The Coalition Forces

Aug. 1, 1998
Every once in a while, change makes sense. The hard part is leading the charge - developing and implementing a strategy. But, as with any campaign, victory is sweet.

Every once in a while, change makes sense. The hard part is leading the charge - developing and implementing a strategy. But, as with any campaign, victory is sweet.

Michael R. Gradeless, DDS

More ways than ever before exist to increase your production. We can do big-ticket treatments with implants, full-mouth reconstruction, and smile makeovers. Laser curing-lights and air-abrasion systems promise to significantly speed up the smaller procedures. Video cameras, imaging systems, and operatory computers with new treatment-planning software can help you educate your patients. Manufacturers of equipment and supplies are marketing new procedures directly to the public and creating increased demand for dental services.

This demand will skyrocket as the huge numbers of Baby Boomers begin to require more and more dental services. Our practices are very busy places. Our gross production is spiraling upwards, and yet, we have to ask, where are the profits?

When corrected for inflation, dentists` incomes are rising very slowly. There have been periods over the last few years when our incomes have decreased. If all this demand is real and all this technology works, how can we increase the profits from restorative dentistry?

Two of the best ways to increase profitability are to add new procedures to the mix you offer, and to substitute higher-value procedures for those you previously performed at lower fees. This is why seminars on implants, full-mouth reconstruction, and cosmetic dentistry are so popular. It is obvious that the lecturers are good at what they are doing, excited about what they are doing, and increasing their profits. We`ve all come back from seminars and made changes that have lasted only about two weeks before we returned to our old way of doing things.

Our problem is not in learning new technical skills; it`s leading our staff to change and anchoring the change in our practice. It is more comfortable to do things as we have always done them and to believe that what works in Las Vegas or California just won`t translate to our practice.

The truth is, whatever change you want to make can increase your profits if you plan properly for the change. I know this can happen because we were able to change from a conventional restorative practice to a cosmetic/bonding-focused practice and increase both our gross production and net profits by over 30 percent in the first year.

While I am proud of most of the clinical results, I don`t believe they are any better than what you can achieve. The reason we were able to profit immediately from the changes in our practice and to permanently integrate the changes into our practice was because of our preparation, training, leadership, and management.

Learning new clinical skills is only a small part of the process necessary to integrate change into your practice. It is easy to learn new clinical skills; dentists do it all the time. What we don`t know how to do is anchor the change. We must make the transition from the way we practice today to the way dentistry will be practiced in the future, and we must find a way to make this change a permanent part of our practice.

Problems with gradual change

The first mistake we make is to try to phase in the change. We still do some procedures the way we always have done them and try to select a few cases on which we practice our new skills. Gradual change diminishes over time. We really want things to get better just the way they are, so we gradually change back to business as usual. Easing into change also causes resentment among staff members. Gradual change requires them to maintain multiple instrument setups, think about multiple-procedure protocols, and simply do more work.

If you want to make a lasting change, you must do some homework first. Take whatever courses you need, do some reading, and talk with other practitioners to educate yourself. Then, take some time to develop your vision of how the change you want to make will fit within your practice. Once you have the education and vision, you are ready to get your staff on board.

Guiding coalition

The first step in getting your staff to go along with the change is to develop a guiding coalition. This means that staff members must help to get the change started. You know which employees believe in you and believe in your practice. They always are ready to help with new ideas. They are either committed employees or willing, compliant employees.

I recommend that one of your guiding-coalition employees be your appointment coordinator. Why? You treat whoever is in your chair and perform whatever procedure is listed on the day sheet. Change won`t happen for at least the next two or three weeks because there aren`t enough openings on the schedule. If you want change to happen, your appointment coordinator must schedule it. If your appointment coordinator is to schedule new procedures, other staff members also must be excited enough about the change to communicate this excitement to your patients.

I developed my guiding coalition in a staff meeting. To develop your guiding coalition, you must communicate your vision with enthusiasm. If you don`t have regular staff meetings or you are not an enthusiastic individual, I recommend you allow the same people who trained you to train your staff.

After you have been to the wonderful seminar, take your employees to the same program that motivated you to change. Yes, it will cost you money, but as the Chicago Bulls have discovered, no one ever said that winning would be cheap. In addition to getting your staff fired up, you will get much more out of the program the second time through. Select your guiding coalition after you see who is most fired up. The guiding coalition must be made up of at least two employees, but if you can inspire all your employees, making the change will be easier.


After you have communicated the vision and developed a guiding coalition, you must eliminate the roadblocks to your success. We saw cost differential as a major roadblock to posterior composites and resin-based or porcelain onlays. At every bonding seminar I`ve attended, I`ve heard many dentists say how much they wished they could do these procedures, but their patients wouldn`t want to pay more than they pay for amalgam. I used to believe this myself and I have found that it isn`t true; people will pay more for what they value, and they value tooth-colored restorations. If you believe that you can deliver high-quality, tooth-colored restorations and you can communicate that to your patients, they will want them.

For me to believe this, I had to take a very big step. I calculated the fee that I would need to build up a posterior composite following all the recommended steps. Then, I raised my amalgam fee to equal my new direct-posterior-composite fee. I was scared to death, but the results were amazing. Nobody complained! Absolutely nobody chose the amalgam over the composite! Patients loved their new fillings that virtually were invisible. When they saw the time and care I put into placing their restorations, they really didn`t think the price was too high.

My appointment coordinator loved having the fees identical. This made appointing the new procedure almost too easy. She would say, "When you come in for us to fix this tooth, do you want us to use a gray filling or the new material that matches your tooth?" The patient would ask, "What is the difference in price?" "Oh, the price is the same." For most patients, that was all that was needed.

When a cautious, skeptical patient would ask which we thought was better, our answer was, "The gray material has been used for over a hundred years and it is very good. While we don`t have that kind of track record with the new materials, there are several ways we think they will be better." If the staff member pointed to one of the new fillings in her own mouth, there was absolutely no question which procedure the patient would choose.

If you communicate your vision to your staff members, inspire them to believe in you, and give them the tools to communicate this vision to the patients, you can make whatever change you want in your practice.

The onlays were even easier for us to bring into the practice because they are a cheaper alternative to crowns. I found that issues of change and price are not nearly as significant as value. Price is not an issue if we communicate the value of our procedures.

There are other potential roadblocks - buying all the supplies you need, training your staff on the new procedures, and finding the time in your schedule to complete the learning curve. I purchased all the supplies I needed from the sales representative at the seminar I attended.

When my staff members saw all the additional steps required to bond posterior composites, they thought there was no way we could fit this into our schedule. Actually, this was a plus because my assistant became aware of how efficiently we must work together to make these procedures cost-effective for our patients.

Handling objections

Change brings objections. Handling objections requires that you and your staff anticipate the objections, plan for them, and develop verbal skills to deal with them. Mostly, you will hear objections about change in general - Why are you changing now? Why didn`t you change sooner?

When you answer objections, always try to talk about the benefit to the patient before describing your procedure. For example: "So that you can have the best of the new procedures, we have trained the entire staff on tooth-colored restorations." Rehearse staff members until they can explain your procedures exactly the way you want them to. Verbal skills are the key that will allow you to make the change while letting your patients know that you are aware of their concerns.

Measure progress

If a change is to become permanent, you must be able to measure your progress. You must create short-term wins for both you and your staff, and you must celebrate your progress. You and your staff will be doing a lot of extra work before you begin to see any results. You will spend a lot of money as the change unfolds. This investment of work and money always comes before any return. The return starts and builds more slowly than we would like. Unless you have some visible results, it is easy to lose your enthusiasm, just as you are about to reach the crossover point where the work and investment decrease and the return increases.

The goal of all this investment is to increase profits. If you cannot measure your results, you may find yourself working harder for a higher gross production while actually decreasing net profits.

We created a monitor sheet, which our appointment coordinator keeps up-to-date. This is a very simple form on which she lists the names of patients we diagnose as requiring the targeted new procedures. There is a column for the value of the diagnosed treatment, a column for the amount of the accepted treatment, and a column for notes. The notes section is for recording reasons patients give for declining or delaying treatment and for any positive patient responses.

This very simple monitor is a valuable tool for tracking the treatment-acceptance rate. Analyzing the patient comments can lead to improved verbal skills for handling objections, emphasizing the patient`s perceived benefits, and improving the case-acceptance rate. We share and celebrate these numbers and shoot for a case-acceptance rate of 90 percent. Celebrating in our office can range from simply giving out "high fives" to taking the entire staff out to lunch. These small celebrations improve staff morale and build teamwork.

Photography is another tool that we use routinely as a monitor. We use our intraoral camera to take before-and-after shots of virtually every bonding procedure we do. These definitely are worth far more than the time it takes and the cost of the film. Many of our staff members don`t get to see our results. When they see this parade of photos showing how much better teeth look after my restorations, they stay motivated and excited about our bonding procedures.

We are saving some of our best shots to create a photo album for the waiting room. Most of the other photos are given away to the patients, allowing others to see our work and promote our practice. This is an area we need to monitor constantly. When we stop taking photos, we gradually lose the staff motivation and the practice promotion. This is a good example of how we have to stay on top of all our procedures to make change permanent.

Anchor the change

Now that the background work is finished and the new procedures are being performed, it is time to anchor the change into your practice. Celebrate your minor successes, but don`t celebrate too soon. Now that you know how much time and materials the new procedures take, it is time to forecast expenses and set production goals. Nothing will anchor a change like seeing improvement in your bottom line.

At this point, it is important that you set standards for performance. It is time to raise the bar higher and increase the benefits to your patients.

Be the leader

Learning and instituting the procedures is something that you can do immediately. The increased profits, however, will come from your activities as the leader of your practice. As the leader, you must develop and communicate your vision, forecast expenses and necessary production, set standards of performance, train and manage, inspire and motivate, monitor the budget, and celebrate success.

In the first year that I made the change to cosmetic procedures, there was a dramatic increase in my profits. The change in procedures was not the only change I made in my practice. I also joined the Pride Management program, and did a lot of reading on business and management in general. Some of the ideas in this article come from the book, Leading Change, by John Potter.

Most dentists spend a lot of time and money improving their technical skills. This is great, but technical skills, business and management skills, and patient relationships really define a dental practice. Each time you improve your technical skills, look for ways to improve your management skills and your patient relationships. When you are improving all three of these legs of your practice, you will have significant practice growth.

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