Quality in Patient Care is a Team Goal

James V. Anderson, DMD, Founder and CEO
James V. Anderson, DMD, Founder and CEO
eAssist Dental Solutions

This article represents the fifth in a series of articles discussing the 14 Management Principles from The Toyota Way https://thetoyotaway.org/ a book authored by *Jeffrey Liker. The principles illustrated in Toyota’s management systems can be applied to improving the efficiency in dental practice operations.

Principle #5 of the Toyota Way is about halting the daily processes when an error is detected to build better quality in the systems and to create the right result the first time. When a worker makes a mistake in a dental practice most likely this person will be blamed for the error. Rarely is the error seen as a system problem. If the error is minor and is considered a frequent occurrence, people tend to accept it, continue working seeing it as someone else’s problem and not theirs.

For instance, during the treatment planning process, it is difficult to determine that a tooth diagnosed for a three or four surface restoration will need a crown when the old filling is removed. Even with an x-ray, it is impossible to see what is lurking under an old filling. According to dentists questioned, 90-98% of teeth with large, old failing amalgam or composite restorations have decay under the old fillings. The decay has destroyed more tooth structure and undermines the remaining cusps to the point where replacing the restoration with a new filling is not a viable option.

To approach the patient with a conservative fix of a filling instead of a crown is the dentists' way of "softening" the inevitable. For the clinical assistant team, this approach throws a wrench in the production because now more and different instruments will be required to complete the appointment for a crown instead of a filling.

The patient is alerted and concerned about why the tooth needs a crown instead of the filling. The appointment time has to be lengthened and the next patient appointed may not be seated on time. Patients do not like surprises and wonder why the dentist was not more thorough in the evaluation of the situation.

Upon questioning the front office team, this same scenario is seen frequently because the doctor is afraid of alarming the patient that they need a crown, which is more expensive than a filling. Patients were told that the old fillings “looked fine” on the x-rays but should be replaced soon. When replacing, the dentist often recommends fillings which most of the time, turn into crowns when the old filling is removed.

The office manager will now have to make changes in the treatment plan, explain to the patient why, and collect a higher amount once the patient is dismissed. The patient is not anticipating the extra cost, and many cannot pay that day.

This system creates more work, stress, waste and can contribute to errors in the process such as mistakes on lab slips, omissions on dental insurance claims and creation of possible collection delays. It is apparent that this system of work needs a better model.

According to Principle #5, providing quality is what drives your value proposition. Utilizing all of the best quality assurance methods available to get the diagnosis and the treatment going toward a sounder outcome is the goal.

Creating detailed clinical notes about the condition of the tooth diagnosed for a filling replacement would be in order and being realistic about what the dentist knows as facts when the possibility of a full crown is the probable outcome.

Noting the following in the clinical notes would help to support the diagnosis result:

  • Large(surfaces) existing amalgam restoration that is leaking and has pulled away from the tooth wall/wear and chipping apparent (surfaces)
  • The explorer sticks in the gaps between the filling and the enamel
  • Discoloration of the tooth under the enamel
  • Deep fracture lines on the tooth indicating a weakening of the tooth structure that is supposed to support the new filling.
  • Age of the restoration to be over five years
  • Patient has symptoms of cold and or sweet sensitivity, pain when chewing and a bad taste in the mouth

Allowing the entire team to give feedback in the process of patient care helps to detect problems or flaws in how things are currently done in practice. If the operation takes the time to stop to fix a problem instead of moving around it or accepting it the way it is, a positive change is likely for the practice environment. When permitted to bring issues to the surface so that they can be solved the staff feels that they are genuinely part of the results. Patients want quality, respect and above all honesty in their dental care and the costs to complete it.  

The morning huddle or planned staff meetings are the vehicles to discuss ways to improve the delivery of service and quality of care. Build into the practice philosophy to stop and or slow down to get quality right the first time and to work on improving it every day.

If you would like additional help, email Dr. Anderson at james.anderson@eassist.me