The Consistency Quest
Posted Apr 28, 2011, Published 2003-11-01
Expectations are powerful. Our expectations of McDonald's, for example, are directly tied to why we eat there. It's not for the quality food or the first-rate service; it's because when we want a quick meal, we know that McDonald's will meet that need every time. Now consider what would happen if McDonald's failed to meet your expectations. If, for instance, it took five minutes to get a burger one day, 10 minutes to get fries the next. Chances are, you'd soon find another place for your fast-food fix.
Your dentist-clients' expectations are no different. Whether your laboratory is high-end, low-end or somewhere in between, your clients expect consistency on each and every case they receive from your laboratory. "The single most important thing is to be consistent," says Elizabeth Curran, CDT, owner of 10-employee Ahwatukee Dental Laboratory in Tempe, Arizona. "You need to have repeatable techniques with repeatable outcomes so the doctor can say with certainty, 'I need 15 minutes to seat this crown'." Inconsistent work-like a crown that doesn't fit or an inaccurate shade-wreak havoc on your customers' schedules and make them look bad in front of the patient.
But unlike McDonalds, you're producing a custom-made product. Technical variables and the realities of production and workflow demands make achieving consistency inherently more challenging in the laboratory. Producing a consistent product requires:
An ongoing commitment to motivating and training your staff,
Implementing effective quality control and scheduling systems, and
Proactive communication with dentist-clients.
Getting your employees on board with your quest for product consistency is critical. Thorough training is the key to giving them a clear understanding of your expectations, how to achieve them and their role in the overall production process. "It's critical that each technician understands the importance of his job and how what he does can affect the final product," says Scott Dyer, CDT, owner of Dyer Dental Laboratory in Las Vegas. "For example, when a technician is working on frameworks he has to understand the parameters of porcelain thickness and structural design and why they are important. Knowing what to look for and why is the difference between success and failure."
To give employees the big picture, Dyer starts out all of his new technicians in the model and die department. In addition to procedural training-like how to disinfect an incoming case-he uses day-to-day problems, like a poorly trimmed model or an unstable die, to illustrate his quality standard. Once the technician is ready to advance, he has a solid understanding of the importance of model work, what's acceptable and what's not.
It's also hard to achieve a consistent product unless everyone is on the same page; this is why step-by-step procedure manuals are so valuable. Detailing your production processes seems like a daunting task, which is why many labs, especially smaller ones, don't do it. While showing a technique takes less time, it doesn't give your employees a point of reference. "You have to have something written down so your technicians have something to fall back on," says Ryan Dutton, co-owner of Dutton Dental Concepts in Bolivar, OH.
Each department in Dutton's lab has a fabrication manual. The denture department's manual, for instance, includes detailed instructions for every step of the denture fabrication process. One procedure outlines exactly how to do a cold cure reline, from drilling the initial holes in the palate for the impression through the final pumice; it even includes an illustration showing where to carve the post dam.
To create his manuals, Dutton tapped into the people who were most familiar with the ins and outs of the daily production process: his technicians. He asked each department to review their fabrication procedures and develop written standards. The teams used manufacturers' product manuals to guide them and experimented when they disagreed on what should become the standard practice. For instance, the lab was using both pinned and pinless model systems so the staff members did a side-by-side comparison and determined that they preferred the results of the pinned system.
While Dutton admits that writing the manuals was a time-consuming process-it took one year-he says they have eliminated a lot of mistakes and reduced the number of remakes by almost half. Another benefit is that, because he involved his employees in the process, he feels they have a greater stake in following the documented procedures. "Giving my technicians a voice in establishing our quality controls helped make them more vested in our quality control efforts and feel like valuable, empowered members of the team," says Dutton.
Curran took another approach to help her write her procedures; she used a formal quality management system called the Dental Appliance Manufacturers Audit Scheme (DAMAS). The system is similar to the ISO 9000 standard that many manufacturers use to standardize their manufacturing processes. "DAMAS doesn't tell you what your procedures should be, it provides you with a framework for defining your laboratory processes so that you are able to repeat them consistently each time," says Curran. For example, she documented everything from the steps required to disinfect an incoming case to how to maintain and calibrate laboratory equipment. (DAMAS is used by European dental laboratories in order to comply with the Medical Device Directive; it will soon be available to the U.S. laboratory industry through the NADL.)
A systematic approach
While a final case inspection is important, it shouldn't be the only quality control system in place. Building a system of checks and balances into the entire production process allows you to find and fix errors more quickly. For instance, you might have a senior technician check each step of a trainee's work, or the department manager review each case before it goes on to the next department. Another approach that fosters employee accountability is to send a quality control checklist around with each case. Each technician is responsible for comparing the case against the list and then approving it. If it doesn't meet the criteria, he has the authority to send it back to the appropriate department to be redone.
Another key element to consider is production workflow. If your technicians are constantly rushing to meet tight deadlines or are overloaded, something has got to give and it's often product consistency that gets shortchanged. Some laboratory owners are turning to pre-scheduling where the laboratory, rather than the dentist, determines the turnaround time for each case. This approach helps ensure an even workflow, which minimizes the pressure of deadlines and enables a technician to focus on his product quality.
For example, Dyer uses a manual pre-scheduling system for his four-technician laboratory. Each technician has a designated block of time and pre-determined number of units he can handle per day. As cases come in, the office manager schedules them into an appointment book according to this set capacity and the laboratory's current workload. Once a technician's slot is full, no more cases are scheduled for him that day. The office manager then calls the dental office with the date on which the case will be delivered. "Our scheduling system maintains a manageable workflow and avoids situations in which we have two or three times as many units than we can do in one day," says Dyer.
There are a variety of software packages on the market that can streamline the pre-scheduling process and be especially helpful as your laboratory expands. When Dutton's lab grew from four technicians to 13, it began experiencing workflow problems. "Combination cases and implant cases were getting lost between departments and our manual system was just creating too much paperwork," says Dutton.
Today, the lab is upgrading to a software program that allows technicians to log into the system through touch-screen terminals located throughout the lab to find out their prioritized workload for each day. In essence, the system acts as a paperless work ticket; it includes all information relevant to the case, including due date and doctor's preferences. The lab is currently "pilot testing" the software alongside the manual system to iron out any bugs. "Our hope is that the system will help reduce remakes, eliminate stress and result in happier, more loyal accounts," says Dutton. (For more information about pre-scheduling your workload, see the Art of the Appointment.)
Just as your employees need to know what you expect, you need to have a clear understanding of your dentist-clients' expectations. "Not everyone likes the same style, so it's key to find out what the client's preferences are. What are the things he looks for first when receiving a case back from the laboratory?" explains Dyer. For example, does the client like tight contacts? What style of laterals does he prefer? What about occlusion?
Documenting client preferences helps ensure that all of your technicians can consistently meet your dentists' needs. Some laboratories use a Rolodex to catalog each client's preferred style, which is then written on the prescription as cases come into the lab. At Lab One in Norfolk, Virginia, C&B technicians are required to refer to their copy of a C&B Preference Log, a comprehensive, alphabetical listing of all its clients and preferences. Other labs use software programs that can store and print out the information directly on the work ticket.
When asking about a doctor's preferences, it can also be helpful to find out why he's asking for his restorations a certain way. Case in point: when a new account asked Dyer's lab to shave the abutment teeth of the crown on the model, the lab complied, but got the case back when the client had to grind down the contacts. It turns out that his previous lab always left the contacts open, so the doctor had compensated by asking for a shaved model. "Once we realized why he was asking us to shave the model, we were able to explain how we could eliminate the problem altogether rather than compensate for it," says Dyer.
Of course, the dentist's work plays an important role in the laboratory's ability to fabricate a consistent product which is why it's so important to develop a level of communication where you're comfortable addressing his inconsistencies. "We understand that our clients aren't able to see all cases or catch all of the errors that go out of their offices, so they rely on us to call when there's a problem," says Karen Crace, Lab One's vice president. "Ninety-nine percent of the time he'll accept responsibility and ask us to send back the case so he can correct it."
Part of establishing this type of rapport is working with the right clients in the first place, clients who share your definition of quality. You need to be clear about your expectations and find clients who are committed to giving you what you need to produce a consistent product. To establish a long-term relationship that's win-win for both parties, the team members have to be in sync.
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