Meeting the challenges of the ADVANCED PRACTICE

Nov. 1, 2003
This four-part series examines the problems — and solutions! — that are unique to the advanced practice. Part one is an in-depth look at how paperless charting can improve your bottom line.

by Jim Pride, DDS, and Amy Morgan

What defines an advanced practice? Is it the amount of high-tech equipment in the office? We at Pride believe it's more than just having the latest technology in your practice. One dentist we know invested in expensive towel warmers for every operatory so that each patient could be refreshed after treatment. However, the office systems were so chaotic that the staff never had time to get the towels! The doctor didn't have all of the basics in place that were needed to get the most out of the innovation. You need orderly staff, systems, and numbers to accommodate innovations and make them a part of your philosophy, vision, and daily routine.

Therefore, it's not the age of the dentist or the number of years in practice, or how modern the office looks, or how high-tech the equipment is, but the mastery that the practice has achieved over the basics that makes it advanced enough to support further growth. Here are some hallmarks of the advanced practice:

* The staff is fully trained.There are training charts and manuals, growth conferences, procedures for grooming new hires, and regular staff meetings and huddles for vital, ongoing, and safe communication. Staff members not only perform their jobs, but also run the systems, with each department functioning as a self-directed team, and each staff member feeling like a co-leader of the practice.

* The systems are not only functioning, but they are proactive in moving the practice toward its goals.The practice has excellent scheduling to build strong patient relationships and high production; effective treatment presentation; marketing for targeted patients that fulfills the practice vision; financial arrangements that are comfortable and convenient for the patient, as well as profitable for the practice; patient education and service that leads patients to value and to commit to comprehensive care and their long-term oral health.

* The cash flow comfortably meets the current needs of the business.This includes a well-compensated staff, as well as funding for the dentist's chosen lifestyle and retirement goals.

The advanced practice: Concerns and solutions

Dentists with advanced practices have already benefited from using the various managerial and leadership "hats" that allow them to reach an advanced stage much earlier in their careers. (For more information on mastering the basics, see our previous series, "The Hats of Dentistry," in the May, June, August, and September 2003 issues.) In this new series on the advanced practice, we will describe the different set of concerns that advanced practices have, as well as some solutions. They are:

1) Maximizing, or honing the staff and systems to the fullest extent for the greatest patient satisfaction, clinical excellence, and financial return. A popular way to maximize your systems is electronic charting. This new method streamlines the paperwork process in all office systems and improves productivity, efficiency, and profitability.

2) Innovating or kicking the practice up a notch of excellence with new technology, new-staff training, new-patient targeting and profiling, and new levels of clinical dentistry. In our next article we will spotlight how to implement a Cerec in the practice. Cerec opens the door to new and more efficient clinical choices to offer a targeted market.

3) Seamlessly transitioning or clearly defining your future direction, preparing your patients and staff for a transition, and ensuring that your practice statistics are positive enough to make your practice desirable in today's highly competitive buyer's market. In the last two articles of this series, we will focus on hiring the right associate and developing him or her as a partner in the practice. This creates unity of vision and focus that supports continued growth and the senior dentist's exit strategy.

Maximizing systems through new technology

With the big picture in mind, let's examine one solution: how to maximize the systems and staff for the advanced practice. The solution is to implement an electronic ("paperless") charting system. We want to introduce you to an exciting young dentist — Bryan Shanahan of Flagstaff, Arizona, (928) 774-2500. In just 12 years of practice, he has skillfully used the "hats of dentistry" to develop a thriving, advanced practice. He is financially on target to retire in 15 years at age 53, if he so chooses. Four years ago, he successfully implemented electronic charting. After that came Cerec, plus many other technological advances.

Dr. Shanahan made these major changes with a planned and realized return on his investment, as well as with rave reviews from his staff and patients. Dr. Shanahan's goal was to streamline and simplify the paperwork so that all the important information was gathered more efficiently, leaving the doctor and staff with the time to focus primarily on building strong patient relationships. The staff members were excited about increasing their relationship-building time, as well as reducing stress and increasing efficiency with the new system. They saw how each of their jobs would be personally enhanced by the innovation. Here's what they say about electronic charting:

"We have no paper charting. It's much more efficient with the computer. And no one has trouble learning the system," says dental assistant Marlena Berry. "When the doctor introduces something new, we never say, 'Well maybe it won't work.' It will work. We never feel we'll give up. And the doctor never waivers."

"I love the new system," says hygienist Rita Ortiz. "I don't think I can ever go back to the old way. Gosh, the new system flows so easily. When the doctor introduced it, we went right into it. I'd advise other staff members going through this kind of change to open their eyes and move forward and to leave their fears behind. Don't think 'I don't want to do it' or 'It's not gonna work.' It will work. Dr. Shanahan teaches us and gets us all in a positive mode about innovations."

"Our paperless charting is very user-friendly, and we have a great staff that was very supportive and understanding when I was learning the system. This is the only place I've ever worked in that's so team oriented. It's just a wonderful thing," says front-office coordinator Stephanie James, who joined the practice after it had gone paperless.

Dr. Shanahan has obviously developed supremely self-confident and positive staff members, which every dentist must do to implement innovations seamlessly and effectively. It's the staff that makes this happen.

"I wasn't always good at inspiring my staff in implementing new technology," Dr. Shanahan recalls. "Ten years ago, I bought a voice-activated charting system that turned out to be a $15,000 mistake. The team didn't buy into it, the hygienists didn't use it, and it was cumbersome for our needs. It failed after six months, but I made payments on it for four years. I stared at it for 10 years, because it taught me a lesson: If I buy technology, I need to do it the right way."

What is the "right way"? Let's look at how Dr. Shanahan, with the guidance of his Pride consultant, made a smooth and successful transition to paperless charting.

How to prepare for paperless charting

Before Dr. Shanahan could smoothly implement electronic charting, he had to completely overhaul his paper charts. Creating an ideal paper system that the team will use in a uniform and consistent way was essential in making the transition.

We at Pride Institute have inspected charts in many dental offices. We often find disarray in these most important written documents. There may be X-rays and referral slips from World War II, notes of every size and shape, random teeth, and other objects that would be better suited for a museum. We see staff members flipping through obsolete papers. Too frequently, the charting is inconsistent. Some charts need a hieroglyphics expert to decipher them. Going paperless with a dysfunctional charting system means you'll be transferring chaos. Our approach is to have an effective paper system, then to transfer excellence.

Charting is the single most important internal form of communication that dentists have. Without a good system, scheduling, financial arrangements, treatment presentation, marketing, continuing care, and patient care in general will suffer. Before going paperless, Dr. Shanahan needed to examine his current charting system. Here are the guidelines his Pride consultant recommended to evaluate his paper charting system:

• Easy access. Is the paper charting system user-friendly? Is there a specific order to the information? Is the information always placed in the chart in the same order for easy access? Is the information clear, concise, and complete? Can anyone in the office pick up a chart and find out everything necessary about the patient? Efficient, easy access to patient information is a cornerstone of effective scheduling, financial arrangements, and treatment presentation.

• Relationship building. Is the chart chock full of relationship-building information about the patient so that each patient experience can be customized? Are there forms to record the patient's dental concerns and complaints, payment history, and personal information? Total quality management demands that you know your customer thoroughly!

• Clinical completeness. Is the information in the charts clinically up-to-date and complete? Are forms used for recording the diagnosis and treatment plan, record of treatment, periodontal exams, etc.? Does the clinical information show not only the treatment the patient has had or is having but also the treatment planned for the future, so that both doctor and patient view dental treatment as a comprehensive, integrated process, rather than as isolated events? Clinical notes provide a black-and-white timeline for success.

• Risk management. Are the charts compliant with all legal requirements? Does every chart contain informed consent forms, privacy statements, and other documents necessary for proper risk management? Effective charting protects the doctor and the patient.

Dr. Shanahan had to go through the process of updating and purging paper charts to ensure they were consistent, clear, concise, and complete. He had to: a) convince his staff first of the benefits of effective charting; then b) help them develop the mechanics of what needed to be placed in the charts; and c) train them on the verbal skills necessary to obtain information from the patient, as well as from co-workers. Therefore, before the transition to paperless charting, the staff already knew clearly what information they wanted from the new charting system and why they wanted to obtain it, so that the change was easier to make.

Whether or not you go paperless, the mark of a sophisticated practice is a great charting system that facilitates office communication and patient care. So, is it time for spring cleaning in your office?

Determine the return on your investment — Another characteristic of the advanced practice is its ability to expect and generate a return on all of its investments. Any innovation that you introduce — a new technology, an additional staff member or an associate, a consulting firm, etc. — must bring a return. The return may generally be financial, but it can also be a reduction in stress or an increase in efficiency or other gain that is important to your practice. Before purchasing something new, define the kind of return on investment that you want from it and how you will measure it. Determining the return on investment before you buy something will help ensure your purchases are based on careful consideration rather than on impulse.

Since going paperless, Dr. Shanahan's hourly production has increased by 30 percent, and he and his team are working one less day per week. Another significant statistical benefit has been an increase in case acceptance, which the staff directly attributes to the increase in relationship-building time that they now have because of the efficiency of the new charting system. This is their statistical interpretation of their return on investment from electronic charting.

Use systems already in place to implement changes smoothly —Prior to converting to the new system, Dr. Shanahan had weekly staff meetings, morning huddles, and daily nonclinical administration time set aside for him and the staff. These established communication avenues were critical in discussing problems, ironing out kinks, and correcting errors in the new charting system. "It took three to four months to transition to paperless," says Dr. Shanahan. "During that time, the new system was the key topic of discussion at our meetings. We'd ask ourselves: 'How was our transition going?' We identified what areas were going right so we could acknowledge the change and reinforce it. We also held open, honest brainstorming sessions to discuss obstacles and problems. We all made a commitment that any failure would be seen as an opportunity, not a setback, so we created action plans to solve problems."

What are the results?

"We have a complete system, with 10 computer stations, digital radiography, and videography at our fingertips. All dental notes, diagnoses, treatment, X-rays, and photos are in the computer. The only things we keep manually are the health history, registration and consent form, and correspondences," explains Dr. Shanahan. "The new system takes me about half the time I used to spend on entering and pulling up data the old way. The same is true for my staff. This time-savings translates into increased productivity, fewer days worked, and — very significantly — more time spent with each patient to build strong relationships, which is what our practice is all about."

Now Dr. Shanahan has more time to do the things he loves — buying another dental office for the fun of revamping it and selling it; teaching seminars around the country for Pride Institute; spending more time with his wife and children; and, of course, finding more innovations to grow his practice and keep dentistry perpetually enjoyable for him, his staff, and his patients.

In the next article, we'll discuss how he successfully introduced Cerec, which required major system changes and brought radical improvements to his practice.

Meet the authors and profit from their insights on developing an ideal practice. They are instructors who conduct Pride's popular seminars on practice management and leadership. For more information on cities and dates, call Pride Institute at (800) 925-2600.

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