CASE STUDY CANADIAN ORTHODONTICS PRACTICE: BRACING FOR PATIENTS ;Dr. Jay Jayson sat down in his office, sipping a hot cup of coffee in preparation for what was sure to be another busy day in his well-established orthodontic practice. He loved seeing the smiles of his patients gradually improve throughout their treatment plans, but he especially enjoyed the final treatment appointment, when everything was removed and patients saw the finished results for the first time. It was rewarding to be part of personal improvement transformations that would last a lifetime! Although Jayson was reasonably comfortable with the operations of his practice, his desire for patientfocused care meant that he was always looking for ways to improve Canadian Orthodontics Practice (COP)both from the patients' perspective and from his own. While patient flow and capacity had rarely been discussed in his orthodontic training, Jayson's interest in these areas had recently increased; he hoped to grow the practice and was considering various alternatives that would also help balance his workload. As he waited for his first appointment of the morning, he wondered how he should prioritize the options: hiring more registered dental assistants (RDAs), renovating the treatment area, or even partnering with a second orthodontist. What results could he expect to see from each option or combination of options? Jayson had been pondering the best way forward almost every morning recently. And just like most mornings, the first of his many patients arrived before he could even finish his coffee. After the last patient of the day left, Jayson decided that since mornings always seem rushed, he would take some time to organize his thoughts before taking his children to their evening sporting activities. He thought it might be a good idea to first go through the treatment process from beginning to end. He knew the reception environment was comfortable, and that the patients felt confident in their treatment and the process, but he was concerned about the impact on patients of any delays in care. Occasionally, patients were late, or processes took longer than anticipated, and this delayed the care of subsequent patients. He knew that scheduling everything to the maximum was not the best approach, but he also did not want to underutilize his RDAs or even himself. It was a constant balancing act.PATIENT PROCESS Most of Jayson's patients brought someone with them to their appointments. The majority of his patients were young teenagers, who were frequently accompanied by their parents, but of his adult patients (who made up about 30 per cent of the practice), many also brought someone along. His clinic was located in a medicalractices building adjacent to a busy shopping mall, so parking was free and ample. Most patients checked in for their appointments on one of the wall-mounted computers and waited comfortably to be called. During a recent renovation of the waiting area, the practice had added video games along one wall, a cozy fireplace along another wall, and a popular free beverage centre with hot and cold drink options (see Exhibit 1a). After a patient checked in, one of the RDAs came and took them to one of the six dedicated treatment chairs. A bench adjacent to the treatment chair was available for those who accompanied the patient; these people were also free to remain in the comfortable waiting area (see Exhibit 1b for a picture of one side of the treatment area, and Exhibit 2 for a simplified diagram of the full treatment area). The patient's process consisted of three steps: 1. They spent four minutes with the RDA, who prepared the patient for the orthodontist's examination by settling the patient in and discussing any new concerns. 2. They spent up to five minutes with Jayson, who determined the recommended treatment; this could include follow-up appointment timing, which the RDA recorded on the wall-mounted computer. 3. Next, the RDA spent eight minutes implementing the procedures prescribed by the orthodontist: reattaching the wires to the braces, tightening to the specified target, or showing the patient how to put on elastics. Jayson's thoughts turned to the RDAs, since they stayed with the patients the entire time. For an RDA, the process lasted about three more minutes after each patient left while they sterilized the chair and prepared the working area for the next patient. Throughout the day, each RDA would continue to treat patients at a single assigned treatment chair. After treatment, each patient would book their next appointment at the reception desk. Depending on their treatment needs, approximately one-third of patients would have three-week recall appointments, another third would be back in a month, and the final third would have six weeks until their next appointment. Jayson had set up the schedule to try to make ongoing appointments as convenient as possible. The practice was open Monday to Thursday, and Jayson dedicated three times during the day to shorter appointments: before work and school, during lunch break, and late in the day. The rest of the day was dedicated to new patient consultations and appointments to either put on new braces or remove braces after the treatment was complete. He was comfortably busy, as patients were scheduled into most of the time slots, four days a week. The new patient consultation room included a treatment chair, so a new patient could be comfortably positioned for their initial assessment and then sit comfortably in the chair as treatment alternatives were presented. Although the primary purpose of the consultation room treatment chair was new patient assessment, Jayson considered using it as a treatment chair for his regular patients if necessary. With his notes on the current facility and processes completed, Jayson began thinking about key questions he wanted answered to help guide his future decision-making: Would hiring more RDAs help him treat more patients? Was there a way more patients could be seen without renovating the treatment area? Jayson realized that the answers to these questions about any actions he should or should not take would require deeper analysis and reflection. He quickly filled a blank note pad with details about the following aspects of his concerns: Page 3 W26090 Service Features Although the most important aspect of a professional service business was the competency of the consultant (e.g., the orthodontist), service industries were often judged by other criteria, as patients could not assess their technical quality. What were some key service features currently in place at Canadian Orthodontics Practice? Were there any opportunities for improvement in the service experience? Process Analysis A process flowchart diagram of the treatment process (see Exhibit 3 for an explanation of key operations management terms) showing durations and resource requirements for each step (e.g., RDA, treatment chair, etc.) would provide insight into some key decision-making metrics, specifically the following: How long was the RDA busy per standard appointment? How long was the patient busy? How long was the orthodontist busy? What was the patient's throughput time (i.e., their entire time in the system)? RDA Capacity Analysis A grid-timeline template charting one hour each of some possible scenarios would provide even greater understanding of key capacity metrics. For example, what was the utilization of the RDAs and the orthodontist? What was the cycle time (i.e., the average time between completions of successive units/patients)? What was the bottleneck (limiting factor) in the process? What was the capacity (i.e., how many patients could be treated in a one-hour interval) under the following scenarios? with only one RDA with two RDAs using all six chairs (i.e., with six RDAs) (determined without the grid) What was the best number of RDAs to schedule? What were the advantages and disadvantages of that recommendation from the perspectives of the orthodontist and RDAs and from the perspective of the patient? Hiring a Second Orthodontist Jayson was considering hiring a second orthodontist, and this possibility had many potential implications. Among these, he would need to consider the following: Besides capacity, what other factors would he need to consider before hiring a second orthodontist? What would the system capacity be with two orthodontists and six RDAs/treatment chairs used? What would be the capacity with two orthodontists and seven RDAs (using the consultation room as a treatment chair)? What were the advantages and disadvantages of these combinations from the perspectives of the orthodontists and RDAs and from the perspective of the patient?