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Process analysis and capacity Process analysis

and capacity
utilization in a dental clinic in utilization
Kazakhstan
Shamsuddin Ahmed 347
School of Business, Narsee Monjee Institute of Management Studies,
(NMIMS), Bombay, India, and
Francis Amagoh
Department of Public Administration, KIMEP University,
Almaty, Kazakhstan

Abstract
Purpose – The purpose of this paper is to investigate the service delivery system of a dental clinic in
Kazakhstan to maximize the clinic’s efficiency.
Design/methodology/approach – The study uses process analysis to determine the capacity
utilization and areas of bottlenecks in the dental clinic’s system.
Findings – The analysis shows that the most severe bottleneck is identified in step 16 of the 20-step
patient flow process. The system efficiency is approximately 62 per cent.
Practical implications – The study will help similar health-care organizations identify areas of
bottlenecks in their operational system. This would allow management to deploy optimal resources that
would improve systems’ performance.
Originality/value – The paper provides a framework for health-care managers to identify how to
reduce patient throughput time and increase patient satisfaction.
Keywords Dental hospital management, Health service, Capacity planning, Efficiency
Paper type Case study

Introduction
Service quality in terms of patient’s satisfaction is an ever more important objective in
the medical sector, especially in dentistry (Camgoz-Akdag and Zineldin, 2010). A critical
component for ensuring service quality in dentistry is efficiency in service delivery.
Customer satisfaction is influenced by perceived service quality, price, situational and
personal factors and by the comparison of expected service with perceived service
performance. Due to high competition, many dental practices are exploring possible
strategies to attract and retain patients. This calls for an increasing focus on
improvement in service delivery (Mazzei et al., 2009).
The current trend in dental care is the pursuit of excellence in service quality and best
practices. The perception of quality of care is based on attitudes displayed by staff, the
willingness of the facility to provide information, the attention shown by individuals
within the health-care facility and the amount of time required to wait for service (Yeh Competitiveness Review
Vol. 24 No. 4, 2014
and Lin, 2007). Increased competition has also forced dental organizations to become pp. 347-356
more market-oriented because most dental care providers offer similar services, but © Emerald Group Publishing Limited
1059-5422
often with varying levels of quality. The purpose of the study is to investigate the DOI 10.1108/CR-04-2013-0037
CR service delivery system of a dental clinic (Denta-Lux) in Kazakhstan. The paper
investigates the sequence of events in the clinic’s service delivery process and its
24,4 capacity utilization rate. Results of the study would help the clinics management
optimize its resources and improve the clinics overall operational efficiency.

Study context
348 Denta–Lux is a group of dental clinics in Kazakhstan, with its head office in Almaty and
subsidiaries throughout the country. While some patients make appointments before
arriving at the clinic, a number of them visit the clinic without appointments and expect
to be treated. The company is considered to be a state-of-the-art group of dental clinics
because it uses some of the latest dental equipments and uses dental staff from Western
countries. The clinical structure consists of the following sections: reception
administration consultation laboratory sterilizing room X-ray room and four medical
rooms. The company uses the latest bio-neutral technologies and materials, such as ZM
(USA), Koltein (Switzerland), Mani (Japan), Bredent and Penfert (Germany). For teeth
whitening, techniques such as special liquid Zoom and Luma-Arch-whitening with
halogen light are used. Denta-Lux is also unique in Kazakhstan because it uses Western
administrative practices, such as 24-hour registration for clients, 3 years’ service
guarantee, family fitness club membership for loyal clients, debit card or credit card
payments and membership for corporate clients at a discount. It also accepts insurance
payments from some of the global insurance companies, such as AIG, Medi-Service and
SOS International. The dental clinic performs the following functions: consultation
complete oral examination various tooth treatments such as extraction and temporary
or permanent filing, simple dental surgery, oral prophylaxis, simple gum treatment,
prosthetics and X-Ray.
The specialized divisions of the clinic are classified as:
• therapy
• orthopedics
• periodontics
• implantation
• children dentistry
• endodontic root canal; and
• diagnosis and oral radiology.

Figure 1 shows the flow of patients and the clinical procedures involved. The critical
variables in defining the capacity of the resources are:
• number of surgeries per doctor per day that can be performed;
• hours of operation in a day;
• average stay of a patient; and
• demand for service in a day.

Most of the resources are expensive for the clinic to maintain; consequently, it is
necessary to optimize their utilization. One of the problems commonly encountered in
maximizing capacity utilization and throughput is the difficulty in comparing capacities
of different types of resources and identifying the bottlenecks. This is because when any
 Process analysis
and capacity
utilization

349

Figure 1.
System flow of patients
through Denta-Lux

resource’s capacity is increased, the bottleneck seems to shift to another resource.

Similarly, if we increase the capacity of an existing bottleneck resource, a new
bottleneck may appear elsewhere. Therefore, it is very difficult to find an optimal
situation whereby each resource is performing at maximum capacity and the system’s
resources generate the maximum throughput for the entire system.

Literature review
There is almost universal agreement that dental patients, as with all customers in
the service industry, are more interested in service providers that offer high-quality
service with minimal waiting time. In patient-centered health-care organizations,
such as dentistry, patient satisfaction is crucial when planning, implementing and
evaluating service delivery. In fact, meeting patients’ needs and creating
patient-centered health-care standards are imperative for high-quality care (Badri
et al., 2009). Because service quality can be improved through innovation, it is
CR essential for organizations to establish quality systems capable of identifying
causes of poor service quality in ways that allow management to take measures that
24,4 enhance patient satisfaction.
Long waiting time in a health-care facility is a major indicator of poor quality
assurance. Long queue is symptomatic of hospital inefficiency and indicative of a
system’s inability to satisfy patients’ demand within a reasonable period of time
350 (Alhatmi, 2010). Thus, various studies have been conducted in an effort to reduce patient
waiting time. For example, Mital (2010) used queuing analysis to investigate service
quality in a hospital in India. Parameters used in the analysis include mean patient
waiting time, average queue length, incidence of long and short delays, etc. The study
was able to provide a basis for estimating the medical staff size and number of beds
needed to provide good quality service in the hospital.
Sambeek et al. (2010) reviewed 68 scholarly articles on decision-making models
used in the design and control processes of patient flows in hospitals. The analysis
shows that while 31 of the decision-making models used computer simulations, 10
used descriptive models and 27 used analytical models. The review also indicates
that descriptive models applied mostly to process design problems, whereas
analytical and computer models applied to all problems at approximately the same
level. Similarly, using SERQUAL instrument, Baldwin and Sohal (2003)
investigated the service delivery of dental care which most significantly impacted
on patient’s perceptions of service quality. Their findings indicate that patient
anxiety and fear, appreciation of punctual and convenient service delivery and
patients’ involvement in the development of treatment plans are factors that impact
significantly on service quality perceptions of dental patients.
Finally, Abelsen (2008) studied the relationships between dental clinics’ attendance
and individual and structural factors among adults in Norway. The individual factors
include various socio-demographic variables. The structural factors are population
density and dentist density. The findings suggest that access to dental services could be
improved either by regulating the supply side of dentistry or by compensating patients
for travel costs in accessing dental services. These studies and others suggest that
analytical techniques can be used to investigate the operational efficiency of health-care
delivery and serve as effective decision-making tools for managers to improve the
quality of health care.

Process of clinical care

The clinical care process identifies steps in the service delivery system. Patients visiting
the clinic go through the following stages:
• at reception, patient is greeted and personal details are collected;
• patient makes request about type of treatment needed;
• receptionist gives patient price list of various services provided by the clinic;
• patient is registered into the clinic’s system;
• receptionist checks schedule of staff to determine availability for patient
treatment;
• receptionist assigns patient to a consultant (dentist);
• patient selects required services and returns price list to receptionist;
 • consultant (dentist) is informed of waiting patient; Process analysis
• patient is transferred to consultant (dentist); and capacity
• consultation between patient and dentist; utilization
• patient is transferred to X-ray section;
• x-ray and other tests are conducted;
• results of X-ray and other tests are collected and shown to patient; 351
• results of X-ray and other tests are stored;
• dentist makes diagnosis based on results of X-ray and other tests;
• dentist implements treatment;
• dentist makes list of all services rendered;
• patient is transferred to receptionist;
• receptionist prepares invoice; and
• patient pays for treatment received.

Forrester’s (1963) structural model is used to develop a system approach to analyze the
patient flow system. This method allows us to understand how the feedback process
generates patterns of behavior within the management system. Such an analysis helps
us to understand the flow efficiency in clinic-patient care. Consequently, we are able to
identify the value-added process in the system and determine how to improve the
efficiency of the clinic’s service delivery system.

Process analysis
From process flow analysis, the essential elements of the treatment process are
identified.
Table I lists the steps involved in treatment from registration till completion
of the clinic visit. Using systems and process flow analysis, the unit load is the
activity times in minutes. A time study reveals that activity number 16 takes the
longest time and that it would take four dentists to clear the bottleneck in the clinic.
The throughput at this section is the lowest and this restricts the number of patient
handling at any time in the clinic. Over a period of one week, the time study shows
that on average 2 patients are served per hour in activity number 16 and that it takes
an average of 285 minutes to complete all the steps with a sample of 10 patients per
day. The number of unit in the resource pool (cp) is 1 per activity, except in activity
number 16.
During the 1 week observation, the time study finds that on average 1.5 to 0.5
patients are preceded per hour for activity 16. To determine the flow time over a
period of 1 week, the time study finds that the average time for treating 10 patients
from activity 1 till the completion of activity 20 is between 293 and 213 minutes.
Considering all activities as essential, it means that even if there are waiting or
delays, the value-added time is still considered the same (i.e. 294 and 213). With this
assumption, we may assume that the process velocity is 1; which is the ratio between
the flow time and value added time. Clearly, from the table it is observed that the
bottlenecks are activities 16 and 12. These are the critical resources in the clinic and
are the activities that pose difficulty in optimizing the clinic’s resources. Addressing
CR Theoretical Theoretical
24,4 Activity
Unit load
(Tp):
Unit load
(Tp): Time: 60 Number of
capacity per 60
minutes:
capacity per 60
minutes:
number average maximum minutes units (cp) Activities average minutes

1 5 5 60 1 Greeting clients 12 12
2 5 5 60 1 Get a request 12 12
352 3
4
5
10
5
10
60
60
1
1
Providing price list
Register
12
6
12
6
5 5 5 60 1 Check staff schedule 12 12
6 5 5 60 1 Make an 12 12
appointment
7 6 6 60 1 Prepare payment list 10 10
8 6 6 60 1 Inform consultant 10 10
9 6 6 60 1 Transfer client to 10 10
consultant
10 20 20 60 1 Consul Options 3 3
11 6 6 60 1 Transfer client to 10 10
X-ray
12 20 30 60 1 X-ray and other 3 2
analysis
13 10 10 60 1 Explain result 6 6
14 10 10 60 1 Store and Document 6 6
result
15 15 15 60 1 Set diagnosis 4 4
16 40 120 60 2 Do treatment 1.5 0.5
17 10 10 60 1 Record services 6 6
provided
18 8 8 60 1 Transfer to 7.5 7.5
Table I. receptionist
Dental treatment, 19 6 6 60 1 Prepare invoice 10 10
consultations and 20 5 5 60 1 Complete payment 12 12
bottlenecks 213 293 60 1

these bottlenecks would improve the systems’ throughputs and make the clinic’s
overall operations more efficient.

Increasing the number of units of bottleneck resources

Adding more units of the resources to the bottleneck resource pool will increase its
theoretical capacity. Because slow pool determines the theoretical capacity of the
diagnostics process, addition of new units to the current bottleneck resources pool
would create new bottlenecks. Changing the dental treatment sequence and reassigning
resources from bottleneck activities to non-bottleneck clinical areas requires greater
flexibility on part of the non-bottleneck resources to handle variation in flow or to
perform the work done by the bottlenecks. To make resources more flexible to serve
patients with adjustable resources requires investment in material resources, tools,
equipments, cross-training and so forth.
To improve the total theoretical capacity we must increase the theoretical capacity of
each bottleneck. The following parameters are defined:
• Theoretical capacity of a resource pool ⫽ (1/unit load) ⫻ (load batch) ⫻ (schedule
availability).
 • A resource pool is a collection of interchangeable resources that can perform an Process analysis
identical set of activities. Each unit in a resource pool is called resource unit.
and capacity
• Unit load of a resource unit is the sum of the work contents of all activities that
utilize that resource unit. Unit load is measured in units of time per flow unit. For
utilization
example, time required to serve one patient in the reception.
• The theoretical capacity of a resource unit is its maximum sustainable flow rate if
it were fully utilized during its scheduled availability, considering no idle period. 353
The theoretical capacity of a resource pool is the sum of the theoretical capacities
of all the resource units in that pool. Theoretical capacities of different resource
pools may vary. Because all resource pools are required to process a flow unit, no
process can produce output faster than its slowest resource pool. Hence, the
theoretical capacity of a process is the theoretical capacity of its slowest resource
pool. Resource pools with minimum theoretical capacity are called theoretical
bottlenecks.
• Capacity utilization ⫽ throughput/theoretical capacity.

Service blueprint
Poor service quality is symptomatic of service failures. A service failure occurs when
customer expectations are not met. Service failures may cause negative responses from
customers and reluctance to repeat purchase, all of which may potentially harm
business profitability or reputation (Chuang et al., 2010). Thus, a systematic approach
that identifies and prioritizes the critical service failure modes as well as prevents them
from occurring is very important and necessary (Lin et al., 2010). The service blueprint
is shown in Figure 2 and illustrates the dental treatment at the clinic as well as all the
services involved. The processes carried out in delivering this service can be categorized
vertically into four phases as follows:
(1) personal greetings and pre-patient arrival;
(2) service diagnosis and pre-consultation;
(3) perform service and treatment; and
(4) friendly closure and post-treatment.

The processes are also categorized horizontally according to the level of patient contact
and interactions with the clinic’s staff. They are classified as:
• level 1 or customer contacts;
• level 2 or onstage or visible contacts; and
• level 3 or backstage or invisible contacts.

In level 1, the patient arrives at the clinic and is greeted by the receptionist, whereby the
patient makes request for service. In level 2, after the patient makes a request, the patient
is advised to wait by the reception staff, and a determination is made whether the
patient’s request can be performed. If the patient’s request cannot be performed, the
patient is notified and possibly referred to another clinic, at which time the patient
departs the clinic. If the patient’s request can be performed, the patient is taken to the
dentist who performs the procedure. In level 3, invoice is prepared for the patient’s
CR
24,4

354

Figure 2.
Process flow of service
delivery in Denta-Lux

treatment. Here, the patient is notified of the cost of the procedure. If the patient is
satisfied with the invoice, payment is made and the patient departs the clinic.
In the context of Figure 1 and from market-oriented customer service viewpoint,
it is important to identify possible failure points within the clinic. Failure points are
where disruptions in efficient service delivery occur. For example, one possible
failure point is in level 1 where the customer may decide not to be treated in the clinic
because of unfriendly greeting or inappropriate behavior by the clinic’s reception
staff. Thus, customers may be made more comfortable by being offered newspapers,
magazines, beverages or informational TV programs at reception area. A second
failure point is the amount of time customer waits before receiving treatment.
Another failure point is the time the customer waits before receiving the invoice
after service. It is important that the invoice for payment be prepared as quickly as
possible before the treatment process is completed. Customers should be given prior
knowledge of the costs involved and billed accordingly.

Conclusion
This study reports on an investigation of the service delivery process and capacity
utilization in a dental clinic in Kazakhstan. The paper identifies all the steps in the
service delivery process and develops a service blueprint to identify and address
possible failure points in the system. From the analysis, it is observed that activities 10,
12, 15 and 16 are bottleneck areas as shown in Table II. The areas with the most
significant bottlenecks and causing the most delays in service delivery are activities 16,
12 and 10. It is therefore clear that the clinic’s management can mitigate the bottlenecks
and increase the system’s operational efficiency by deploying more resources in these
 Distance in Time in
Process analysis
Activity meters minutes Chart symbols Process description and capacity
1 – 5 Greeting clients utilization
2 – 5 Get a request

3 – 5 Providing price list

355
4 – 10 Register

5 – 5 Check staff schedule

6 – 5 Make an appointment

7 – 3 Give a payment list

8 – 3 Inform consultant

9 3 5 Transfer client to
consultant
10 – 20 Consulting

11 7 5 Transfer client
to X-ray
12 – 20 Implement X-ray and
other analysis
13 – 5 Show analysis result

14 – 5 Storage analysis result

15 2 15 Set diagnosis

16 4 40-120 Implement treatment

17 – 5 List all services made

18 2 5 Transfer to receptionist

19 – 5 Prepare invoice

20 – 5 Get a payment

18 180-260

Key Action Transferring Inspection

Delay Storage
Table II.
Treatment procedure flow
chart for Denta-Lux
CR bottleneck areas. More specifically, the clinic needs to deploy adequate number of
medical staff and dentists at activity 16 which has the highest number of bottleneck to
24,4 increase patient flow in the overall system.

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Corresponding author
Francis Amagoh can be contacted at: famagoh@yahoo.com

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