An article in the Weekend FT magazine caught my eye by Gillian Tett (it’s the best of the weekend papers in my opinion).
Ms Tett related how twenty years ago, Nasa scientists hired the sociologist Diane Vaughan to study the causes of the 1986 Challenger space shuttle disaster. Vaughan came up with a concept she christened, “the normalisation of deviance”.
This idea suggests that disasters cannot always be blamed on a single, catastrophic decision by someone, but that they often occur because people inside organisations start to make numerous small decisions that gradually change their idea of normality. (Hence the “normalisation of deviance”.)
In the case of the space shuttle, Vaughan discovered that in the weeks before the shuttle crash, some engineers had repeatedly ignored safety guidelines in minor ways. To their colleagues, these misdemeanours seemed so small so no-one sounded any alarms. However, because the engineers kept getting away with these behaviours, their slippages started to seem normal. Or, to put it another way, the engineers’ definition of what was acceptable quietly changed and standards slipped — until the Challenger crashed.
So, what relevance does this have to a dental practice?
Well, in my experience of being a multiple practice owner and having worked with several hundred practice owners these last 15 years, folk who work in dental practices are great at the normalisation of deviance!
A dental practice should be process driven. It’s obvious really, delivering good clinical dentistry, great customer service and quality business administration are all fundamentally dependent on following processes. There really is no room for making things up as you go along. However, my experience is that gradually and silently, elements of the clinical process, customer service and administrative process get dropped. Now, the consequences are unlikely to be as serious as the space shuttle disaster – however, at best, dropping process will damage your business and at worst may damage your patients…
I suggest you make your own list of processes that you once introduced (for good reasons) and which have now been quietly dropped either by you or by your team. You may need to involve your practice manager as there are likely to be administrative and measurement processes that are no longer being applied. If you get forensic about this (and maybe you need to) you will uncover behaviours which were once rare and are now commonplace, which again could damage your business success or your patients.
Here’s some behaviours I find regularly in practices:
- Clinicians starting late
- Clinicians running late
- Clinicians discounting/changing the fees
- Clinicians moving patient appointments so they can go home early
- Receptionists letting the phone go to answerphone (especially at lunchtimes)
- Not collecting and analysing monthly KPIs
- Clinicians not asking patients to refer
- Clinicians not offering patients complete choices of treatment options
- Anybody looking at their mobile phone during clinical sessions or looking at the internet on the practice computers
- Hygienist appointments which have become about cleaning teeth rather than getting rid of periodontal disease
- Clinicians leaving Referral letters and Treatment Plans for days or even weeks
- Suppliers and Associates paid late
- Meetings starting late
- Practice credit cards used by principal for personal spending
And of course, all elements of compliance are prone to the normalisation of deviance and clearly here is where patient safety could be compromised. (I remember working for a weekend emergency clinic in the 1980s in Plymouth. A nurse handed me a pair of forceps which I clumsily dropped. She simply picked them up off the floor and handed them back to me!)
Hot to stop this? Well, I think practice owners in some way conspire with their teams to let processes go. They decide not to make a fuss about minor infringements for the sake of keeping the peace. However, soon they find that a bunch of let-go processes are causing real problems for the business or the patients (or the CQC inspectors). I suggest you operate your practice like Rudy Guiliani when he was New York’s Mayor, that is: “Zero Tolerance” of not following process!