June 3, 2026 • 40 mins
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A dental practice can look busy, feel exhausting, and still be quietly losing tens of thousands in revenue. We sit down with Ravinder Nottra, a profitability coach for dentists, to unpack how Lean and Six Sigma can turn the daily chaos of overruns, long waits, and inconsistent workflows into something you can actually see, measure, and improve.
We start with a familiar pain point: the “30-minute wait”. Rav shows how delays are rarely caused by one big mistake, but by a cascade of small defects that stack up, then links that operational drag to the numbers that matter: no-shows, overheads, and how small percentage wins can translate into meaningful profit. From there we dig into Lean thinking, mapping the patient journey to strip out waste, and Six Sigma, reducing variation so your diary becomes predictable rather than hopeful.
You will hear practical examples from McDonald’s consistency, Formula 1 pit stops and SMED, plus surprising bottleneck lessons from the NHS and Heathrow that apply directly to reception, chair time, and pre-appointment communication. Rav also shares three tools you can use immediately: the Five Whys, Pareto thinking, and tight standard operating procedures that protect quality and boost practice valuation by making performance repeatable.
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Disclaimer: All content on this channel is for education purposes only and does not constitute an investment recommendation or individual financial advice. For that, you should speak to a regulated, independent professional. The value of investments and the income from them can go down as well as up, so you may get back less than you invest. The views expressed on this channel may no longer be current. The information provided is not a personal recommendation for any particular investment. Tax treatment depends on individual circumstances and all tax rules may change in the future. If you are unsure about the suitability of an investment, you should speak to a regulated, independent professional. Investment figures quoted refer to simulated past performance and that past performance is not a reliable indicator of future results/performance.
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Episode Transcript
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Dr James (01:43):
Welcome back to the Dent to Invest podcast.
I have sat here in front of metoday particularly
interestingly, Mrs.
Ravinder Nottra.
Rav's speciality is somethingcalled the Neme Technique, and
also in addition to that,something else called the Sigma
technique.
She combines them both andapplies them to the dental
industry to come up with twospecial recipes that can boost
(02:05):
our profitability, not just asassociates and practice owners,
but also more generally insofaras putting revenue across all
business interests because thiscan be applied to anything.
And it is worth mentioning thatToyota used these methods, the
Sigma method, in the 1950s tobecome the business that they
(02:25):
are today.
And we all know how that went,so let's tune into this one for
sure to find out more.
As ever, you can claim your CPDfor this episode within the
official Dentists who InvestSmart Money Members Club.
Smart Money Members Club alsoincludes multiple mini courses
and webinar series on financefor dentists, including how to
become as tax efficient aspossible, as well as
understanding investing.
(02:45):
All of this content counts asverifiable CPD, and you can
download your certificates thereand then upon completion of
each lesson.
In addition to this, we alsoinclude a whopping 10% discount
on your dental indemnity and a5% discount on lab bills for
dental principals, amongst otherperks and discounts for
members.
Please use the link in thedescription to claim your
(03:06):
verifiable CPD for this episode.
Rav, well, I mean I'm lookingforward to this.
The point of this podcast is toteach people about things that
they've never heard of for andbring new ideas to the dental
industry.
So I get a funny feeling thatwe're gonna do both today on
(03:26):
this podcast.
So, Rav, when it comes toyourself, I think it's best to
intro you as a profitabilitycoach for Dennis.
Is that fair to say?
Rav (03:35):
Yeah, that's correct.
Dr James (03:37):
Nice one.
Alright, well, listen, I thinkwe should just jump straight in
with the main course, so tospeak, the meat and potatoes off
this podcast, which is to talkabout both those techniques that
we mentioned in the intro.
So the first one is the leantechnique, the second one is the
Six Sigma technique, which isthe technique that Toyota used
to become the business that theyare today.
Interested to hear about bothfor sure.
(03:57):
And then what we should talkabout is how we can combine them
to be as successful as possiblein our businesses, not just as
principals, but obviouslyincluding associates in that
bracket as well, because we arebusinesses too, of course, and
we have to look at ourselves inthat sense, particularly
whenever it comes toprofitability and yes, of
course, being ethical andfulfilling our duty of care to
(04:17):
the patient and everything alongthose lines.
So, how about that as a placeto start?
Rav (04:21):
That sounds great.
Dr James (04:23):
Cool, let's jump straight in.
Rav (04:25):
Yeah, let's jump straight in.
So, what I'll do, let me askyou uh a question to all the
listeners.
So, when was the last time youfinished a full clinical day?
And did you know where yourday's revenue came from?
So, most practice owners Ispeak to, they say they can't
remember or they just don'tknow.
(04:47):
So, what I'd like to do todayis introduce you to a way of
seeing your practice using amethodology that is being used
by many businesses across theworld for many years.
So that includes McDonald's,Heathrow Airport, uh, Formula
One, and the NHS.
So, what we'll do, James, ifit's all right with you, we'll
(05:10):
talk about one really simpleexample of some of the pain
that's we face in practices on adaily basis.
And we can call it the30-minute wait.
So a patient comes in andthey're waiting around 30
minutes before they see aclinician.
So there's lots of reasons forthat, and I'll just pick out
(05:30):
three as an example.
So the reason they could bewaiting could be the day started
eight minutes late, so that 9a.m.
appointment overran, and thenas a result, it's called a
cascade defect in manufacturing.
So every patient then has aproblem when they come in,
they're always having to waiteven more.
(05:51):
The second reason could be thesurgery turnover took 14 minutes
instead of five minutes ofpreparation.
And then the third reason couldbe the patient before them
arrived 12 minutes late.
So these are just a fewexamples.
Now that one of those doesn'tcause a 30-minute wait, but a
few examples put together uh do.
So those of it, those areeveryday examples of the kind of
(06:14):
pain we face, especiallyoperationally on a day-to-day
basis.
So if we take it up a fewlevels and look at the financial
framing, now Christian Co'sreport tells us that 15% of
patients either cancel or don'tturn up.
(06:35):
And that can be as high as 30%for some dental practices.
Now, the average turnover for adental practice in the UK is
around 867,000.
So 15% of that alone is worth£130,000 worth of booked revenue
(06:55):
that's just evaporated.
And then adding to that, onemore start, so 62% is the
average overhead a dentalpractice is paying.
So for every pound that adental owner makes, they're only
keeping around 40 pence perpound.
(07:16):
And then just adding to that,so if we look at the EBITDA and
the impact on that, so 200 uhsorry, 200,000 pounds
improvement in EBITR, and I'veseen this happen in some of the
practices I've worked in, atseven times multiple adds a
valuation of 1.4 million pounds.
(07:37):
So that can be found in thingslike untracked uh outstanding
balances from patients,procurement, overspend, hundreds
of manually invoiced processes,or a dormant patient base that
sits in the thousands.
And I saw this in my last case.
Now, I've got a fewthought-provoking questions for
(07:58):
you, James.
So uh the first one is if yourpractice turned over £800,000 a
year and your overhead is around62%, recovering just 5% of that
revenue will give you £40,000annually.
So what could you do with that?
Dr James (08:18):
Uh well, I mean, it's uh it's it's certainly nothing
to sniff at, uh, isn't it?
You know, it's uh I think weget blinded by the figures as
dentists sometimes.
You know, sometimes when we'vegot practices that are making, I
don't know, six figures, sevenfigures, something along those
lines, that we forget that theseuh what seemingly small
percentage improvements uhactually put a noticeable amount
(08:40):
of cash into our back pocketbecause 40,000 pounds in
somebody's back pocket, I mean,a lot of people never see that
money in their whole life.
Rav (08:48):
Do you know that could be the difference between having a
full-timer and not?
So another question.
I mean, if you're a practiceowner, you're going into work
and you're fully booked for theday, but did every appointment
start on time?
And did every appointment,every patient, leave with a the
next appointment booked in?
So if you're answering no toany of those questions, then
(09:11):
you're not actually full, you'reactually leaking revenue.
And if your most experiencednurse left tomorrow, could your
practice run at the samestandard the next day?
So if not, then youroperational knowledge is living
in people's memory rather thanin systems or processes.
So that itself is a risk to thevaluation of your practice.
(09:35):
So now let's talk about theexciting bit.
So this is the methodology now,and you've already mentioned
Toyota.
So there's two parts to this.
So I'll talk about lean first.
So lean came about in the1950s, so Toyota was almost
about to go bankrupt and theyneeded to compete with American
firms.
So the way they wanted to dothat was first of all look at
(09:58):
their operations and look atwhere they can reduce waste.
So Tai Chiono started lookingat his operation and asking a
few simple questions.
So he said, out of everythingthat's produced in this factory,
what are we doing that actuallybuilds the car?
And what are all the processesthat we are doing around the
(10:20):
car, which is waste.
So, for example, correctingerrors, producing too much.
So, this is where the lensaround lean came in.
And what he said was you onlyproduce what you need and when
you need it.
So this was known as theproduct Toyota production
(10:41):
system.
So it's another another TPS.
Um, and basically he said youfind everything in a process
that does not add value for yourcustomer and you remove it.
So the bridge to dentistry, youcould think of it as the
30-minute appointment.
So if you think of all thosewasteful activities that you are
(11:05):
doing, when you when you comeinto practice, think of it as um
waiting in a queue that'swasteful.
Um completing the form, whichyou've already done online and
you're really doing it again.
Um when you are going into thechair, the clinician then is
(11:25):
pulling up the notes, and youcould have done some of this
beforehand.
So it's removing the waste andlooking at all the time they're
spending in a practice, how muchof that is waiting, and how
much of that is actually spentreceiving clinical treatment.
So if you map that out, you'llbe quite surprised how much
clinical time is spent on thepatient compared to the minute
(11:45):
they walk in the door to whenthey walk out of the door.
So that's lean.
Um, so lean is looking at theprocess, naming it, and then
removing all the wastefulactivities.
Sig Sigma is a methodologylooking at variation.
So when you are a clinician, uhyou conduct a clinical process,
(12:08):
and that could be doing afilling, for example.
So the clinical process ofdoing a filling is almost
identical from one clinician tothe other.
The variation sets in when itcomes to the other tasks that
have to be done either side.
So talking to the patient,prepping the chair, prepping the
(12:29):
tray, prep, taking payments,having a conversation with your
nurse.
So that creates a variation.
Ideally, what you want is forevery standard of treatment to
have a uh standardized timewhich you can allow some
variation for.
(12:50):
So if doing a filling takes 15minutes, you can allow a few
minutes each either side forvariation.
But the point is to have anallocated time for each of your
treatments so you have somevariation, but you can allocate
your time more effectively.
And we can talk about that andhow we use data.
(13:11):
So nobody has systematicallyapplied uh Six Sigma to the
dental practice and theoperation until now, so we can
explore more uh examples ofthose.
One thing I do want tointroduce you to is tack time.
So tack time is a Germanterminology and it refers to
(13:31):
heartbeat or rhythm.
So if your clinic is open foreight hours a day and you have
16 patients, your TAC time is 30minutes.
So you know your 30 minutes areallocated for 16 minutes for 16
patients.
By the end of the day, you'llfinish on time, all your
treatments will be complete, andyou'll know where your revenues
(13:52):
come from.
So TAC time is looking at theavailable clinical time divided
by patient demand.
If you start to fall behind,you are then chasing patient
demand.
So once you start fallingbehind, you'll start to see
delays and bottlenecks.
So that can be your measure.
So your tack time is theheartbeat of your incoming
(14:13):
demand.
So now we can look at someindustry examples.
Um so this is where it comesalive, and I think this is where
you start to see um how theworld operates with this
process.
So if you go to McDonald'sdrive-thru, it's pretty
(14:33):
consistent.
So the taste of a burger, it'snot the best.
If you buy a burger inBirmingham or in London, it
tastes more or less the same.
And that's because McDonald'sare not known for the
best-tasting burgers, they'reknown for consistency and
process.
So if you go through thedrive-thru, you'll know you'll
be waiting a couple of minutes.
You won't be waiting 15-20minutes because that's not what
(14:54):
you expect.
So, what McDonald's are doing,they are investing in process
and then people follow theprocess.
It's not the other way around.
So it's consistent, it'spredictable, regardless of
shift, staff member, orlocation.
So if you are going to apractice and you're booked in
(15:16):
for a composite restoration, oneassociate might take 30
minutes, one might take 47.
So you've got some deviationthere, and that's when your
delays start to set in inpractice.
So the process again of acomposite restoration is
identical, but everything thathappens around it is not.
(15:38):
So McDonald's have astandardized written process for
everyone who works there,regardless of who's in that day.
And actually, you could do thesame for dental practice.
So for a composite restoration,you could have a tray card for
each appointment type, you couldhave a pre-appointment
checklist, everything needs tobe documented, and then you've
(16:00):
got a documented handoverprotocol that any clinician can
follow on any day.
So it's about documenting whatyou want to be the standard.
And any deviation from that isfine.
So you can set your deviation.
I'll allow five minutes eachside of my standardised process.
So a composite restoration, ifthat takes around 30 minutes,
(16:24):
you might allow a variation of25 to 35 minutes.
So if you think of the bellcurve, it's if it's flat, then
you've got too much variation.
You want to make your bellcurve tall and slim, and you've
got a limit each side.
So if you have an associate whois taking far too long, they
(16:45):
might have a trainingrequirement or they might need
more support.
But equally, if they finish in15 minutes, that might also be
an issue because they might becutting corners, which could be
putting your business at risk.
So it's always good to have astandardised time for any of
your treatments.
(17:05):
You can then allocate your timemore effectively and
efficiently.
And it also gives yourassociates or your team members
some guidance around what isexpected from them.
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(19:01):
of this podcast.
Rav (19:06):
I mean, yeah, you can ask a question right now, you know,
in your practice, when you lookat the most carmine procedure,
does it take the same timeregardless of which associate is
in?
So if it doesn't, then thatvariation is going to be costing
you time and money across theweek.
Dr James (19:28):
Yeah, yeah.
No, I I hear you, I hear you.
I mean, um, I think you couldprobably further subdivide that
into uh complexity, uh, youknow, uh, because obviously uh
certain root canals are going totake way longer than other root
canals.
Um and definitely the devil'sin the detail, yeah.
But yeah, high level, okay,cool.
(19:49):
Yeah, you do want to ex if youknow if one associate is doing
an upper central incisor in like45 minutes for a root canal,
and then another one is doing itin like two hours, then
obviously we definitely want tolook into that, you know.
So I I I think that yeah, I Ilike I like it from that
perspective.
It's definitely good to explorethese things.
Rav (20:11):
Yeah, cool.
And then the second example isaround Formula One and the pit
stop.
So imagine 1950s uh Silverstonecar tire change.
So that used to take anywherebetween 30 seconds to four
minutes, so huge variationthere.
And nobody really looked at theprocess or asked questions.
(20:33):
So what was happening there wasthey were they weren't
preparing well for when the carstopped and came in.
It was only when the carstopped, came in, did they start
to go and fetch a tire, look atthings.
It was all really messy.
Um, the mechanics were trippingover each other, then they'd
bring the wrong tire out.
So quite often things wentwrong, and quite often the tire
(20:54):
changeover was four minutes.
Um and then a Japanese engineeraround the same time called
Shigio Shingo was looking at theproduction line of
manufacturing, and he waslooking at the changeover time.
So a machine is running, youhave to stop it to change over
the die, for example.
And then he asked questionsaround what tasks can we do
(21:18):
while the machine is running, sowhen the car's running, and
what task can we do when the carhas stopped, or in this case,
when the machine has stopped.
So if you separate those tasksout, you have internal tasks,
which can only be done when thecar has stopped, and external
tasks, which can be donebeforehand or after.
(21:39):
So this methodology is calledSMED, so it's single-minute
exchange of dye, and it's thediscipline of converting
internal work to external workas much as possible.
So, how does that relate todentistry?
You can think of it as yourchair time, because that's
costing you money, or you canthink of it as your waiting
(22:01):
room.
So the waiting room queue isnot caused by what's happening
in the waiting room, it's what'scaused by what's happening
beforehand.
So you go into a practice, youspeak to receptionists, you
might have to fill out a form.
You might be late because ofparking, and then the clinician
then takes a while to pull uptheir notes.
(22:22):
So you could be waiting a goodfour to five minutes before you
actually sit down.
Whilst you're talking, there'sa cue starting to build.
So these are some of the tasksthat when we look at before they
arrive into practice, which isthe pit stuff, what can be done
before they arrive?
So, I mean, at the moment, Ithink most practices send out a
(22:45):
text to remind them.
But actually, you can call thembeforehand, confirm the
procedure.
Do they know how much it costs?
Do they know where to park?
Can you send them the forms tofill out digitally rather than
doing it on the day?
So once they come in, theymight not even have to interact
with the receptionist.
(23:05):
They can come in and maybe justclick to say, I've arrived.
So the receptionist is nolonger dealing with anyone who's
coming into practice.
She can therefore deal with allthe patients then who are
leaving to book in their nextappointment and take payment
from them.
So that's another, it's acleverer way of looking at how
to reduce that bottleneck inpractice, which then has a knock
(23:28):
on effect on the chair time.
So then you can utilize thechair time to bring in more
patients.
Does that make sense?
Dr James (23:35):
Nice.
Yeah.
So I I guess uh the key thesisor philosophy of this technique
is.
Just exactly what you weresaying at the start.
We look at everything thatdoesn't add value, yeah.
And we remove it, or as youwere saying in the analogy of
the Formula One car, like whatstuff can we do while the
engine's running, and what stuffcan be done beforehand?
(23:55):
Because even though, yeah, Iget that, that it's it's kind of
how can I say this?
It's all stuff we kind of know,but do we do it as a whole
thing, you know?
Do we actually have asystemized way to do it?
Or in all the things that wehave to do in a day, you know,
what is actually distracting usfrom doing this really important
stuff.
So we need to say it out loud,yeah.
And there's a saying that Ilike we need to be reminded more
(24:17):
than we're taught, basically,because like I was saying, we
kind of know this stuff isimportant, but it just falls by
the wayside.
Whereas actually, if we focusedon this stuff, we'd probably
have more time to do otherthings as well.
So it's about priorities.
Rav (24:28):
100%, yeah.
And I I do hear that a lot.
I haven't got time to do it.
But I think the best way to seeit is what's the current
process costing you now?
So if that receptionist is tiedup, you can't answer the phone.
And you might have a query comethrough for an Invisalign, um,
and then they'll go ring thenext dental practice, and then
you could have potentially lostthree or four thousand pounds of
(24:50):
sale.
Dr James (24:51):
You know what?
Can I just say something onthat really quickly?
When you hear someone say, uh,I don't have the time to do
this, what they're basicallysaying is I don't, I this is not
a priority for me.
Because everyone's got time,everyone's got the same amount
of time, right?
Um, even the most successfulpeople in the world have the
same 24 hours in the day as us,but they're just better at
knowing what they shouldprioritize and what they
(25:13):
shouldn't.
Whereas what I see people do alot in business is prioritize
the wrong things.
Um, and then when someone triesto give them input on
prioritizing other stuff, theysay they don't have the time,
right?
Which kind of basically lowlevel suggests that they want to
just keep doing the same thingthey did before, even though
they're also simultaneouslycomplaining about that because
they've seen the help of aconsultant.
(25:34):
So, what I'm saying is beopen-minded, guys.
And I I've done I'm not sayingI haven't done it before, I've
done it a million times, but Ialso know of that little
psychological delusion.
So sometimes I catch myselfabout the set and I'm like, hmm,
maybe not, James.
Let's let's let's listen tothis one out, or yeah, let's uh
let's give this a go.
And then sometimes uh you know,there's been times before where
(25:55):
I've been stunned, I've beenlike, oh my god, this is
actually miles better.
But you've got to beopen-minded in the first place.
And I don't have time, smokescreen.
Rav (26:03):
Yeah, definitely.
Uh and you know, I mean, thisexample I'm going to refer to,
this is really powerful.
So this is relates to the NHS.
The NHS use lean and Six Sigmaand have done for a number of
years.
But if you would just thinkabout A.
And uh just the camera.
Dr James (26:24):
Just keep going.
Rav (26:25):
Okay, so if we think of AE and the time spent in AE, so you
may wait several hours.
I think four hours is thetarget time, but think of how
much time you actually receivein clinical treatment, and then
you could be waiting again.
Now, when people automaticallythink the reason you wait so
long in AE is because there's aproblem with capacity.
(26:48):
So there's not enough triagenurses or there's not enough
doctors around to look at youguys who come in with a broken
leg or whatever it is.
But when lean was applied, itactually the bottleneck wasn't
there, it was right at the endof the process.
So the problem was thereweren't enough beds up on the
wards, and the reason therewasn't enough beds on the wards
(27:09):
is because the discharge processtook too long.
So you'd be discharged and thenyou'd wait a few hours for a
letter, a few hours to be pickedup, you might wait for pharmacy
sign-up.
So you could be in hospital foranother seven, eight hours
before you are actually leavingthat bed.
And once that bed becomesavailable, then someone on AE
(27:32):
can then move upstairs into thebed.
So the bottleneck was actuallyin the discharge process on the
board of patients leaving ratherthan in AE itself.
So AE just got clogged upbecause they there was nowhere
for these patients to go.
So I guess what I'm saying isthe bottleneck isn't always
where you think it is until youstop and map the process and
(27:56):
then start to measure it.
And then the Heathrow Airport,and I wanted to share this one
because this is so simple, it isa little bit of common sense,
but at Heathrow Airport, whenpeople are going through the
scanners, um, that's where thethat's where the bottleneck
occurs because that is only whenthey start to remove their
(28:17):
shoes, take what uh laptops outof bags, um, and then that that
had a compound effect on therest of the queue.
So the queue just got longer.
All they did was put somesimple signage up along the
queue to say, in two minutes'time, you will be going to the
scanners.
Please make sure your shoes areremoved, bags are out, phones
(28:38):
are out, keys are out, and soon.
So that didn't even costanything apart from the cost of
signage.
Um, but as a result, theydidn't invest in extra security
lanes or extra staff.
They just invested in a littlebit of signage, and the result
was incredible.
It had a massive impact on theQ tie, which dropped right down.
(28:58):
So going back to the previousexample, you can do this in
dental.
So, you know, you spend sevenminutes or so gathering
information with a patient thatarrived at 10 o'clock.
That information can be donebefore they arrive to practice.
So I have another question.
(29:18):
Um what and it's for you andfor listeners.
So, what does your currentpractice send out in terms of
communication between when theybook in an appointment and when
they arrive in practice?
Dr James (29:32):
Um, well, I'm gonna guess the typical stuff is if
it's a first appointment,obviously they're gonna need
medical history and and uh youknow, how can I say this?
Uh presenting complaints andsocial history and everything
along those lines, um, or thereason for attendance at the
very least, even if they don'thave a complaint.
And then after they're gonnahave subsequent appointments,
(29:52):
you want email reminders andtext reminders, some sort of
cadence on that front, at leastat the very, very, very least,
to remind them about their nextappointment.
Rav (30:01):
Yeah.
And I think it's thinking abouthow effective you can be before
they're in practice.
So always think of yourpractice and your chair time as
the most precious resource, andit's thinking about what else we
can do with the patient to keepthem engaged before they arrive
and after they've left.
(30:22):
So um we'll move on to the nextbit now.
So this is around the sort oftest stakes and a few simple
tools that you guys can takeaway with.
So we have around, well, justover 2,000 practices in the UK
that are owned by mid-sidedgroups, so sort of three to 29.
And it's worth noticing that umas practice starts to scale up,
(30:47):
that's when the processes startto creak and break down.
So if you've got one practice,it could be running really well,
but it might well be relying oninstitutional memory and the
skill of people in the practice.
When you try to open a secondone, you try and replicate that,
and then by the time you get tothe third one, it starts to
(31:07):
creep down and problems start tooccur.
So there's delays, there'scomplaints, sickness, and so on.
So if you think of a singlepractice that might have poor
processes, that might be costingyou somewhere between 40 to
80,000 a year.
Now, a five-site group that'sjust going to be multiplied.
(31:28):
So every site then will belosing money every year, and it
does become harder to manage tostaff, and it becomes harder to
sell.
So corporate buyers now look atthat as part of the valuation.
So it's always a good idea tohave standard operating
procedures in place before youeven start to scale up.
(31:49):
So going back to the £200,000improvement in EBITDA, if you
think of that as seven times,that adds £1.4 million to the
sale price of your practice.
And that £200,000 I canguarantee will be somewhere in
your practice without you havingto spend more money on staff
(32:10):
opening hours before you evenimplemented AI tools to make
your process run moreefficiently.
It will be in there somewhere.
And the last practice I went tosee, that was a three-site
practice, and there was half amillion pounds sitting in his
practice in various processesright across his operations that
(32:32):
he didn't know he had.
And that was to do with the wayhe was using suppliers, the way
he was procuring um sicknessand so on.
So that was even before westarted to look at implementing
something new.
So that's massive.
Um, and then the three tools Iwant to mention um really simple
for you guys to take away,implement straight away.
(32:55):
So the first one is called thefive whys.
And it's if you think of alittle child always saying, why,
why, why, it's a little bitlike that.
So you might have a problem.
Let's go back to the patientwaiting 25 minutes.
So you ask why, and it'sbecause a previous appointment
overrun.
So, why did the previousappointment overrun?
(33:15):
Because the wrong tray was setup, as one example.
And why was that?
Because the nurse who came in,she was quite new and she didn't
know how to set it up.
And the reason is there was nostandard way of setting up the
tray for that type of procedure.
So this the answer is we justneed to put some standard
(33:35):
processes in place so anyone whocomes in, no matter whether
they're experienced orinexperienced, can pick that up
and deliver the same standard asany other tray.
So the fix isn't always to runon time, the fix is to have a
written tray standard.
So that's the five whys.
The second one is I think wetalked about this earlier, was
(33:56):
Pareto.
So this is the 80-20 rule.
And this you can apply this toanything and everything in your
practice.
But if we track the calls ofappointments that overrun, if
you track them in a month, yourtop 20 reasons will fall within
two or three reasons.
So, and you just focus onsolving those two or three
(34:19):
reasons because the chances arethey'll keep coming back.
So it could be incomplete notesor missing materials.
If you solve those twoproblems, then 80% of your
problems around patientsoverrunning will be solved, and
you can apply that to anything.
Dr James (34:36):
Nice.
Rav (34:37):
Um, and then finally, tool three, standard operating
procedures.
So this is one thing everypractice should have.
And you can have it on any anyprocess that you have you have
in practice, whether it'sraising an invoice, whether it's
how a patient is checked in,and that should be the right way
(34:58):
to do it.
The variation to thoseprocesses at the moment is
invisible, and that is costingyou money.
Having a standard operatingprocedure, it's so easy to
write.
And I would encourage you guysto have only one or two people
write them in practice just tokeep it consistent and to have a
date on there, a versioncontrol, and to always keep it
(35:20):
short and punchy, and it's onlyone SOP per process.
So each SOP starts with a verb,and it's literally you to tell
them what to do, take out allthe fluff, and it's just
step-by-step instruction.
If your practice can't functionum at a certain standard
without a specific person, thenyou know that knowledge lives in
(35:42):
their head and it doesn't livein systems and processes.
So that's a business risk.
Dr James (35:47):
You're not gonna rely on them, right?
It's all it's literally allabout how to write a good
checklist, which soundsobviously dry.
Okay.
Yeah.
Uh, but um I never thought thatI'd feel uh so how can I say
(36:09):
this, uh, enthusiastic about abook on checklists, is all I can
say.
Uh, because it teaches you howto write them really well.
And it's it's can it covers inuh the book, you know, let's say
they've got a reallycomplicated project where
there's lots of different peoplewith lots of different areas of
expertise.
How do we make sure that theyall talk to each other and
approve things so that thingsare done properly?
(36:32):
And yeah, he talks about thedifferent types of checklists
and how they should be powerfuland punchy, like just the
important things that you needto get done, not like a
prescriptive list of everysingle item um and how powerful
they can be, and obviously howmassive businesses use these to
make sure everything isstandardized.
So the humble checklist is ishuge for your business, and
(36:55):
again, not just for an associateuh principal, but also for an
associate as well, so that youcan make sure that you're doing
things consistently.
Uh, so yeah, it's it's weshouldn't overlook and
underestimate the humblechecklist and doing it well.
Rav (37:07):
Yeah, I agree.
I must admit, when I first cameacross them, I thought, oh,
this is not the most excitingthing, but actually it is, and
it's everyone's Bible, and theyalso need to be in a place where
people can access them quiteeasily.
So if they're hidden away insystems where you've got to
click five times to find them,they need to be easily
accessible.
(37:28):
And and you know, keepencouraging your team to keep
pulling them up for any process,and then it becomes a way of
life, and that's the culturethat you build within your
practice.
So it's good to know that youuh get excited about them too.
It's not just me, James.
Um, okay, so the fun I thinkfinally for me, um, as I start
(37:49):
to bring this to an end, uh,there's one thing you guys can
do this week in practice is topick a problem and pick a
problem that perhaps has creptup quite a few times.
You might try to solve it.
Um and look at how you cansolve it, map it out, map any
problem you come across inpractice.
(38:09):
I'd encourage you to map itout, not just yourself, but with
a couple of members of yourteam, because they're involved
in the process, and you'll beamazed at what starts to jump
out at you.
You'll suddenly start to seehow long one part of the process
might take, where the painsits.
It might not be right acrossthe process, it might just be at
one step.
So that's one thing I'dencourage you to do.
(38:32):
The other thing I want tomention is in the podcast link,
there is a free e-workbook thatyou guys can use.
So if you've been listeningtoday, you'll be able to put
into practice uh what you'veheard.
So that's around um the pitstop analogy, looking at
bottlenecks, looking at howvariation might set in across
(38:54):
your practice.
And if you want to have aconversation with me, then let
me know.
That should generate a reportfor you as well.
So it gives you it's there's awaste calculator, it gives you a
rough idea of how much revenueyou're leaking.
Um, and you can complete that.
If you want to contact me,there's a button at the end
where you can uh come through tome.
(39:15):
And I think the final thing Ijust want to finish off on is
Lean Six Sigma.
It's not just a methodology forcertain businesses, it's a way
of seeing any operation, and youcould even apply it to your
home life, you can apply it toanything that you do.
Um, and it's a way of seeingthings in a different way.
(39:36):
I mean, this has just been areal quick whistle stop tour of
a few tools, but there's so muchmore to it.
So if you're looking toimproving your practice, um then
please have a look at thecalculator, go on the workbook,
and if there's anything youneed, just to reach out to me at
SeepMa Smile.
Dr James (39:56):
Sounds good.
So, yes, that workbook that Ravspoke about just a second ago
is going to be in the podcastdescription, guys.
So if you take a look in there,you'll be able to find the link
and that'll be clearlydemarcated.
Welcome back to the Dent to Invest podcast.
I have sat here in front of metoday particularly
interestingly, Mrs.
Ravinder Nottra.
Rav's speciality is somethingcalled the Neme Technique, and
also in addition to that,something else called the Sigma
technique.
She combines them both andapplies them to the dental
industry to come up with twospecial recipes that can boost
(02:05):
our profitability, not just asassociates and practice owners,
but also more generally insofaras putting revenue across all
business interests because thiscan be applied to anything.
And it is worth mentioning thatToyota used these methods, the
Sigma method, in the 1950s tobecome the business that they
(02:25):
are today.
And we all know how that went,so let's tune into this one for
sure to find out more.
As ever, you can claim your CPDfor this episode within the
official Dentists who InvestSmart Money Members Club.
Smart Money Members Club alsoincludes multiple mini courses
and webinar series on financefor dentists, including how to
become as tax efficient aspossible, as well as
understanding investing.
(02:45):
All of this content counts asverifiable CPD, and you can
download your certificates thereand then upon completion of
each lesson.
In addition to this, we alsoinclude a whopping 10% discount
on your dental indemnity and a5% discount on lab bills for
dental principals, amongst otherperks and discounts for
members.
Please use the link in thedescription to claim your
(03:06):
verifiable CPD for this episode.
Rav, well, I mean I'm lookingforward to this.
The point of this podcast is toteach people about things that
they've never heard of for andbring new ideas to the dental
industry.
So I get a funny feeling thatwe're gonna do both today on
(03:26):
this podcast.
So, Rav, when it comes toyourself, I think it's best to
intro you as a profitabilitycoach for Dennis.
Is that fair to say?
Rav (03:35):
Yeah, that's correct.
Dr James (03:37):
Nice one.
Alright, well, listen, I thinkwe should just jump straight in
with the main course, so tospeak, the meat and potatoes off
this podcast, which is to talkabout both those techniques that
we mentioned in the intro.
So the first one is the leantechnique, the second one is the
Six Sigma technique, which isthe technique that Toyota used
to become the business that theyare today.
Interested to hear about bothfor sure.
(03:57):
And then what we should talkabout is how we can combine them
to be as successful as possiblein our businesses, not just as
principals, but obviouslyincluding associates in that
bracket as well, because we arebusinesses too, of course, and
we have to look at ourselves inthat sense, particularly
whenever it comes toprofitability and yes, of
course, being ethical andfulfilling our duty of care to
(04:17):
the patient and everything alongthose lines.
So, how about that as a placeto start?
Rav (04:21):
That sounds great.
Dr James (04:23):
Cool, let's jump straight in.
Rav (04:25):
Yeah, let's jump straight in.
So, what I'll do, let me askyou uh a question to all the
listeners.
So, when was the last time youfinished a full clinical day?
And did you know where yourday's revenue came from?
So, most practice owners Ispeak to, they say they can't
remember or they just don'tknow.
(04:47):
So, what I'd like to do todayis introduce you to a way of
seeing your practice using amethodology that is being used
by many businesses across theworld for many years.
So that includes McDonald's,Heathrow Airport, uh, Formula
One, and the NHS.
So, what we'll do, James, ifit's all right with you, we'll
(05:10):
talk about one really simpleexample of some of the pain
that's we face in practices on adaily basis.
And we can call it the30-minute wait.
So a patient comes in andthey're waiting around 30
minutes before they see aclinician.
So there's lots of reasons forthat, and I'll just pick out
(05:30):
three as an example.
So the reason they could bewaiting could be the day started
eight minutes late, so that 9a.m.
appointment overran, and thenas a result, it's called a
cascade defect in manufacturing.
So every patient then has aproblem when they come in,
they're always having to waiteven more.
(05:51):
The second reason could be thesurgery turnover took 14 minutes
instead of five minutes ofpreparation.
And then the third reason couldbe the patient before them
arrived 12 minutes late.
So these are just a fewexamples.
Now that one of those doesn'tcause a 30-minute wait, but a
few examples put together uh do.
So those of it, those areeveryday examples of the kind of
(06:14):
pain we face, especiallyoperationally on a day-to-day
basis.
So if we take it up a fewlevels and look at the financial
framing, now Christian Co'sreport tells us that 15% of
patients either cancel or don'tturn up.
(06:35):
And that can be as high as 30%for some dental practices.
Now, the average turnover for adental practice in the UK is
around 867,000.
So 15% of that alone is worth£130,000 worth of booked revenue
(06:55):
that's just evaporated.
And then adding to that, onemore start, so 62% is the
average overhead a dentalpractice is paying.
So for every pound that adental owner makes, they're only
keeping around 40 pence perpound.
(07:16):
And then just adding to that,so if we look at the EBITDA and
the impact on that, so 200 uhsorry, 200,000 pounds
improvement in EBITR, and I'veseen this happen in some of the
practices I've worked in, atseven times multiple adds a
valuation of 1.4 million pounds.
(07:37):
So that can be found in thingslike untracked uh outstanding
balances from patients,procurement, overspend, hundreds
of manually invoiced processes,or a dormant patient base that
sits in the thousands.
And I saw this in my last case.
Now, I've got a fewthought-provoking questions for
(07:58):
you, James.
So uh the first one is if yourpractice turned over £800,000 a
year and your overhead is around62%, recovering just 5% of that
revenue will give you £40,000annually.
So what could you do with that?
Dr James (08:18):
Uh well, I mean, it's uh it's it's certainly nothing
to sniff at, uh, isn't it?
You know, it's uh I think weget blinded by the figures as
dentists sometimes.
You know, sometimes when we'vegot practices that are making, I
don't know, six figures, sevenfigures, something along those
lines, that we forget that theseuh what seemingly small
percentage improvements uhactually put a noticeable amount
(08:40):
of cash into our back pocketbecause 40,000 pounds in
somebody's back pocket, I mean,a lot of people never see that
money in their whole life.
Rav (08:48):
Do you know that could be the difference between having a
full-timer and not?
So another question.
I mean, if you're a practiceowner, you're going into work
and you're fully booked for theday, but did every appointment
start on time?
And did every appointment,every patient, leave with a the
next appointment booked in?
So if you're answering no toany of those questions, then
(09:11):
you're not actually full, you'reactually leaking revenue.
And if your most experiencednurse left tomorrow, could your
practice run at the samestandard the next day?
So if not, then youroperational knowledge is living
in people's memory rather thanin systems or processes.
So that itself is a risk to thevaluation of your practice.
(09:35):
So now let's talk about theexciting bit.
So this is the methodology now,and you've already mentioned
Toyota.
So there's two parts to this.
So I'll talk about lean first.
So lean came about in the1950s, so Toyota was almost
about to go bankrupt and theyneeded to compete with American
firms.
So the way they wanted to dothat was first of all look at
(09:58):
their operations and look atwhere they can reduce waste.
So Tai Chiono started lookingat his operation and asking a
few simple questions.
So he said, out of everythingthat's produced in this factory,
what are we doing that actuallybuilds the car?
And what are all the processesthat we are doing around the
(10:20):
car, which is waste.
So, for example, correctingerrors, producing too much.
So, this is where the lensaround lean came in.
And what he said was you onlyproduce what you need and when
you need it.
So this was known as theproduct Toyota production
(10:41):
system.
So it's another another TPS.
Um, and basically he said youfind everything in a process
that does not add value for yourcustomer and you remove it.
So the bridge to dentistry, youcould think of it as the
30-minute appointment.
So if you think of all thosewasteful activities that you are
(11:05):
doing, when you when you comeinto practice, think of it as um
waiting in a queue that'swasteful.
Um completing the form, whichyou've already done online and
you're really doing it again.
Um when you are going into thechair, the clinician then is
(11:25):
pulling up the notes, and youcould have done some of this
beforehand.
So it's removing the waste andlooking at all the time they're
spending in a practice, how muchof that is waiting, and how
much of that is actually spentreceiving clinical treatment.
So if you map that out, you'llbe quite surprised how much
clinical time is spent on thepatient compared to the minute
(11:45):
they walk in the door to whenthey walk out of the door.
So that's lean.
Um, so lean is looking at theprocess, naming it, and then
removing all the wastefulactivities.
Sig Sigma is a methodologylooking at variation.
So when you are a clinician, uhyou conduct a clinical process,
(12:08):
and that could be doing afilling, for example.
So the clinical process ofdoing a filling is almost
identical from one clinician tothe other.
The variation sets in when itcomes to the other tasks that
have to be done either side.
So talking to the patient,prepping the chair, prepping the
(12:29):
tray, prep, taking payments,having a conversation with your
nurse.
So that creates a variation.
Ideally, what you want is forevery standard of treatment to
have a uh standardized timewhich you can allow some
variation for.
(12:50):
So if doing a filling takes 15minutes, you can allow a few
minutes each either side forvariation.
But the point is to have anallocated time for each of your
treatments so you have somevariation, but you can allocate
your time more effectively.
And we can talk about that andhow we use data.
(13:11):
So nobody has systematicallyapplied uh Six Sigma to the
dental practice and theoperation until now, so we can
explore more uh examples ofthose.
One thing I do want tointroduce you to is tack time.
So tack time is a Germanterminology and it refers to
(13:31):
heartbeat or rhythm.
So if your clinic is open foreight hours a day and you have
16 patients, your TAC time is 30minutes.
So you know your 30 minutes areallocated for 16 minutes for 16
patients.
By the end of the day, you'llfinish on time, all your
treatments will be complete, andyou'll know where your revenues
(13:52):
come from.
So TAC time is looking at theavailable clinical time divided
by patient demand.
If you start to fall behind,you are then chasing patient
demand.
So once you start fallingbehind, you'll start to see
delays and bottlenecks.
So that can be your measure.
So your tack time is theheartbeat of your incoming
(14:13):
demand.
So now we can look at someindustry examples.
Um so this is where it comesalive, and I think this is where
you start to see um how theworld operates with this
process.
So if you go to McDonald'sdrive-thru, it's pretty
(14:33):
consistent.
So the taste of a burger, it'snot the best.
If you buy a burger inBirmingham or in London, it
tastes more or less the same.
And that's because McDonald'sare not known for the
best-tasting burgers, they'reknown for consistency and
process.
So if you go through thedrive-thru, you'll know you'll
be waiting a couple of minutes.
You won't be waiting 15-20minutes because that's not what
(14:54):
you expect.
So, what McDonald's are doing,they are investing in process
and then people follow theprocess.
It's not the other way around.
So it's consistent, it'spredictable, regardless of
shift, staff member, orlocation.
So if you are going to apractice and you're booked in
(15:16):
for a composite restoration, oneassociate might take 30
minutes, one might take 47.
So you've got some deviationthere, and that's when your
delays start to set in inpractice.
So the process again of acomposite restoration is
identical, but everything thathappens around it is not.
(15:38):
So McDonald's have astandardized written process for
everyone who works there,regardless of who's in that day.
And actually, you could do thesame for dental practice.
So for a composite restoration,you could have a tray card for
each appointment type, you couldhave a pre-appointment
checklist, everything needs tobe documented, and then you've
(16:00):
got a documented handoverprotocol that any clinician can
follow on any day.
So it's about documenting whatyou want to be the standard.
And any deviation from that isfine.
So you can set your deviation.
I'll allow five minutes eachside of my standardised process.
So a composite restoration, ifthat takes around 30 minutes,
(16:24):
you might allow a variation of25 to 35 minutes.
So if you think of the bellcurve, it's if it's flat, then
you've got too much variation.
You want to make your bellcurve tall and slim, and you've
got a limit each side.
So if you have an associate whois taking far too long, they
(16:45):
might have a trainingrequirement or they might need
more support.
But equally, if they finish in15 minutes, that might also be
an issue because they might becutting corners, which could be
putting your business at risk.
So it's always good to have astandardised time for any of
your treatments.
(17:05):
You can then allocate your timemore effectively and
efficiently.
And it also gives yourassociates or your team members
some guidance around what isexpected from them.
Dr James (17:15):
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of this podcast.
Rav (19:06):
I mean, yeah, you can ask a question right now, you know,
in your practice, when you lookat the most carmine procedure,
does it take the same timeregardless of which associate is
in?
So if it doesn't, then thatvariation is going to be costing
you time and money across theweek.
Dr James (19:28):
Yeah, yeah.
No, I I hear you, I hear you.
I mean, um, I think you couldprobably further subdivide that
into uh complexity, uh, youknow, uh, because obviously uh
certain root canals are going totake way longer than other root
canals.
Um and definitely the devil'sin the detail, yeah.
But yeah, high level, okay,cool.
(19:49):
Yeah, you do want to ex if youknow if one associate is doing
an upper central incisor in like45 minutes for a root canal,
and then another one is doing itin like two hours, then
obviously we definitely want tolook into that, you know.
So I I I think that yeah, I Ilike I like it from that
perspective.
It's definitely good to explorethese things.
Rav (20:11):
Yeah, cool.
And then the second example isaround Formula One and the pit
stop.
So imagine 1950s uh Silverstonecar tire change.
So that used to take anywherebetween 30 seconds to four
minutes, so huge variationthere.
And nobody really looked at theprocess or asked questions.
(20:33):
So what was happening there wasthey were they weren't
preparing well for when the carstopped and came in.
It was only when the carstopped, came in, did they start
to go and fetch a tire, look atthings.
It was all really messy.
Um, the mechanics were trippingover each other, then they'd
bring the wrong tire out.
So quite often things wentwrong, and quite often the tire
(20:54):
changeover was four minutes.
Um and then a Japanese engineeraround the same time called
Shigio Shingo was looking at theproduction line of
manufacturing, and he waslooking at the changeover time.
So a machine is running, youhave to stop it to change over
the die, for example.
And then he asked questionsaround what tasks can we do
(21:18):
while the machine is running, sowhen the car's running, and
what task can we do when the carhas stopped, or in this case,
when the machine has stopped.
So if you separate those tasksout, you have internal tasks,
which can only be done when thecar has stopped, and external
tasks, which can be donebeforehand or after.
(21:39):
So this methodology is calledSMED, so it's single-minute
exchange of dye, and it's thediscipline of converting
internal work to external workas much as possible.
So, how does that relate todentistry?
You can think of it as yourchair time, because that's
costing you money, or you canthink of it as your waiting
(22:01):
room.
So the waiting room queue isnot caused by what's happening
in the waiting room, it's what'scaused by what's happening
beforehand.
So you go into a practice, youspeak to receptionists, you
might have to fill out a form.
You might be late because ofparking, and then the clinician
then takes a while to pull uptheir notes.
(22:22):
So you could be waiting a goodfour to five minutes before you
actually sit down.
Whilst you're talking, there'sa cue starting to build.
So these are some of the tasksthat when we look at before they
arrive into practice, which isthe pit stuff, what can be done
before they arrive?
So, I mean, at the moment, Ithink most practices send out a
(22:45):
text to remind them.
But actually, you can call thembeforehand, confirm the
procedure.
Do they know how much it costs?
Do they know where to park?
Can you send them the forms tofill out digitally rather than
doing it on the day?
So once they come in, theymight not even have to interact
with the receptionist.
(23:05):
They can come in and maybe justclick to say, I've arrived.
So the receptionist is nolonger dealing with anyone who's
coming into practice.
She can therefore deal with allthe patients then who are
leaving to book in their nextappointment and take payment
from them.
So that's another, it's acleverer way of looking at how
to reduce that bottleneck inpractice, which then has a knock
(23:28):
on effect on the chair time.
So then you can utilize thechair time to bring in more
patients.
Does that make sense?
Dr James (23:35):
Nice.
Yeah.
So I I guess uh the key thesisor philosophy of this technique
is.
Just exactly what you weresaying at the start.
We look at everything thatdoesn't add value, yeah.
And we remove it, or as youwere saying in the analogy of
the Formula One car, like whatstuff can we do while the
engine's running, and what stuffcan be done beforehand?
(23:55):
Because even though, yeah, Iget that, that it's it's kind of
how can I say this?
It's all stuff we kind of know,but do we do it as a whole
thing, you know?
Do we actually have asystemized way to do it?
Or in all the things that wehave to do in a day, you know,
what is actually distracting usfrom doing this really important
stuff.
So we need to say it out loud,yeah.
And there's a saying that Ilike we need to be reminded more
(24:17):
than we're taught, basically,because like I was saying, we
kind of know this stuff isimportant, but it just falls by
the wayside.
Whereas actually, if we focusedon this stuff, we'd probably
have more time to do otherthings as well.
So it's about priorities.
Rav (24:28):
100%, yeah.
And I I do hear that a lot.
I haven't got time to do it.
But I think the best way to seeit is what's the current
process costing you now?
So if that receptionist is tiedup, you can't answer the phone.
And you might have a query comethrough for an Invisalign, um,
and then they'll go ring thenext dental practice, and then
you could have potentially lostthree or four thousand pounds of
(24:50):
sale.
Dr James (24:51):
You know what?
Can I just say something onthat really quickly?
When you hear someone say, uh,I don't have the time to do
this, what they're basicallysaying is I don't, I this is not
a priority for me.
Because everyone's got time,everyone's got the same amount
of time, right?
Um, even the most successfulpeople in the world have the
same 24 hours in the day as us,but they're just better at
knowing what they shouldprioritize and what they
(25:13):
shouldn't.
Whereas what I see people do alot in business is prioritize
the wrong things.
Um, and then when someone triesto give them input on
prioritizing other stuff, theysay they don't have the time,
right?
Which kind of basically lowlevel suggests that they want to
just keep doing the same thingthey did before, even though
they're also simultaneouslycomplaining about that because
they've seen the help of aconsultant.
(25:34):
So, what I'm saying is beopen-minded, guys.
And I I've done I'm not sayingI haven't done it before, I've
done it a million times, but Ialso know of that little
psychological delusion.
So sometimes I catch myselfabout the set and I'm like, hmm,
maybe not, James.
Let's let's let's listen tothis one out, or yeah, let's uh
let's give this a go.
And then sometimes uh you know,there's been times before where
(25:55):
I've been stunned, I've beenlike, oh my god, this is
actually miles better.
But you've got to beopen-minded in the first place.
And I don't have time, smokescreen.
Rav (26:03):
Yeah, definitely.
Uh and you know, I mean, thisexample I'm going to refer to,
this is really powerful.
So this is relates to the NHS.
The NHS use lean and Six Sigmaand have done for a number of
years.
But if you would just thinkabout A.
And uh just the camera.
Dr James (26:24):
Just keep going.
Rav (26:25):
Okay, so if we think of AE and the time spent in AE, so you
may wait several hours.
I think four hours is thetarget time, but think of how
much time you actually receivein clinical treatment, and then
you could be waiting again.
Now, when people automaticallythink the reason you wait so
long in AE is because there's aproblem with capacity.
(26:48):
So there's not enough triagenurses or there's not enough
doctors around to look at youguys who come in with a broken
leg or whatever it is.
But when lean was applied, itactually the bottleneck wasn't
there, it was right at the endof the process.
So the problem was thereweren't enough beds up on the
wards, and the reason therewasn't enough beds on the wards
(27:09):
is because the discharge processtook too long.
So you'd be discharged and thenyou'd wait a few hours for a
letter, a few hours to be pickedup, you might wait for pharmacy
sign-up.
So you could be in hospital foranother seven, eight hours
before you are actually leavingthat bed.
And once that bed becomesavailable, then someone on AE
(27:32):
can then move upstairs into thebed.
So the bottleneck was actuallyin the discharge process on the
board of patients leaving ratherthan in AE itself.
So AE just got clogged upbecause they there was nowhere
for these patients to go.
So I guess what I'm saying isthe bottleneck isn't always
where you think it is until youstop and map the process and
(27:56):
then start to measure it.
And then the Heathrow Airport,and I wanted to share this one
because this is so simple, it isa little bit of common sense,
but at Heathrow Airport, whenpeople are going through the
scanners, um, that's where thethat's where the bottleneck
occurs because that is only whenthey start to remove their
(28:17):
shoes, take what uh laptops outof bags, um, and then that that
had a compound effect on therest of the queue.
So the queue just got longer.
All they did was put somesimple signage up along the
queue to say, in two minutes'time, you will be going to the
scanners.
Please make sure your shoes areremoved, bags are out, phones
(28:38):
are out, keys are out, and soon.
So that didn't even costanything apart from the cost of
signage.
Um, but as a result, theydidn't invest in extra security
lanes or extra staff.
They just invested in a littlebit of signage, and the result
was incredible.
It had a massive impact on theQ tie, which dropped right down.
(28:58):
So going back to the previousexample, you can do this in
dental.
So, you know, you spend sevenminutes or so gathering
information with a patient thatarrived at 10 o'clock.
That information can be donebefore they arrive to practice.
So I have another question.
(29:18):
Um what and it's for you andfor listeners.
So, what does your currentpractice send out in terms of
communication between when theybook in an appointment and when
they arrive in practice?
Dr James (29:32):
Um, well, I'm gonna guess the typical stuff is if
it's a first appointment,obviously they're gonna need
medical history and and uh youknow, how can I say this?
Uh presenting complaints andsocial history and everything
along those lines, um, or thereason for attendance at the
very least, even if they don'thave a complaint.
And then after they're gonnahave subsequent appointments,
(29:52):
you want email reminders andtext reminders, some sort of
cadence on that front, at leastat the very, very, very least,
to remind them about their nextappointment.
Rav (30:01):
Yeah.
And I think it's thinking abouthow effective you can be before
they're in practice.
So always think of yourpractice and your chair time as
the most precious resource, andit's thinking about what else we
can do with the patient to keepthem engaged before they arrive
and after they've left.
(30:22):
So um we'll move on to the nextbit now.
So this is around the sort oftest stakes and a few simple
tools that you guys can takeaway with.
So we have around, well, justover 2,000 practices in the UK
that are owned by mid-sidedgroups, so sort of three to 29.
And it's worth noticing that umas practice starts to scale up,
(30:47):
that's when the processes startto creak and break down.
So if you've got one practice,it could be running really well,
but it might well be relying oninstitutional memory and the
skill of people in the practice.
When you try to open a secondone, you try and replicate that,
and then by the time you get tothe third one, it starts to
(31:07):
creep down and problems start tooccur.
So there's delays, there'scomplaints, sickness, and so on.
So if you think of a singlepractice that might have poor
processes, that might be costingyou somewhere between 40 to
80,000 a year.
Now, a five-site group that'sjust going to be multiplied.
(31:28):
So every site then will belosing money every year, and it
does become harder to manage tostaff, and it becomes harder to
sell.
So corporate buyers now look atthat as part of the valuation.
So it's always a good idea tohave standard operating
procedures in place before youeven start to scale up.
(31:49):
So going back to the £200,000improvement in EBITDA, if you
think of that as seven times,that adds £1.4 million to the
sale price of your practice.
And that £200,000 I canguarantee will be somewhere in
your practice without you havingto spend more money on staff
(32:10):
opening hours before you evenimplemented AI tools to make
your process run moreefficiently.
It will be in there somewhere.
And the last practice I went tosee, that was a three-site
practice, and there was half amillion pounds sitting in his
practice in various processesright across his operations that
(32:32):
he didn't know he had.
And that was to do with the wayhe was using suppliers, the way
he was procuring um sicknessand so on.
So that was even before westarted to look at implementing
something new.
So that's massive.
Um, and then the three tools Iwant to mention um really simple
for you guys to take away,implement straight away.
(32:55):
So the first one is called thefive whys.
And it's if you think of alittle child always saying, why,
why, why, it's a little bitlike that.
So you might have a problem.
Let's go back to the patientwaiting 25 minutes.
So you ask why, and it'sbecause a previous appointment
overrun.
So, why did the previousappointment overrun?
(33:15):
Because the wrong tray was setup, as one example.
And why was that?
Because the nurse who came in,she was quite new and she didn't
know how to set it up.
And the reason is there was nostandard way of setting up the
tray for that type of procedure.
So this the answer is we justneed to put some standard
(33:35):
processes in place so anyone whocomes in, no matter whether
they're experienced orinexperienced, can pick that up
and deliver the same standard asany other tray.
So the fix isn't always to runon time, the fix is to have a
written tray standard.
So that's the five whys.
The second one is I think wetalked about this earlier, was
(33:56):
Pareto.
So this is the 80-20 rule.
And this you can apply this toanything and everything in your
practice.
But if we track the calls ofappointments that overrun, if
you track them in a month, yourtop 20 reasons will fall within
two or three reasons.
So, and you just focus onsolving those two or three
(34:19):
reasons because the chances arethey'll keep coming back.
So it could be incomplete notesor missing materials.
If you solve those twoproblems, then 80% of your
problems around patientsoverrunning will be solved, and
you can apply that to anything.
Dr James (34:36):
Nice.
Rav (34:37):
Um, and then finally, tool three, standard operating
procedures.
So this is one thing everypractice should have.
And you can have it on any anyprocess that you have you have
in practice, whether it'sraising an invoice, whether it's
how a patient is checked in,and that should be the right way
(34:58):
to do it.
The variation to thoseprocesses at the moment is
invisible, and that is costingyou money.
Having a standard operatingprocedure, it's so easy to
write.
And I would encourage you guysto have only one or two people
write them in practice just tokeep it consistent and to have a
date on there, a versioncontrol, and to always keep it
(35:20):
short and punchy, and it's onlyone SOP per process.
So each SOP starts with a verb,and it's literally you to tell
them what to do, take out allthe fluff, and it's just
step-by-step instruction.
If your practice can't functionum at a certain standard
without a specific person, thenyou know that knowledge lives in
(35:42):
their head and it doesn't livein systems and processes.
So that's a business risk.
Dr James (35:47):
You're not gonna rely on them, right?
It's all it's literally allabout how to write a good
checklist, which soundsobviously dry.
Okay.
Yeah.
Uh, but um I never thought thatI'd feel uh so how can I say
(36:09):
this, uh, enthusiastic about abook on checklists, is all I can
say.
Uh, because it teaches you howto write them really well.
And it's it's can it covers inuh the book, you know, let's say
they've got a reallycomplicated project where
there's lots of different peoplewith lots of different areas of
expertise.
How do we make sure that theyall talk to each other and
approve things so that thingsare done properly?
(36:32):
And yeah, he talks about thedifferent types of checklists
and how they should be powerfuland punchy, like just the
important things that you needto get done, not like a
prescriptive list of everysingle item um and how powerful
they can be, and obviously howmassive businesses use these to
make sure everything isstandardized.
So the humble checklist is ishuge for your business, and
(36:55):
again, not just for an associateuh principal, but also for an
associate as well, so that youcan make sure that you're doing
things consistently.
Uh, so yeah, it's it's weshouldn't overlook and
underestimate the humblechecklist and doing it well.
Rav (37:07):
Yeah, I agree.
I must admit, when I first cameacross them, I thought, oh,
this is not the most excitingthing, but actually it is, and
it's everyone's Bible, and theyalso need to be in a place where
people can access them quiteeasily.
So if they're hidden away insystems where you've got to
click five times to find them,they need to be easily
accessible.
(37:28):
And and you know, keepencouraging your team to keep
pulling them up for any process,and then it becomes a way of
life, and that's the culturethat you build within your
practice.
So it's good to know that youuh get excited about them too.
It's not just me, James.
Um, okay, so the fun I thinkfinally for me, um, as I start
(37:49):
to bring this to an end, uh,there's one thing you guys can
do this week in practice is topick a problem and pick a
problem that perhaps has creptup quite a few times.
You might try to solve it.
Um and look at how you cansolve it, map it out, map any
problem you come across inpractice.
(38:09):
I'd encourage you to map itout, not just yourself, but with
a couple of members of yourteam, because they're involved
in the process, and you'll beamazed at what starts to jump
out at you.
You'll suddenly start to seehow long one part of the process
might take, where the painsits.
It might not be right acrossthe process, it might just be at
one step.
So that's one thing I'dencourage you to do.
(38:32):
The other thing I want tomention is in the podcast link,
there is a free e-workbook thatyou guys can use.
So if you've been listeningtoday, you'll be able to put
into practice uh what you'veheard.
So that's around um the pitstop analogy, looking at
bottlenecks, looking at howvariation might set in across
(38:54):
your practice.
And if you want to have aconversation with me, then let
me know.
That should generate a reportfor you as well.
So it gives you it's there's awaste calculator, it gives you a
rough idea of how much revenueyou're leaking.
Um, and you can complete that.
If you want to contact me,there's a button at the end
where you can uh come through tome.
(39:15):
And I think the final thing Ijust want to finish off on is
Lean Six Sigma.
It's not just a methodology forcertain businesses, it's a way
of seeing any operation, and youcould even apply it to your
home life, you can apply it toanything that you do.
Um, and it's a way of seeingthings in a different way.
(39:36):
I mean, this has just been areal quick whistle stop tour of
a few tools, but there's so muchmore to it.
So if you're looking toimproving your practice, um then
please have a look at thecalculator, go on the workbook,
and if there's anything youneed, just to reach out to me at
SeepMa Smile.
Dr James (39:56):
Sounds good.
So, yes, that workbook that Ravspoke about just a second ago
is going to be in the podcastdescription, guys.
So if you take a look in there,you'll be able to find the link
and that'll be clearlydemarcated.
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