by Dr. James R. Pride and Amy Tuttle-Morgan
When we discussed a series of mini-articles with Dental Economics' editor Dr. Joe Blaes, he requested something quite different from typical practice-management writings. Knowing we keep monthly statistics on hundreds of clients, Dr. Blaes asked for a behind-the-scenes account of the link between the management techniques we introduce and their direct effect on production, collections, and practice success. After hearing numerous accounts of our improving dental practices, Dr. Blaes wanted to know how we achieved the results that we - and our clients - claim. And so this series was born.
These articles will reveal powerful concepts not commonly used - and the all-important implementation of them - which have made so many dental practices more successful. The facts and figures we give are true, only the names have been changed to preserve privacy.
Our six articles will describe the story of one dentist on a year-long journey of practice growth. This general dentist (we will call him Dr. Bob Johnson) approached the Pride Institute a year ago with an urgent concern. He had just restructured his debt to help finance his retirement and felt unable to meet the new obligations with his old paycheck. Dr. Johnson also wanted to strengthen his leadership skills. Like many dentists, he didn't know how to ask his staff for the things he needed and that frustrated him. He, in turn, frustrated his staff by encroaching on their lunch breaks and after-hours time to complete the day's schedule.
Dr. Johnson has always been a competent, caring dentist who neither has a million-dollar practice nor wants one. He is a human being - a dentist who loves his work and enjoys chat time with patients who are also friends. Nevertheless, Dr. Johnson was dreaming of working smarter, not harder, in a way compatible with his personality. He understood that he was a businessman who was also a dentist. His clinical skills were not in question, but he knew he had a way to go with his business skills.
Imagine his surprise when we suggested an annual plan not only to service his debt and fund his retirement, but also to give him a $36,000 raise, boost staff compensation by $25,000, fully pay his tuition, increase his production from $486,000 to $590,000, and work three fewer days as well as fewer hours each day doing it! We also built continuing education, morning huddles, weekly staff meetings, and a daily "admin" period into the existing schedule. We eliminated the half-day of administrative work on Fridays so the doctor could be at home with his family and budgeted $20,000 in leasehold improvements and equipment purchases. And we did not want Dr. Johnson to give up his visiting time with patients or to become anything but the dentist he chose to be. His response? He thought we were crazy!
A year later Dr. Johnson has achieved the very goals he thought were impossible. Any motivated dentist can accomplish this. How does a stunning success story like this happen? In this and successive articles, we'll explain the remarkable story of Dr. Johnson.
Half of any equation in a dental practice represents the patient's clinical needs and the primary reason for being a dentist. The other half represents the business needs of the practice, because it is difficult to provide the appropriate care if the needs of the enterprise are not being met. The tool that sets the business goals for the year and directs everyone's actions is the annual plan. Without goals, which become finish lines, dental team members never know if they have done enough.
The proper approach to annual planning is to budget the year's expenses as if making a Christmas "wish list" of things you'd like to have, then develop a challenging, but achievable, annual plan to meet them. This mindset directly contradicts that of most dentists, including Dr. Johnson, who said, "I make a certain amount, so let me learn to live within it."
The Pride Concept is to live not merely on what is leftover after the bills are paid, but to produce what is needed for both business and living expenses. We helped Dr. Johnson change his thinking to, "This is what I'll need to live the way I want to, and here's what I have to produce to do it." This new para digm stretches the limits of the possible.
Another Pride Con cept is: Intro duce changes incrementally by phasing them in gradually during the annual plan. Achieve great things by proceeding in small steps. Rather than arrive like a bull in a china shop to topple the established office routine and to overwhelm Dr. Johnson and his staff, our approach was more subtle, leading to a Corollary Pride Concept: Do not try to change all of the systems and staff behaviors at once. Instead, make one or two fantastic improvements in the practice. These first successes enable everyone to accept management improvement as possible and nonthreatening. We call this quick dose of easy-to-swallow medicine a "sudden-impact plan." For Dr. Johnson, with his newly acquired debt, our sudden-impact plan focused on boosting production.
The expenses we budgeted required the doctor's daily production to rise through the year from $1,950 per day to $2,800. While an increase of nearly $1,000 a day may seem extreme to some, we saw - and the doctor realized - that it was within his capabilities. We achieved this incrementally with a first-quarter (Q1) goal of $2,200 per day, which would service the new debt and pay Q1 expenses. We further broke the Q1 target into monthly goals and helped Dr. Johnson and his team achieve them in four simple ways:
Fee increase. We analyzed Dr. Johnson's fees and found them to be unacceptably low. Because the practice was engaged in a formal program of improvement, we felt justified in raising fees to the 80th percentile for the area. While this fee level is less than we ultimately wanted for the doctor and, all of us believed, less than the quality of the doctor's services warranted, the 80th percentile certainly would be achievable and a big win for the staff. We also were careful not to increase fees too much at one time, as this could be detrimental to the practice. The fee increase accounted for one-third of the first quarter's production increase.
Preblocking. In Q1, we focused the staff on only one management technique, but a powerful one: preblocking the schedule. Targeting $2,200 in daily doctor production, we calculated that a large percentage should stem from significant dentistry of a crown fee or higher. With a Pride Institute formula, we determined that the practice needed 2.5 preblocked appointments per day, or two on two days and three on the other two days of the four-day workweek. The staff's challenge was to fill these preblocked appointments with procedures of a crown fee or higher. Preblocking avoids schedules in which the doctor performs new-patient exams all day, with very low production, as well as days in which the doctor performs difficult procedures all day, which are both physically and mentally exhausting.
The balanced schedule is ideal because it meets goals and avoids the problems of underproduction and overproduction. Dr. Johnson thought that his staff members were already preblocking, but the truth was that it only happened occasionally. The Pride Concept is: Preblocking needs to occur each and every day, without excuses. This requires a high level of leadership skill, which we spent a great deal of time developing with Dr. Johnson.
Ideal-day scenarios. In order to teach the staff members how to schedule to the production goal, we asked them to compose "ideal-day scenarios." These were sample schedules of various procedure mixes that filled the preblocks and met the daily goal. The scenarios were the staff's finish line. Another Pride Concept: Always create a finish line. Often we find no goal line in a practice. So, even on high-production days, the staff lacks a feeling of achievement. We wanted to avoid that by clearly defining goals for success. Notice that the staff - not the doctor or consultant - created the scenarios. Empowering the team is essential to management improvement; therefore, we (the Institute and the doctor) guided the team in solving problems, rather than doing it for them. Defining goals in terms of ideal-day scenarios is achieved by applying a leadership concept.
Decreasing new patients. We preblocked for new patients to reduce their number from 27 to 15 per month. We aimed for quality, not quantity, by targeting a patient profile that fit Dr. Johnson's vision. This vision called for patients who wanted long-term care and agreed to a comprehensive exam, rather than episodic treatment. This is not easy to do and can only be fully achieved if the staff develops superior listening skills and an exceptional interviewing process for new patients.
For that first quarter, we targeted Dr. Johnson's daily production to rise from $1,950 to $2,200. He actually achieved $2,156 per day, an outstanding achievement slightly short of the goal. The shortfall is explained by the transfer of periodic exams from doctor to hygiene. (The practice had been crediting hygiene checks to the doctor, while we include them in hygiene production.) This accounting transfer boosted daily hygiene production from $600 to $853, despite our having no goal to improve hygiene in Q1. Therefore, the total office production for Q1 actually exceeded the goal.
Dr. Johnson's production rose with fewer new patients, because needed treatment was already diagnosed in the practice. At this point, we did not change the doctor's new-patient exam or case presentation, although they needed improvement.
We reiterate the need to tread slowly, rather than bulldoze a practice with too much change all at once. Dr. Johnson's staff met the goals by scheduling the doctor's normal amount of diagnosed treatment more efficiently. To fill the preblocks, treatment that was normally spread out was performed sooner, which is a great benefit to the patient as well. The doctor produced more diagnosed treatment per hour on fewer patients. The resulting higher production per hour also made it possible to reduce the number of hours worked.
The practice's average total production for the year prior to starting management improvement was $40,501 per month. In the first three months of the new program, the practice achieved, respectively, $44,760, $41,732 (working fewer days), and $47,065.
In our next article, we'll explain the one extra thing we did in the third month to spike Dr. Johnson's production almost 20 percent from the previous year's average.
For more information on improving your practice using the methods described in this article, call Pride Institute at (800) 925-2600.
- Produce what is needed for both business and living expenses.
- Introduce changes incrementally by phasing them in gradually during the annual plan.
- Do not try to change all of the systems and staff behaviors at once.
- Preblocking needs to occur each and every day, without excuses.
- Always create a finish line.