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Ehab Heikal

Management of

Lee & Johns “The fundamentals of good medical care, 1993”, defined the principles of quality medi-cal care specifying that the aim of medical care isn’t only to improve the health of patients, but also to meet their expectations and satisfy them.

The later statement is the topic of this article; quality from the patient’s perspective. The patient cannot tell whether your treatment was up to the standards or not, the same applies to you when you go to a restaurant or hotel. You do not check the quality of wood of the furniture or the quality of the carpets or tiles; instead you have other attributes to check the quality.

Quality has several definitions. From my point of view; the best that fits our case is the equation of Effectiveness + Efficiency. Effectiveness is do-ing the right thing; while efficiency is doing things right. So Quality would be defined as “Doing right things right”.

Types of Quality: There are 3 types of quality:

Expected quality1. is based either on what you think it will be or what you want it to be.Perceived quality2. is based on what you think it is.Actual quality3. is based on facts or numbers (statistics).

Perceived and expected qualities are qualitative while actual quality is quantitative.

Start by asking yourself: Are people part of your service?The answer is YES, and this manifests in the fol-lowing aspects:

Interaction between patients.• *People are part of the service production. (As-•sistants, nurses, receptionists).Quality would be affected by those people.•

“Quality & Standardization”the Dental Office

* The patients in your waiting room will affect your ser-vice in many different ways. They can increase or de-crease the expected quality by sharing their positive or negative experiences. They could willingly or mistakenly reveal a special price discount that you have given them for a reason or another, and so on. Thus, always stick to a perfect appointment system; don’t let patients in-teract.

Is “Time Factor” of Any Relevant Importance?

Waiting to have the service done is crucial.•Service time versus outcome time is impor-•tant.Is service time an indication of its quality?•

So if you perform 100 restorations per hour, does that mean you are very efficient? And if you per-form one restoration in 2 hours, does this mean that you have done it reaching the utmost qual-ity? Of course the answer to both questions is NO. In both cases, we have to realize the service time versus the outcome time.

We have agreed on the definition of quality (doing right things right), and we have also discussed the types of quality including the Perceived quality. This Perceived quality has 5 dimensions:

Tangible:• Appearance of all physical ele-ments.Reliability:• Dependable and accurate perfor-manceAssurance:• Competence, courtesy, credibil-ity and security.Empathy:• Easy to access, good communica-tion and patient understanding.Responsiveness:• Speed to meet patients’ needs.

Dental patients consider reliability the most impor-tant attribute. For you it is also the most impor-tant one because it creates high level of patient

Dental Practice

BDS, DF, DIM, MBAMiddle East & Africa, Area •Manager, Morita Corp.Lecturer, Practice •Management School of Dentistry, MSA Universityeheikal@gmail.com •

Dental Practice

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retention, leads to favourable word-of-mouth, enables you to charge patients larger bills, reduces the cost of re-performing the service, increases employees’ moral, reduces employees’ turn-over rate, increases productivity, and also increases profitability.

Now assume you have a barrel that you are trying to fill with patients, but your barrel is never full due to the fact that it is full of gaps and holes that leak away patients!What is the cause for the existence of those gaps and how can we close them?Let’s have a look at the model in (Figure 1).

Gap 1If you have certain perceptions of the patients’ expectations, and you assume that they are cor-rect while in fact they are not, then you will take some actions that you think your patients like, but in reality, they do not like or do not care for it. Thus, Gap 1 is created. It is due to:

Lack of marketing research.•Ineffective upward communication. (i.e. your •front line staff do not report to you concern-ing patients comments, complains, or the in-formation reaching you is filtered).Increased levels of management. (No direct •contact between you and your front line staff as the information and reports has to go through middle management).

Gap 2If you do not properly translate your perception of the patients’ expectations into formal written procedures and rules and specifications to be ap-plied by you and your staff, then Gap 2 is created. It is Due to;

Lack of Management commitment. (You are •too busy with your technical work, neglecting your managerial role).

No formal process of goal-setting.•Lack of standardization.•Inability to perceive quality feasibility.•

Gap 3If you set the proper procedures for your service, but your staff fails to follow these procedures, or service is delivered to the patients in a different manner, then you suffer from Gap 3 due to;

Lack of employees’ job-fit.•Lack of technology fit.•Perceived low control over job.•Poor supervisory control system.•Role conflict. (Was it assistant A or B that •should have changed the saliva ejector after the last patient left?).Role ambiguity. (Should the instruments be •wrapped and sterilized or wrapped after sterilization?).

Gap 4If your external communication with your patients including advertisement, word of mouth…etc. does not meet the delivered service, or made your patients over expect the quality of your service, then you have created Gap 4 which is due to;

Poor horizontal communication. (Communica-•tion between you and the customers whether direct or through advertisement).Propensity to over promise patients.•

Gap 5Finally if the patient’s expected service does not meet his perceived one, then Gap 5 exists. Normal-ly this gap is not your fault unless it was created by your advertisement or over promises prior to the treatment. It is also due to the patient’s exter-nal communication with friends, through word of mouth, his past experience or even his personal needs at that time. In unscheduled emergency cases, for instance, the patient finds that he/she

have to wait for a long time as you have other regular sched-uled patients which hold you from fulfilling his/her demands as fast as expected.

Hints for Improving Service Quality & Productivity

Develop mutual trust with •patients.Understand patients’ habits •and expectations.Pre-test any new procedures •or equipments.Publicize benefits.•Perceptions' Managment of Patients' Expectations

PerceivedQuality Model

Managment’s Perception of Patients’ Expectations (Figure 1)

Dental Practice

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Eight Steps and Four Core Phases for the Quality Cycle Recognize, Define, Measure, Analyze, Improve, Control, Standardize, and Integrate.Measure, Analyze, Improve and Control are known as M-A-I-C.

What to Measure?I• nputs:Time1. Cost2. Performance (Appraisal)3.

O• utputs:Income 1. & profitNumber of retained patients2. Referrals from existing patients3. Accuracy (Complains & re-makes)4. Sustainable patients’ satisfaction5.

2- BenchmarkingBenchmarking is a continuing process of measur-ing products, services and practices against your strongest competitors. More simply stated, it means using the best competitors as the yardstick against which you compare and measure yourself. If your firm comes up short, then improvements must be made to ensure that your services are just as high in quality as those of your competi-tors.

Internal Benchmarking:Compares process among diverse functions within a single center. Trend analysis is vital. Like compar-ing between different clinics in the same center, or comparing the speed and attentiveness of the reception with that of the accounting depart-ment. Or even a comparison between different centers that you own.

Competitive Benchmarking:Looks at direct competitors and measures

Phone Call, Online Reservation System

Clean, Comfortable, Entertaining

Clean, Sterile, Ready

Post-Operative Instructions, Follow Up Discharge Flow Chart

Teach patients to use innovations (like booking •online, sending you direct complains and re-marks through email..etc.).Monitor performance & seek improvement.•

Tools for StandardizationEveryday 38 Million people visit McDonalds in 23,500 branches in 109 countries. People are actually flocking into a system not a hamburger. McDonalds was among the first organizations that standardized their process. You find the design, the uniforms, the atmosphere, and even the taste the same wherever you go around the world. What McDonalds has done is known in the busi-ness world as McDonaldization.

Tools of Standardization are:

1- MeasurementYou can’t change what you can’t measure:

We don’t know what we don’t know.•We can’t do what we don’t know.•We won’t know until we measure.•We don’t measure what we don’t value.•We don’t value what we don’t measure.•

The power of measurement lies in the fact that you Manage by Fact Rather Than Manage by Feeling.

So you need to measure and refine your measure-ment. If you have 100 patients in a week, 99 of them were satisfied, but one of them was dissatis-fied for 10 different reasons. If you measure pa-tients’ satisfaction, you will consider a 99% satis-faction rate, but if you re-fine your measurement, you will end up by 90% only. The reason for that is that those 10 reasons of dissatisfaction could have been fairly distributed among 10 patients; it just happened by chance that they all fell in that poor patient’s lap.

(Figure 2)

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patients’ loyalty, satisfaction & market share and other KPI (Key Performance Indicators).

Functional Benchmarking:Focuses on process and firms with similar pro-cess in other vertical sectors. E.g. Medical centers, beauty centers, and even hotels or restaurants. Just check what makes customers attracted to that hotel or restaurant (Of course look at indi-cators other than technical ones. You will not measure your dental service against the quality of food for example, but measure your speed of response, friendliness and so on).

3- ChecklistsChecklists are lists of points, procedures, things to-do, and items to check. They can be used to ensure for example that the assistants follow your guidelines of what to do in-between patients (like disinfecting the chair, changing the saliva ejector and the head rest cap and so on). You can make a checklist for the clinical practice guideline and clinical protocol. You need to create a check list for every procedure in the clinic. Never rely on the memory of your staff.

4- Job DescriptionJob description is one of the most important tools of standardization. It will;

Minimize waste of time•Minim• ize errorsEliminate• conflictReduce job ambiguity•

Job description should be tailored for the:Dentist•Assistant•Hygienist•Receptionist/Office Manager•Financial Controller•Janitorial Staff•Infra Structure Members e.g. Accountants•

Normally you need to tailor your job descriptions according to your needs. The dentist’s job de-scription is done according to his/her post (owner, manager, staff member) and according to the size of his/her business and business requirements.

These descriptions are just guidelines that you can change according to your needs and size of busi-ness. But having everything in writing means that you set clear boundaries and expectations, no one can then claim that he/she was not informed or that doing X or Y was not his/her duty.

5- Flow ChartsA flow chart, which is also called a “process

chart,” is a picture (graphical representation) of a process.

Why Use Flow Charts?Flow charts are easy-to-understand diagrams showing how steps in a process fit together. This makes them useful tools for communicating how processes work, and for clearly documenting how a particular job is done. Furthermore, the act of mapping a process out in a flow chart format helps you clarify your understanding of the pro-cess, and helps you think about where the process can be improved.

A flow chart can therefore be used to:Define and analyze processes; •Build a step-by-step picture of the process for •analysis, discussion, or communication; and Define, standardize or find areas for improve-•ment in a process,Also, by conveying the information or pro-•cesses in a step-by-step flow, you can then concentrate more intently on each individual step, without feeling overwhelmed by the big-ger picture.

We have 2 stages in a flow chart (Figure 2). A front stage and a back stage; exactly like the restaurant. The front stage of a restaurant is the dining area which you see and sit in, while the back stage is the kitchen. Thus you can draw your flow charts for both your front and back stages together. You can draw flow charts for all your services, for example a flow chart for an endodontic treatment. Figure 2 is a very simple flow chart that starts from the moment the patient calls for an appointment till after he leaves.

Of course, you need to incorporate check lists with flow charts. For example, in the first step (re-ceiving a phone call), you need to create a check list for the receptionist on what to say to the patients and what to ask, and thus you have to create scenarios. A scenario planning starts with the question:”what if?” So what if the caller is a new patient? What if it was a regular patient? VIP? Emergency case? You can create either a checklist or write down several scripts for the receptionist to follow in a simple flow chart.

So you will end up creating sub-charts for every step in the main flow chart. It is much work at the beginning, yet it pays back at the end.

A Final Word:Creating Team Based Offices

82% of U.S. dental offices use teams to per-•form some tasks (ADA meeting, 2004).

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Self-directed teams have several distinguishing • characteristics:

Perform naturally interdependent tasks –Use decision making consensus –Team’s members perform enriched jobs –Teams are also highly trained –Employers empower the teams & individual –members

Retain Your Team to Maintain QualityCreate a magnetic environment. You have • spent a lot of time and e�ort in training your sta�, so keep them.Set clear expectations. (Job descriptions are an • asset).Train and develop employees. (They are your • treasure and main resources).Provide positive & constructive feed back. Don’t • criticize the person, rather criticize the act.Declare your standards & boundaries.• Encourage your team to come up with solu-• tions.

And always remember that the only place where you �nd SUCCESS before WORK is in the diction-ary, so you need to work hard to achieve quality. Working hard on improving quality makes you work less when you achieve it,