Redesigning an oral health visit for kids who need sealants—Part 1

Picking up The Sealant Story

Consuming fluoridated water and using fluoride toothpaste are the two biggest interventions to prevent cavities in kids.  In third place:  sealing new permanent molars.  I introduced the sealant opportunity in this post about effective oral health measurement.

In a current oral health improvement collaborative, clinic teams are working to seal more permanent molars in kids aged 6 to 14.  The practical change we’re promoting:  when a kid who needs sealants comes to the clinic, get the sealants done in that visit.  Don’t flag the need for sealants and schedule another visit!

One of the teams I’m coaching tested the change in one visit last month.   As part of the Plan step in the PDSA cycle, the team predicted that adding sealants to the work flow would increase the time needed for the visit.  To assess their prediction, they timed the visit:  they had to add 17.5 minutes to the standard exam time to accommodate the extra sealant work. 

In the Study step of the Plan-Do-Study-Act method, the team realized they could reduce the extra time they observed in the first test.  They came up with two changes: make sure parents or guardians have information about sealants ahead of the visit and assure the provider has a kit with sealant and sealant tools ready to go.  Those change ideas set up one or more new tests, with a prediction that the team can shrink the extra time needed to apply sealants.

Repeated PDSA cycles using these first two change ideas and keeping eyes open for more opportunities should yield further progress, where progress is measured by getting sealants done and reducing the time needed to do it.

A little bit of improvement advice can catalyze the team’s progress.

Alternatives to Adding Time to an Exam

As the project team predicted, if you add steps so a provider will seal teeth on top of existing work, the total work will take more time.   Should it?

If the clinic has lots of capacity --more providers than demand for services--it might make sense to simply extend exams to handle the extra work.  However, almost all oral health clinics are constrained, with more demand than time to see patients.

When faced with a need to improve work that has time or staffing constraints, how can you avoid the obvious solution to add time or staff?

Here’s advice from the ‘Goldratt School’ of improvement*, in the order of typical opportunity and simplicity of countermeasures: 

(1)    Eliminate waiting time and delays within the visit;

(2)    Reduce set-up time for sealants and other procedures within the visit;

(3)    Improve quality of information or materials used in the visit (no rework);

(4)    Only work on the tasks that are necessary for an excellent visit.

If you’ve worked diligently through all four actions, you may still need to add time to the visit or add staff (e.g. four hands at work in the visit).   However, you will have reduced the amount of resources needed by improvement work and will have learned a lot about the operation to apply the added resources efficiently.

In Part 2 of this post, I’ll link the Goldratt sequence to Lean advice to ‘Go See’ and several types of waste.

*See the presentation by M. M. Umble and M.L. Srikanth in Synchronous Manufacturing:  Principles for World Class Excellence, South-Western Publishing Co, Cincinnati, 1990, pp. 180-185.