TUBS AND TRAY SET-UPS
Everyone is looking for an edge. Everyone wants to lower their overhead and their stress level. Finally, everyone is looking for little known secrets of productivity. I think you will be surprised at how easy it is to eliminate one clinical staff position, meet OSHA requirements, and double your operatory efficiency.
At some point in every doctor’s career, you will find yourself looking at new equipment, talking to the local dental reps about expanding and/or moving to a new location so that you can add 4 or 5 more operatories so that you can take your practice to the next level. In this strategy you assume that if you have reached a production plateau with your current number of operatories and staff, that to go to the next level you will need to expand or relocate. This could be the worst move you could make and probably is the last thing you should do.
• Are you producing at least $20,000-$25,000/employee/month?
• Are you producing at least $25,000-$30,000/operatory/month?
• Is your overhead within the 50-60% range?
• Is each of your hygienists producing at least $1100-2,500/day?
If your answer to any of these questions is no, then it is not time for you to expand. Expansion will always spell disaster if the basics are not in place. Many years ago we had a doctor who had great production, good overhead, and the perception that he needed to upgrade his office. He had already purchased the perfect lot in his town, paid to have the plans drawn, and had everything out for bids. It was at about this time that he asked me what I thought about his plans. I took a few days to look at the cost, bids, location, plans and finally called him up to discuss his future. The short story is that he only had to produce 300% more each month to take home the same amount of profit. He basically had a “no way, that can’t be right” kind of response and I assumed he would go ahead with his plans. I didn’t hear from him for a month or so. When I did, he had actually put the lot up for sale, shelved his plans in order to maintain his profit margin, and figured out another way to take his practice to a new level. This is a smart guy who runs his practice by the numbers and always keeps the end in mind. He will always have choices in what he does because of his attention to the details of running his practice. His decision to not build was probably a turning point for his great profitability.
There is a myth in dentistry that implies that if you want to produce more, you need more staff and more operatories. This is not true until you meet or exceed the $25,000/Employee and $30,000/Operatory benchmarks, which actually does create a physical blockage. We can take a 6 op office with 3 doctors and 4 hygienists, open the practice to 6 days a week, divide each day into two six hour shifts and have each doctor doing $83,000/month, the hygienists doing over a $100,000/month and never have more than one doctor working at a time. This creates an incredibly profitable model with low overhead. While there are many strategies that make this possible, I wanted to focus on how to design operatory and sterilization efficiency thru the use of tubs and tray setups.
When I was in high school, my part-time job was working as an orderly and all-around do whatever it takes helper in our local hospital. I spent a lot of hours in the surgical arena helping in surgery and stocking, cleaning up, and preparing for the next surgery. For any of you who have not had these experiences, you would be surprised at how sparse the surgical suite is: Light, table, and hookups for gas. Everything else is brought in from a central sterilization area. Every procedure was standardized to allow a specific set-up for each situation. Once the surgery had begun, the goal was to never need to bring in any additional personnel, supplies, or instruments. This requires planning, speed, and efficiency to consistently produce a successful outcome.
To my surprise, when I graduated from dental school in the 70’s, I was sold the Pelton-Crane Executive delivery system. I was told that is was the state of the art in Dentistry. It was 8 feet wide with rear delivery system, drawers, amalgamator, nitrous, and about 20 drawers to store everything you could possibly need for any procedure. Unlike the hospital, we were told to keep everything in the operatory. In this way if something comes up that you did not plan for, it was right there. It was contaminated, cluttered, and disorganized, but it was right there.
Fast forward a few decades and we start to see a change. It just never made sense to me not to go back to a hospital model. In the early 90’s dentists were page one in the newspapers, and headlines on the Sixty Minutes TV show for not sterilizing our hand pieces. Running scared, we started to wear scrubs, gloves, protective shields and masks to look like a “real doctor” in order to deflect criticism of our lack of sterilization and general cleanliness. Yet, even today we see current operatory, sterilization, and storage designs that still look like the 70’s. Face it: If you store stuff in an operatory, you cannot meet OSHA standards of sterilization. Open a drawer and touch something, fail to barrier or wipe down, and wait 20 minutes and you are violating protocol. We’re not mentioning the fact that those drawers swallow up materials that seem to remain there past their use before date: Wasted materials, poor strategy, and an antiquated protocol.
Let’s set contamination and sterilization aside and look at just the ergonomics of cleaning and preparing the operatory for the next patient. How long should it take to dismiss, clean, restock, seat, bib and begin with the next patient? I see schedules with 20-30 minute turnover times. How can we improve on this and still be efficient and effective with our system?
Let’s start from scratch and assume that we have an empty space. No technology, no cabinets, no sinks, no cubbyholes or equipment. Just an empty room in which to plan for the most efficient use of space while keeping in mind our desire to be able to turn it quickly and still meet OSHA standards. We want the most efficient use of space while still retaining the feeling of a quality open operatory.
Probably one of the smartest people I know is Dr. David Ahearn who has dedicated himself to de-cluttering a disorganized and congested operating suite for a dentist. His company, Design Ergonomics, is the leader in space efficient dental office design. The trouble with change is that we all “filter” what we read, see, and hear through our past experiences and prejudices. We need to clear away those things that might keep us from being open to new ideas and ways to make our practices prosper. Put down this article, and go to www.desergo.com (800-275-2547), or go to https://www.youtube.com/watch?v=scyNPDvvJ0Q to watch a simple video of a “room morph”. In a matter of minutes you will see the normal operatory transform into a new, very efficient look. It’s OK not to like everything in the video. I still like madras shirts and Annette Funicello beach movies from the sixties. What I would like you to see is that many areas of operatory design are open to transformation into a better working model. What I hope you get out of the video is that there is a way to do operatory design differently than most of us currently use. This should open your eyes to the fact that the status quo will not suffice. When you are done with change, you are done. If there has been one constant in Dentistry over the last 30 years it has been change. Do whatever it takes. It is interesting to consider that the reason that the 70’S style ops are still around is that the dental suppliers need to sell you more cabinets to prop up their profits.
So how can we take what we have and improve on the flow and efficiency without making a huge investment in redesign? Step one is to remove everything possible from the operatory and relocate it to the sterilization area and storage closet. Try to pare down all the “stuff” that has accumulated in your operatory. Expect to get some push back from the staff. They, like you, have fixed ideas and feel uncomfortable with change. Whenever making changes, always list the benefits it will bring and try to involve the staff at the earliest part of its inception. You will get a better result when the people you are managing own the process. Let it be their idea. The goal here is to remove everything so that whatever is left can be covered with a barrier. Barriers are more efficient to place and remove allowing a faster turnover without having to spray, wipe down, and wait. To save money in our office, we went to a dry cleaning supply company and used shirt bags for covering trays, sweater bags for x-ray heads, and coat bags for carts and chairs and stools. We tried to cover everything. We could turn a room in a couple of minutes. Once you have removed everything from the operatory that you can, be sure and resist the urge to let it refill. Instead, improve your tub and tray set ups to reflect any shortages of supplies or instruments or changes in clinical procedures. Constantly improve the system to make it as efficient as possible.
Let me describe what our operatories contained prior to starting any procedure. The operatory design was by the Pride Institute and had two rear openings with a power panel between them. No doors. The chair faced a widow spanning the entire width of the room. Track light, X-ray mounted on the power panel at the rear of the chair, rear delivery system using an Adec cart, Nitrous unit, cavitron/prophy jet, electric hand pieces, CPU under one of the side cabinets containing a sink, with two monitors (one for the patient, and one for patient information). There was an intraoral camera and curing light hung from the Adec cart at the twelve o’clock position. The only other thing in the entire operatory was a carpule warmer. With this list, you must realize that everything else is brought in and removed on a tub and tray set up.
TUB and TRAY Set-ups:
Let’s take a look at what is on a tray and how we set up a tub and tray specific for each procedure. You can go to www.zirc.com and see every type of tub and tray you could imagine.
The Sterilization area is divided into dirty, clean, and sterile areas. The tray and tub setups are located in an upper cabinet on the sterile side. Everything that would go in the tub or tray is located in drawers below the cabinet on the sterile side for easy access. These drawers are restocked from our bulk supply closet every few days. Philosophically, we have enough trays that we could probably go all day without sterilizing. We don’t, but we could. The same was true for hygiene also. Extra instruments don’t get sick, take maternity leave, complain, or ask for raises or benefits. Buying equipment and instruments to eliminate the need for extra staff is always profitable. We probably had 20 or so hand pieces, with 40 or so tray setups (NOTE: Every tray was color coded for each procedure. The hygiene trays were small, half size trays color coded for each hygienist because they wanted to make sure they had the instruments that they had personally sharpened and used previously. People are visual learners so color code everything and be sure to take a picture of each set up so that they can be laminated and posted so even a 10 year old could get this right.)
1. Basic tray set up: This is the first and foundational tray set up that was used in every procedure. Everything from fillings to C&B and endo used this tray. It was a standard size Zirc tray with no dividers, just flat. It contained, 2 mirrors, 2 cotton forceps, 1 explorer, 1 scaling instrument, 1 plastic instrument, ½ Hollenbeck carver, slow speed hand piece, high speed hand piece, 6 cotton rolls, syringe with needle, McKesson medium mouth prop, universal clamp, pliers, rubber dam (2) with frame already attached, bur block with #6 round, #2 round, 2 KS 2 diamonds, 2 great white crosscut carbide burs, football shaped and small flame shaped finishing burs, and a straight 15 flute bull nosed finishing bur (all doctors in the practice agree to the bur set up and no one adds or takes away a bur without everyone agreeing), bib, and a few 2×2 gauze.
2. Composite tub: We used the standard tray and the assistant would bring a tub with sectional matrix, blue rubber cups and discs for polishing, flex discs for anteriors, and compules of posterior composite, and syringes of all colors for anterior composites.
3. Crown and Bridge tub: We add a tub with a gun rack (Plexiglas stand with a place for heavy body, and light body impression material, blue mousse for temporary impressions, and our material to make temporaries with several shades, along with dual arch impression trays), two sizes of retraction cord, Cut-Trol to control bleeding, Accu-film carbon paper, and Vita 3D shade guide. Add anything else you might only use for C&B.
4. Endodontic tub: Medidenta 1500 ultrasonic endo hand piece, Gyromatic reciprocating hand piece for blocked canals, regular rotary hand piece, files, paper points, Thermafil, gutta percha points, EDTA, endodontic sealer by Brassler, and rubber dam and supplies. Once again, add anything you might use for an endodontic procedure.
5. Oral surgery trays: We had three separate trays. One for lowers, one for uppers, and a special set up for wisdom teeth that included more elevators, striker hand piece with burs, material for bone augmentation, surgical aspirators, and gauze.
In all three set ups I always included a diabetic syringe to load a couple of cc’s of Dexamethasone to inject into the buccal fold following surgery for quadrants of dentistry to prevent swelling, muscle trismus or post op soreness. I trust you’re getting the idea here. Create a system, refine it, standardize it, and then take photos of the setup once you have it the way you want. Post the photos in the sterilization area until the set ups become second nature. Also place photos in your office manual along with your job descriptions. If you find that you are sending your assistant out of the operatory to fetch something after starting a procedure, then add it to the set up. You should not have to stop or interrupt a procedure once you start. Take the time to refine the setup and perfect it.
The key is that everything is brought in and taken out of the Op. Everything is color-coded and all of the tray set-ups are assembled the day before, not as you go. In other words, there are dozens of these in the cabinets ready for anyone to take down and go. We used bur blocks that were also coordinated with every doctor so that every bur that we use was on there, but we were very fugal about making sure the selection was efficient and effective. Nothing extra, nothing left out. In fact, if you run in to a situation where you need an instrument 3-4 times a month that is not on your set-up, add it. I want to make sure that you never have to leave the patient or send your assistant to fetch anything that you need to do a procedure.
Make this fun, organized, and don’t short change yourself by not investing in the instruments you need. This is how you Summit.
Michael Abernathy, DDS