) 6 Place all hygiene appt requesting prime time on ASAP list ( if due for appt)

Perio Recheck D0190 (X) 3Perio eval D0180 (X) 3

Limited Exam- Focused Exam D0140 (1) 3 LOE- Patient calls has a tooth (one specific area) to be evaluatedOn 1 Dr days we can add 4th column for emergencies, recheck, adj dentures, bite adjustments, sedation follow up. Not anything that will require treatment

Emergency Oral Exam D9110 (1) 3 EOE- Emergency visits- Pain only Internally Referred New Patients

Complete Oral Exam D0150 (1) 3 Ledgers must reflect treatment actually done and not scheduled

Periodic Exam D0120 (1) 3 If a pt misses this appt- place an event to follow up with pt. No redo’s unless doctor approval of case into other doctors schedule

Consult D9310 (/) 3

1 Surf Anterior Composite D2330 /X// Fillings-each additional tooth add 1 (X)2 Surf Anterior Composite D2332 /XX// for MAX of (XXX//) per quad3 Surf Anterior Composite D2333 /XX// Interproximal add additional X for adjustments4 Surf Anterior Composite D2334 /XXX//Chairside Veneer D2960 /XXX//1 Surf Posterior Composite D2391 /X/

2 or 3 Surf Posterior CompositeD2392 OR D2393

/X// 3 or more surfaces usually results in an a Porcelain Onlay

1-2 AA'sSurface Filling Codes

/X/ (3 or more add X/

Fixed ProstheticsBUPG (Conventional) D2950 + D2750 / XXX / (3) Crown/Bridge/Veneer- (each addt'l tooth add 1 (X) and 1 (/) High production

Anterior Crown D2750 or D2740 /XXX / (3) Must be prepaid

EMAX Crown D2740 / XXX / (9)Can offer up to 10% off to fill a last minute opening- No other discounts to be applied.

Cerec crown, onlay, crownlayD2740/D2643/D2630

/ XXX / (8)

Veneer/Lumineer D2962/D2963 / XX / (3)

Hygiene

Scheduling Multiplier™

SCHEDULE MIDDAY APPTs FIRST

Basic

New Patient Appointments

Exams



Fixing Business Problems

Capacity1. Time2. Rooms3. Production Per Hour (Efficiency)

Training & Retaining Staff1. Create replicable systems2. Create accountability ladders

Patient RetentionMake your Patients comfortable and the service convenient & they will come back.

It really is that simple.

177GROUND ZEROWhat Happens Upstream? | Business Problems

1 2 3 4 5 6 7 8 9

Side Compartment

9 Instrument Slots

Side Compartment

1. Mirror2. Explorer3. Perio Probe4. Posterior Explorer5. Anterior Sickle

6. Gracey 1/27. Universal 5/68. Gracey 11/129. Gracey 13/14

A/W Syringe

Hygiene Cassette

Replicable Systems are EASY to Train


Assistant - Junior Level


Assistant - Junior Level

• Know Core Values • Huddle Prep and Engage • Proper Procedure Set Up • Cassette & Bur Block Set Up • Make Root Canal Blocks • Appt. On Time FulÞllment • Prepare Patient for Treatment • Use of Comfort Menu • Proper Patient Position • Manage Appointment Properly • Proper Clinical Notes • Describe N20 to Patients • N20 Set Up • Emergency Protocol • Grasp of Info on Routers

• Practice & Speak with ConÞdence • Proper Appointment Dismissal • Grasp of Impression Guidelines • Proper Impression Technique • Making Study Models • Fabricate Bleaching Trays • Composite Appointments • Root Canal Appointments • Extraction Appointments • IV/Oral Sedation Set Up • Second Sedation Position • Proper Head Set Usage • Intra Oral Camera Usage • Know Marketing Promotions • Cross Training

Call for more information on scheduling, training systems, checklists, HeartChartsTM and additional position listings, call Design Ergonomics and speak with a Practice Liaison.




Obtaining New Patients1. The Math of Growth

2. Referrals are the most cost effective method of gaining New Patients

A Breakdown on the Math...

• 50 New Patients per month at a Retention Rate of 70% = 35 Returning Patients added each month• 48 minutes per Hygiene appt times 35 Recall Patients = 28 hrs/mo (this is added to the schedule 6 months out, and repeats every 6 months thereafter)• A full time Hygienist’s schedule of 35 hr/wk = 140 hr/mo ... 28 hours is 1/5th of that.

Again, these 28 hours stack in 6 month intervals on Recall.

Therefore, in 2.5 Years (5 of the 6-month intervals) the additional Hygiene hours will equal a Full Time Hygienist’s schedule.

196GROUND ZEROChange Is Possible | Things You Need

New Patients per month: 20

Retention rate (returning to Hygiene):

Recall Hygiene hours added to the schedule 6 months out:

50

8

Pretty light growth…

%

200GROUND ZEROChange Is Possible | Things You Need

About one-Þfth of a full-time HygienistÕs schedule - every 6 months.

%

50

70

28

New Patients per month:

Retention rate (returning to Hygiene):

Recall Hygiene hours added to the schedule 6 months out:vs

0

10

20

30

40

50

60

70

80

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

New Patient Source vs Marketing Spend by Quarter

NP Referral Source External NP Referral Source Internal Marketing Spend ($1000s) External Marketing Spend ($1000s) Internal




Revenue1. Revenue (an profit) is not a “problem”. It’s what happens when you

fix all the other problems and leverage them to your advantage.

Example: Leveraging Capacity in terms of Doctor Operatory Performance per Hour versus paying off capital expenses.

Change is Possible in Your Current Practice

Summary1. Understand your Patient Demand2. Train for Lean Production3. Retool your Existing Practice4. Get More Capacity

BETTER • FASTER • CHEAPER


Cost Difference

ProductionHours to

Recoup Cost Difference*

Enough to drill A tooth -cheapest you can Þnd - -

Room Type vs Production/Hour

* Based on applying 10% of your Revenue to paying off Capital Expenses

The most common approach to going upscale

OutÞtting your ÒSpaÓ?

Maximized EfÞciency & Patient Experience

Expanded EfÞciency & Moderate PT Experience

$90K $1100

$60K $800 488$39K

627$69K

2446$159K

3600$234K

Cost to Equip3 Rooms

DoctorProduction

per Hour

$21K $450

$255K $650

$180K $650


Faster

Documents

Ground Zero - Design Ergonomics Inc. · Ground Zero: Strengthening Your Practice From the Operatory Out! David J. Ahearn, DDS • Pacific Dental Conference, 2019 • Vancouver, BC