When I introduce agile I do that through a nice little quandrat originally from the This is Lean book by Pär Åhlström and Niclas Modig, and visualized by Håkan Forss. I’ve wrote about it here. This post will only focus on the top left triangle - where we focus on maximizing resource utilization.
But I’ve noticed that personal stories sticks better and I have used a story about my dentist to show an example of a setting that focuses heavily on the resource utilization.
I lately was called back to a checkup at the dentist and did some further research. It was a fascinating peek into a world where many people was working hard, smart and diligent to achieve an outcome that was not any good for me as an end customer (aka the wrong thing, in my book).
I wanted to share this story with you, as I think it teaches us a lot about where focus on resource utilization can lead us… everyone working very hard to do the wrong thing.
Part I - the emergency
Here’s the original story to start with: I woke up an early morning in February (2016, I think) with the worst tooth-ache in my life. I was actually screaming out loud at one point. I headed on to the “emergency dentist” and promptly x-rayed.
“That’s an old root canal job that has gone bad. It needs to be redone.”, the nice dentist told me cheerfully. “Great”, I said through the veil of pain. “Do it! Do it now - I’ll pay you whatever you want”, I calmly responded. “Ap ap ap”, the dentist smiled behind his protective mask. “You have crown on your tooth and we need to drill through it. It’s really complicated and hard and needs to be done under a microscope. There’s a dentist called Torbjörn that can help you. He is awesome”.
In the meantime I got painkillers and antibiotics and was sent home. As I stepped inside the door I called Torbjörn and begged “Please, Torbjörn, help me. I’m in pain! Can you do something”.
Torbjörn was a jovial, secure man and assured me “No problems, my friend. I’ll help you. Let’s see … today is February 12”. I heard him flip through, what must have been a big booking calendar… Many pages… And then suddenly
“Ok there we go.” He was back. “May 18th. 1130. How’s that for you”
Reflection on part I
Why did they do that to me? I was in pain for days and on painkiller for weeks. I actually had to wait 4 months until it was my turn.
Well… Torbjörn is a specialist only doing complicated root canal jobs. He is probably compensated pretty hefty for that. And the microscope he is doing his work with / through is … expensive to say the least. So the Swedish dentist department wants to ensure that he is being busy all the time. I know this. Because I asked him. And it turns out that if he has a one hour without a patient one day - they ran at a loss that day! For this reason, Torbjörn has a nurse to prep me (ah, well all patients) so that once he enters the room the drilling can begin. The dentist office also has 3-6 other dentist (all specialist, I presume), and three secretaries helping them to stack the schedule full. Reasonable, one would think, as one hour unbooked would mean a loss for the day.
I know this too, since I asked them, and sure enough; they we continuously and diligently ensuring that no hour in the day was unbooked.
This is what the second part of the story is about
Part II - the callback
Torbjörn fixed my tooth in 2-3 pretty advanced treatments and I was then asked to schedule a callback and checkup about a year later. When a year had past, one of these secretaries called me and gave me a timeslot, just a month from the time she called me, in September.
Sadly I was out of town that day and asked for a later slot. She sighed and started that same flipping-through-pages-of-the-booking-calendar again; “Well, the next available slot is … in … December 5. 1130-1145. It’s just a short check-up.”
I took it, of course, and last week I was there to do the checkup. I came early naturally since I didn’t wanted to miss that slot and risk another wait. But as I came early I couldn’t bare myself but started to interview and listen to the secretaries. I even found the time to tweet about it.
But sure enough, my observations since last time was correct, they all cheerfully told me. On average the dentists there was fully booked for the next 2 months. There was not even a check-up slot. Everything was packed full. The worked hard to do so, they told me.
They proudly told me that there was a waiting list for waiting. You could go on a list that they started to call through if one dentist got a cancellation, due to sickness, for example. “Then we can quickly call these people”, she pointed to a list with about 30 numbers, “and quickly fill that empty slot again.”
I also overheard, more than one, calls that went like this: Secretary: “Hi… Oh, it’s broken in half? Ouch - that sounds painful. Well… sadly, we are fully fully booked. The next timeslot is … next Thursday. Can you come in around 0745?” At this point, Torbjörns nurse, came out, moved me into the chair and Torbjörn cheerfully entered. He snapped 2-3 x-rays, looked at them for about a minute and I was on my way. I was cured!
Reflections on part II
The thing that was so interesting for me to observe and think about was that everyone here was doing an excellent job. They even innovated and evolved the way they managed the queue to ensure it never ran empty. They met each customer with great service and were almost singing “No we are fully-booked until March. But I can put you on the waiting-list, if you want.”
The waiting room was nice and had coffee and even an automated check-in system so that I didn’t have to interrupt the booking-function.
But what is the value they created? Busy dentists. No one there (at least not in behavior and words) was focused on the flow and value for the end-customer. If anything we were just slowing the busyness of the dentists down - that’s why Torbjörn often did other more important things, while I was prepped for his treatment.
All the patients calling in was in pain (I know I was, when I got to wait for 4 months) but could not be handled. Not because the system was overloaded but rather around the system was managed.
I didn’t get that far, but I’m betting that cost is an important factor when it comes to how the dentist office was measured for success. Probably also utilization of the available dentist-hours; such-and-such many SEK is paid to keep this office open and such-and-such many percentage utilization is the average per dentist.
Summary
The people, working at the dentist office, were nice, generally awesome and did a great job doing the wrong thing. Nowhere to be found was a focus of creating value for the patients.
The reason they did this is, most likely, because the system was setup to promote this behavior. End-customer-value was very far from the minds and actions of everyone in the office, even though they were nice and treated us with good service and respect. They might even want to focus on the end-customer-value - but the system was not set up to promote that. They, literally, could not do that.
What kind of behavior are the systems you are in promoting? Are those the behaviors that we want to have? The behaviors that our company wants, even? What can you, I, we do to accomplish a change there?