Internal Disorganization is Curable
More than any other type of business, it is important for a dental office to be self-managing.
This is not a statement made by someone who has spent his life in dentistry. In fact, only for half of the last fourteen years of a 30+-year business career have I been involved with dental offices in any way other than as a cringing, reluctant patient. Having begun my business career working for Ross Perot soon after he founded EDS while I was still going to college (and then several years after military service), I was exposed to one of the fastest-paced companies in the world. In fact, EDS and Perot were in the Guinness Book of World Records as the fastest growing company ever as late as the early 80’s. In addition, I have founded or been CEO of a half dozen other firms in various technical and finance businesses. Sorry for quoting from my resume, but I am attempting to make the point that I do not have a biased opinion toward the difficulties of dentistry. I have a rather wide general business background plus advanced degrees in business management.
Yet, I have experienced conditions in dental offices that are unique to the industry, conditions that other businesses do not face.. The reasons for this uniqueness are:
Pace. With the exception of a handful of dental practices that are highly specialized in cosmetic and/or restorative cases, dental offices are almost non-stop activity. Patients are greeted, seated (front), re-seated (back), treated, unseated, re-appointed (ideas for a rhyme here?), completed (pay at front), and de-greeted. Maybe, I took the attempt at rhyming too far, but the point is that dozens of patients daily must be taken through many stages in a dental office.
Small Staff. There is not enough income per patient to hire a huge staff to accomplish this task, as is the case in most medical practices. Therefore, in most dental offices a staff of half a dozen, or fewer, will perform each and every one of these steps for each patient as well as all other activities like cleaning, sharpening, researching, developing, scheduling, collecting, reassuring, instructing, answering phones, buying supplies, etc.
No Direct Supervision. This small-ish staff cannot afford the luxury of a full-time supervisor, so most tasks and sequence of tasks are performed by the individuals without supervision, detailed guidelines, and often without much training in the area of their responsibility. Each individual employee learns to perform her (usually) tasks based upon some slight training from the doctor or another employee who has almost no time to do this training. Experienced employees bring with them methods, which were used in other offices because that is what they know. Yet, each dental office has a unique personality as do individual dentists. What often results behind the scenes in a dental practice is a type of chaos that cannot be defined in English as well as by the Russian word “Bezobratsia”. (somewhere between bedlam and a four-year-old’s soccer match). Then, there are pediatric dental offices.
Patient Tension. Since I know I am “preaching to the choir” here, I will add simply that not all patients are happy to be in a dental office. Their attitudes are not always understanding of even the slightest miscue.
Managerial Inexperience. In fact, there are many dentists who are excellent managers. However, that is not the majority. There is little management training provided for dentists during their required schooling. Unless they learn from family, outside reading, seminars, or the pain of “trial and error”, dentists are generally not possessed with the best, most effective management expertise. Good dentists (at least the type I want to patronize) are caregivers by instinct. That is almost a completely different instinct from what is required for effective and efficient managers/supervisors.
The picture painted looks pretty dismal, but there are a number of highly effectively operated dental offices. How can this ever be? Each dental office I have seen which is efficient, effective, profitable, and still calm has one thing in common. The entire team knows precisely what to do under any set of circumstances and does not waver nor require instruction throughout the day’s activities. Watching from afar one gets the impression that they are watching a well-rehearsed play being performed. There are no wasted actions, not bickering, and no indecision. From a professional businessman’s perspective it is a joy to behold.
Usually, this type of practice is a result of people who get along well and whose personalities complement each other. They are typically a fairly mature team having been together for some time. There is mutual respect and very little gossiping or backbiting, if any. Amazingly, there is seldom a lot of daily oversight from the doctor who is busy seeing patients while this team is handling everything else. Unfortunately, even these excellent practices can slip back into “bezobratsia” when a key employee leaves. Most often, the entire structure and organization is in the minds of the individual staff members themselves. A new person comes on board with a different personality and different experience, and the office stress level increases dramatically.
The only way to initiate order and guarantee its continuity is for the office itself to be the repository of the effective procedures, systems, and protocols. There are five basic areas of a dental office that must be organized into protocols for an assurance of smooth internal operations in a dental practice effectively competing in the free world. These can broadly be defined as scheduling, hygiene (not all specialties, of course), finance, personnel management, and marketing.
If a dental practice has these five protocols customized to fit that practice’s personality, written in clear understandable language, understood and followed religiously by each member of the team, and updated regularly for changes in staff and/or business conditions, that practice can operate smoothly. Admittedly, there is still a need to employ the right people, but there is more leeway in this area even, if they have a script to follow in any and all situations. There are many really great employees who leave dental practices, or are asked to “shine their lights elsewhere”, but who could have been highly effective had there been a real structure.
We seem to forget how difficult it is to get a handful of people to agree on a restaurant. Yet, in many dental offices there is the expectation that these people will work together smoothly and pull in complete unison without either a full-time supervisor to work out the kinks, or a common set of instructions to guide them. Many people love improvisational theatre, and I can handle a little of it myself, but the vast majority of successful plays have a script, which in detail tells the actors every little move to make. That way different actors can be cast without the play suffering immeasurably. While the actors may be good or bad, good theatre is created where, as Shakespeare wrote, “The play is the thing.”
Having lived about half my life in and around Dallas, I still have a fondness for the local sports teams, and I endure their trials and enjoy their successes. With the Cowboys, Rangers, Mavericks, and Stars this has been a rather serious roller coaster ride at times. Now, the Mavericks (a basketball team with an owner that Dallasites would call eccentric, but others generally find obnoxious) have the best record in the NBA, and they even seem to have a chance to compete for the championship. Bear in mind, this is Texas where basketball is that sport you use to fill the time between football season and spring football practice. I can’t really believe these guys could actually beat the major elite teams like the Lakers, Jazz, Sun, Pistons, Celtics, etc. in the playoffs. Somehow, I suspect that Lakers are just lurking in the background until the playoffs, and Shaq will put about half the Mavs in traction, but who knows? The Stars did win a Stanley Cup several years ago. Miracles do happen.
Have a great week,
Hurston Anderson
813-963-7228
PS: Internal organization can be accomplished either through the managerial expertise of the doctor or other manager. However, it is also possible to get help from others. We have a range of workbooks, which are designed just for the purpose of providing internal organization. This is the Protocol Series. In addition, there is a special discount right now for those who are interested in the getting the latest (2002 Edition) Practice Management Cookbook, which is the most widely used dental office reference book in the world.
Our website now contains information on these books, as well as other services we offer, past issues of Weekly Tidbits essays, an on-line form for a Free Practice Production Potential Analysis, and a place to sell and buy through bid surplus dental supplies and equipment. We are just getting deeply into using our website, so comments and suggestions are welcomed.
Your Hygiene Department & Our Website.
Just this last week we made major additions to our website http://www.WiseDentist.com One of these additions was adding an on-line version of our Practice Production Potential Evaluation Form, which allows dentists rather discreetly to ask us to analyze the progress of their practices based upon the answers they supply as compared to our data collected from thousands of dental offices throughout North America. Many dentists have availed themselves of this free service, and we are happy to complete these analyses, which not only give a numeric goal but ideas (broad, admittedly) of actions that should help, if change is suggested.
I have personally looked at about three dozens of the forms, and there are some great dental practices out there. Also, of course, there are some dental practices that are in pain. There is one thing that is true for all I have seen, and that is that none are maximizing the potential of their hygiene department.
Possibly, some might think that we are using the wrong base data in our model. Maybe we are like the mother who was watching her son, a new member of a high school’s marching band, performing during halftime of a football game. She was the picture of a proud mother as she watched her beloved child carry his trombone that Friday evening. When she noticed that not everyone was marching together, she nudged her husband and exclaimed, “Look there. Everyone is out of step but our Joey.” We are not out of step, and we are not using the wrong base data. We are using data collected from actual dental practices with which we have been working. My expectations for hygiene departments are based upon exactly what is being accomplished daily in numerous dental practices.
Why do the vast majority of dental practices under-produce in hygiene? Part of the problem is that dentists expect too little from hygiene. Oddly, there are voices out there that keep lowering this already low level of expectation. Most of them are respected “experts” who speak on the circuit or write articles for magazines (printed and internet). They say that hygiene is simply a “loss leader” in a dental office. It is a required service you have to expect to lose money performing. Yet, simple arithmetic would retort that opinion.
It would seem that too many dentists do not really believe in preventive dental care. It is as if the whole idea of frequent and comprehensive prophy’s and exams are just a vast conspiracy to get patients to come into the dental office twice a year. I have not attended dental school myself, so maybe that is one of those secrets that all dentists know, but those of us who are not dentists haven’t been told. Yet, given human nature, somehow I doubt that any group could keep that big a secret. I rather assume that good dental care, care that is designed to keep patients healthy and eating with their own teeth all their lives includes professionally cleaned teeth, frequent exams, and in cases of early gum disease specific attention to that disease. These treatments fall primarily within the purview of the hygienists, however. Hygienists don’t own dental practices. Most dentists can get a lot more excited about a root canal and crown than they can about two quadrants of root planing.
Another problem is that an entire dental practice has to be perfectly coordinated and in complete agreement on the importance of hygiene treatment, or the patient will not believe either. Unless we are convinced they will not be convinced, and you cannot fake sincerity. In most offices only the hygienists themselves are true believers, and sometimes even they are just going through the motions. It takes a great deal of concentrated, coordinated effort to keep the hygiene schedule full without cancellations and no-shows, and the hygienist is just one cog in the wheel.
A hygienist anywhere in North America can produce at least $1,000 per day from 750 active patients and an appropriate number of new patients. I include in this total all revenue generated from the hygiene appointment including exams and x-rays. Are there any patients in any practice who should not be appointed for regular cleanings and exams? Is a dental office properly serving patients who are allowed to skip these appointments without reminders? Is there a potential legal liability when a patient is not at least reminded of the importance of regular cleanings and exams? Certainly, there might be patients who could remain healthy while extending there re-care (recall) periods to a year, but is longer than that good dental care? Be assured for every 12-month hygiene patient there is at least one with periodontal issues requiring 3-month hygiene. We have discovered that these balance out over 750 patients in every practice.
750 patients who have two hygiene appointments per year represent 1,500 hygiene appointments. A hygienist who works 8 hours per day for 4 days per week will be available to see patients about 1,536 hours per year. By including an appropriate mixture of new patient prophy’s and periodontal maintenance, plus essential exams and x-rays, it is easy to see how a hygienist can produce $125 per hour. Okay, it seems high when you have a situation where the hygiene schedule is pre-booked with healthy mouths. Eureka! We have seen one of the problems. I believe staunchly in pre-appointing, and I plan to write extensively on that subject with hopes of quelling the movement the other direction. It is not pre-appointing that is the problem. It is doing it lackadaisically. It is not leaving enough room for more productive treatments in the hygiene schedule. Sometimes, that is because the hygienist would rather see “her patients”. Put her on an incentive plan, and you can see that attitude change quickly. There is a technique to this that can satisfy both needs. Trust me.
I believe that there is an unnecessary loss of an enormous amount of income throughout dentistry due to under-production in hygiene departments. The sad thing is that dentists could see their practices grow and prosper greatly from better attention to this area. I believe hygienists should be paid 1/3 of their production. That means that if a hygienist produces $1,000 per day for 16 days a month, I believe that hygienist should earn about $50,000 per year. That may seem awfully high to some dentists, but which is better; paying $150 per day for $450 per day in production, or paying $333 per day for $1,000 per day in production? Stinginess in hygiene compensation is its own reward.
I saw the data from a great dental practice this week, exemplary, top 10% for sure. One dentist, five chairs, one hygienist, 2 assistants, and 1.5 administrative specialists are producing $80,000 per month from 1,800 patients with 25 new patients per month. My guess is that this dentist is doing very well financially, too, probably about $350,000 to $400,000 per year. Unfortunately, hygiene is only producing $10,000 per month or $555.55 per day (18 days for them). This means that more than half the patients are not receiving adequate hygiene care. Actually, this should be a two-hygienist office at least, but even if this single hygienist’s time could be effectively used, this practice would increase monthly production by $72,000 per year, and most of this would be net income, less only the additional supplies and hygienist’s compensation. Still, there is the issue of the untreated patients, but that can be step 2.
I am not finished with this subject, but I am beginning to exceed the time most of you have to read this type material, I fear. I will revisit this soon because it is so important. I do want to re-emphasize that passively ignoring the shortcomings in most hygiene departments or simply blaming it on the hygienist are like flushing money down the toilet and ignoring the genuine dental care needs of many patients. Don’t let it fester. Fix it.
I am getting to be a hockey fan, more and more. Although a native Texan where the only ice we had during my childhood was used in our tea glasses, I am married to a Minnesotan who with all her relatives actually understands things like “red lines” and “icing”. So, I watched some hockey these past few weeks. It was too bad that so much controversy surrounded these Olympics. I am especially sorry for the Russians whose grip on the Olympic games has been harder and harder to maintain as so many of the old USSR provinces have split away and as spending for sports has been forced more into the private sector due to their financial crisis. In my personal opinion, against great odds they still performed remarkably well, but it is difficult to accept a reduced position no matter who you are. Most of all, today, I want to tell a secret to all my Canadian friends. “Don’t tell my American countrymen, but I couldn’t help but be proud for you as you took home both Gold Medals for your national sport, hockey. Go, Canada!” Curling is really from Scotland, anyway, I hear.
Have a great week,
Hurston Anderson
813-963-7228
Visit http://www.WiseDentist.com and let me know what you think. There are viable solutions to difficulties in hygiene in the workbooks and consulting sections. Also, you will notice that we have completed the third edition of our Practice Management Cookbook, which we are offering at a substantial discount to previous cookbook purchasers, as well as to new purchasers. This website is still, obviously, a work in progress, and I have spent much too much personal time with my involvement. I wanted to delegate, I tried to delegate, but in the end I lost my patience (after losing a substantial amount of money, first). I will be less critical of others who fall into the same trap in their dental offices.
Happiness, Success, and Love in Dentistry
It was his first visit to this county seat just one county west, and things were certainly bustling due to the construction of the new dam. His parents and younger siblings had recently moved here because his father was supplying cedar charcoal for the WPA project. The Depression had devastated the family forcing the loss of the family farm originally acquired by his great-grandfather for service in the Texas Revolution, as well as the bank, grocery store, garage, produce company, and the big house in town. These setbacks had delayed college, so at 28 he had been teaching for just two years.
Fortunately, the past few years had been much kinder to all. This reunion was just a week before the school was to reopen and immediately after his three-month trip to Mexico visiting college friends and boxing for small purses along the way. At 6’3” and about 190, he was in the best condition of his life, and the tan he had gotten in Mexico along with the brand new shiny riding boots, white shirt, and tan jodhpurs (actually in fashion at the time he insisted much later) earned him extra long glances from the young ladies in the bus station. He pretended not to notice.
She had moved one county east from her original home with her parents and younger siblings because her father had lost his welding shop in the Depression, and there was always work for welders on the new dam. At 22 she was beginning to be considered an “Old Maid” by some in her family. Almost 5’10”, reed thin, bespectacled, and a bit bookish she was a definite challenge for most of the fellows around town. Her younger sister had already presented their parents with a grandchild while she was toiling away at the dry cleaners in town not even remotely interested in anyone romantically. But now was the best time of the day. The supper dishes were dried, and she had just settled on the front porch swing with a glass of lemonade to read while there was still enough light.
As he rounded the corner just two blocks from his parent’s home carrying his beat-up suitcase with hat pulled down low to keep the sun out, he glanced toward the porch of the house across the street. Their eyes met a little longer than normal, and he tipped his hat while smiling broadly. Later, he said she was the prettiest girl he had ever seen. Later, she said that he was fresh, obviously full of himself, and dressed oddly, but he was somehow interesting.
54 years later almost to the day she departed after several months of suffering. He really never got over her death, and when he died a little over five years later at Thanksgiving he had just been talking about how anxious he was to see “Mama”, his nickname for her. Times had not always been great for them and their five children, but there was always love. Love for each other, love for their children, love for their country, love for God, and love for humanity in general. It is the most powerful force on earth, the key to happiness, and it costs nothing but the courage to take a risk. If you want to be happy, find reasons to love.
Francis Hutcheson, the early eighteenth century Scottish philosopher who along with contemporary Englishman John Locke is often credited as the father of the modern democratic movement taught that “The desire to be moral and virtuous, and treat others with kindness and compassion; the desire to be free including political freedom; and the desire to enjoy our natural rights in society, as civil rights, are universal desires. Human beings want these rights because these are the things that lead to human happiness.” We in the West who live in the most powerful, most prosperous society in the history of mankind too often waver from these basic truths.
The way to find happiness in any enterprise including a dental practice is to do the right thing even when it is not easy; to treat everyone with whom we deal fairly, honestly and respectfully; to establish sound internal systems within which the entire team can operate effectively; and to recognize the beauty in the humanity of all. As the leader of an enterprise, we have unique opportunities and unique responsibilities. Among these responsibilities is protecting our staffs, patients, and families from disruption, which might be caused by people who are not capable of operating in a civilized environment. This includes belligerent and unruly patients, troubled staff members, and, even ourselves sometimes.
We cannot change others who are uncomfortable with a warm, caring, stress-free climate, so we must take the responsibility to replace them, but we can change ourselves. Too often, dentists cannot understand why turnover is so high, why morale is so low, why stress is so high, why production is so low, and why everyone seems so tired all the time. There is even the belief that really successful dental practices are running at sprint speed all the time. Our modern culture has convinced us that we can only succeed as a hard charging, take no prisoners, self-indulgent, money grubbing type-A person. Those with this personality sometimes do have success, but it is ephemeral, and it comes with no happiness whatsoever.
I think the problem is too often financially driven. Since we are running a financially inefficient practice, we think we must push harder to produce more. The real answer is to cure the disease not just treat the symptoms. When a dental practice has a great team (not the word only, but the reality), effective and efficient internal operational protocols, and a leader who will not get in the way, it cannot be stopped. We see this regularly. Dental practices that have never produced more than $65,000 per month click internally, and almost overnight they begin producing more than a million a year. Recent graduates open de novo practices, and they are consistently producing more than $60,000 per month before their second anniversary. The reason is remarkably simple. These dentists hire the right team that complements them, they install tried and true internal systems, and they do dentistry rather than trying to be managerial tinker-ers.
This installment marks the sixth year I have been writing these Weekly Tidbits of management advice for dentists, and I know I get monotonously repetitive sometimes, but that is because this is so very simple. Yet, it is not intuitive. There are only two reasons that a practice is not performing effectively. Either the team is incompetent reflecting on the hiring judgment of the boss, or it is working with ineffective procedures. 99% of the time it is not incompetence. It is never some uncontrollable external element that holds us back like demographics or the economy or whatever. In the words of the great philosopher, Pogo the possum, “I have seen the enemy, and he is we.”
I do not know anything about figure skating. I couldn’t tell a Lutz from a Salcow (sp), but I do know when the fix is in, and a very sad thing happened two nights ago in Salt Lake City. This is particularly disturbing because sports to me have always had a certain purity. The fastest runner wins the race. Somehow I hope to hear that this was all not political, that there are those who are reliable, unbiased experts knowing Lutzes from Salcows who can analyze the two performances and point out why the gold medal winners deserve their victory and the silver medal winners were properly treated. Both pairs seem like great competitors. Can there be nothing pure and honest, even the Olympics?
Have a great week,
Hurston
813-963-7228
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I cannot honestly state that it is the only way to provide the internal structure necessary, but I know that we have workbooks and services that do work. The most popular of our workbooks is the Practice Management Cookbook ($199.95 plus s/h of $12.50), which provides a reference source to solve daily questions. It is chocked full of sample letters, scripts for handling different situations, marketing ideas, personnel management tools with examples, and much, much more. Just the Policy and Procedure Manual alone will usually cost many times more. (fax cc#, exp date to 813-963-5974)
The Protocol Series is designed to help dental offices to hone and document their internal procedures in the five critical areas including scheduling, hygiene, finance, personnel, and marketing. Workbooks can be purchased individually at $179.95 plus s/h or they may be purchased as a set for $750 s/h included. It is not necessary to reinvent the wheel. (Fax cc#, exp date to 813-963-5974)
If you don’t think that a book will work in your office because it requires so much of your time or because you cannot wait, you really should give us a call. Our in-office consultants are the most reasonable in the country, and we have incredible references. Our clients always increase monthly production by more than $10,000 per month, and often that is not even their objective. By solving the internal issues the increase is automatic. To start the ball rolling, just email me that you want a free analysis. That will tell us both if we should proceed.
