The interesting thing about dentistry is that all of us face the same challenges. We all work in a 10 by 12 room, use the same instruments, hire the same types of people for employee positions, all deal with scheduling, insurance, cancellations/no shows, multiple types of treatments, etc. You name it. We, as a group, have much more in common than we have differences. The second interesting thing is that we all are on the same continuum. We start out just barely not dangerous, work as associates, continue to get education, expand the range of services, learn the tricks of the trade, realize that our dental education was woefully short on any business or leadership training, and hopefully commit to never ending improvement in our clinical results. Because of the tedium of this continuum we all face, many have overlooked the truth that at some point in our career our efficiency and speed should improve. Take a step further and you could deduce that at some point you will find that you can only lay bricks so fast and still get a great result. This is true for every clinical service you offer. Initially, in a practice, we don’t have to be very efficient or quick. We don’t really have many patients. But over time, the number of new patients should increase, the range of services you offer should grow, and if you are inspiring the people that come to see you, you will eventually find that you get booked further and further out. This is usually accompanied by one of two things. Your overhead continues to grow, but even with more patients you can’t keep up. The longer interval of starting treatment on new patients or your inability to get treatment done on your recall patients means increased cancellations and no shows as well as more and more patients yielding to attrition by going to another office that can get them back into the office for treatment within 4-10 days during a peak demand time. For most practices this just slips up on them and before you know it, they are booked out 2-3 months in advance. You stop marketing because you don’t have anywhere to put them on your hygiene schedule, much less to do any treatment that they might require. Time passes and without you realizing it, your attrition rate and lack of recall will cripple your practice and damage your reputation in the community.
It doesn’t happen overnight. Most times we never realize we’ve done it. Some of us have tried to improve, but all of us surely realize that at some stage we reach a point of maximum capacity due to clinical speed. When I was practicing every day, we would routinely have various doctors and their team members visit us. I remember being stopped by one of the doctors who gave me a blow-by-blow of the procedure I had just finished. He said: “Do you realize that your patient arrived at 8:00, and forty minutes later you had prepped number 19 for a crown, done a root canal, built up the tooth, taken the impression and seated the temporary, taken photos pre and post-op along with digital x-rays for the insurance, and the patient was out of the chair and paying at the front desk at 8:41?” My answer was: “I guess so. That’s about how long it takes most times. I’m not trying to hurry; it just ends up taking about that much time.” Now I’m not saying I never run into an endo that might take longer, but the average one is going to take 20-30 minutes, and we can do a single crown prep in under 30 minutes any day of the week. But, and there is always a “but”, everything is staged to make this happen. Everyone is responsible and contributing to the satisfaction of the patient as well as performing the procedures as efficiently and effectively as possible. This consistency is based on protocols and systems that are fine-tuned to be teachable, scalable, repeatable, and adaptable in every situation.
If you think about it, assuming that we have perfected everything else in a dental practice, clinical speed can ultimately limit the amount of production we can do in a day. If it takes you an hour to do a crown, and you had the perfect day of one crown per hour or about 8 crowns, the most you could ever produce on that perfect day would be 8 times the fee for a crown. That’s a lot, but my office would routinely do 1.5 to 2 times that amount. This included seeing a large number of with kids, 4 hygienists to check, and a variety of emergencies and various procedures during an average day. So how do you consistently lower the amount of time it takes to do the best crown prep you can do? You decide to do it. You make it a priority. It doesn’t matter what the service or procedure is, you want to make sure that you are efficient and end up with a great result. Speed and better results stem from competence and confidence in your protocols and services. Confidence and competence breed efficiency and effectiveness. No more prep and pray. This should eventually get you to the point that every procedure, along with any type of patient, consistently creates a sustainable successful practice regardless of the economy or any other external condition.
A few years ago, there was a multi-dental school research project involving the amount of time that the average senior dental student needed to actually prep for a crown. After all the research, they found it took an average of 4 minutes after anesthesia to actually “prepare” the tooth for a crown. Everything else was just cleaning up and taking impressions and placing the temporary, which can take a dental student a long time. So why does it take the average dentist somewhere south of 60 minutes to do the whole procedure? Why does it take any service you offer the amount of time it takes you? Have you really taken the time to study the what, when, and how of every component of your clinical protocols? Fine-tuning these areas is guaranteed to increase your productivity, patient satisfaction, direct referrals, and decrease stress. I have seen doctors take an hour and a half to two hours for just one crown. What could they possibly be doing for that length of time? You could vaporize a tooth in about 90 seconds with the right burs and an electric hand piece.
As an example, let’s take it step by step and walk through each stage of a 30-minute crown prep. While we have narrowed this to a simple crown prep, the thoughts and actions apply to any service you render. Don’t get lost in the details, concentrate on the big picture: You can improve your results and speed. Now I am not suggesting that this amount of time or any other time is the benchmark you should strive for. But I would have to say that many of you just piddle around for way too long. I guarantee that a patient would prefer a shorter appointment compared with a longer one with the same or better result. You should strive to improve your productivity with speed that leads to excellence. If you charge a $1000 for a crown and it takes you an hour for the prep appointment and 30 minutes for the seat, you are producing at the rate of $666.66/hour. Shorten the prep to 40 minutes and the seat to 20 minutes and you now are producing at $1000/hour: big difference, big production, and bigger profit. That’s a raise of about 35%. That’s an extra 30 minutes a day per crown that you could add even more production. This is what makes good practices great in the profitability arena. NOTE: We sometimes are “exceptional thinkers”. I mean that you will think of the one time this did not work or the one exception that makes this a fallacy or myth. Step back and consider that anyone can improve their results and the amount of time it takes to perform it.
Prior to any appointment: This would include everything that should have occurred prior to the actual prep appointment taking place. We need to treatment plan and do case presentation so there is no doubt that the patient wants to do the crown, understands why it needs to be done, can afford it, and has been appointed at a time that fits their schedule. Have them pay in advance so that money or the discussion about it will not happen on the day you perform the service. Fail on any one of these, and you will have a no show, or an unhappy patient that will not refer others to you or follow through with treatment. 99% of the things listed above are performed and controlled by your staff. We cannot keep marginal staff any longer. Hire for attitude and train them well. Expect results and create consequences for lack of performance. If your staff is not excellent, you won’t even get the opportunity to mess up the relationship with the patient. Stop “negotiating” with your staff to make the changes needed to take your practice to the next level.
The philosophy of productive dentistry: Rule #1: Always be on time. You are either early or late. There is no way to be just on time. Never being on time says you don’t value the patient or their time. The ripple effect is more cancellations and no-shows, running late on the next patient, increased staff stress, the inability to do more same day dentistry, and poor internal referrals. This is always a symptom of poor treatment planning and a lack of good systems. Be On Time, Every Time. Use a tub and tray setup system for all instruments and materials. Everything is covered and nothing is kept in the room. Proper tub and tray setups will eliminate ever having to pause during treatment so that your assistant can get something else. It should take less than two minutes to turn a room. If you will go back into our newsletter archives you can retrieve an article on how to organized and implement an entire tub and tray setup system. If you can’t find it, just email me and I will send it to you. While you’re hunting for the article take a moment and do a Google search for Dr. David J. Ahearn or go to www.desergo.com and get an idea of how your operatories should be set up for speed, efficiency, and profit. (Be sure to watch the morphing operatory video on YouTube: https://youtu.be/scyNPDvvJ0Q). There should never be a time that the assistant would need to leave the room to retrieve something for the crown prep. If that ever happens, it should be added to the setup. Systematize, refine, and continue to improve your setup and systems. Keep in mind that the very act of having to put down in writing what needs to be on each setup is a necessary system in itself. Take the time to develop this and training assistants becomes a non-issue.
NEXT WEEK IN PART 2 – A detailed description of the 30-minute crown prep.
Michael Abernathy, DDS