Identifying the Silent Killers of Productive Dentistry
This topic will take two or three levels of understanding and because of its importance we will break this up to allow each of you to absorb its importance while quickly taking action steps to remedy this silent killer of profit and production. On any journey, it is common place for most of us not to take into consideration all of the possible negative outcomes that can occur if we are not vigilant. The 180 Degree Dental Journey is also fraught with many unseen dangers that may or may not prevent us from reaching our destination.
These silent killers take the form of Cancellations and No Shows and attrition. All of us know the results of each, but I want to make sure you tie more importance to both occurrences. Recently, in a newsletter, Seth Godin made mention of false metrics. I won’t quote it all, or any of it, word for word. But allow me to paraphrase it and also give it a dental office spin. We will title this, False metrics appearing real. We all follow certain numbers in our practice. From my perspective, I feel many teachers, coaches, and even doctors are looking at the wrong numbers or fail to truly understand the numbers or metrics they should be looking at. There is a challenge: Just because they’re easy to measure doesn’t mean they matter. If they appear in round numbers or percentages and are easily compared to those from others, we’re tempted to compare. But something that looks like a useful metric might not be. Let’s assume we hear that a practice is doing $5,000,000 a year in collections. A very simple number to look at but for most doctors it means nothing. At first glance most offices doing less would be “wowed” by such a large number. It is a metric that looks like it is useful until you find out their overhead is 90%. Now no one is impressed and the number looks terrible. You get the idea. I don’t want you to stop measuring your practice numbers but we need to look at the correct ones and understand the significance of where they fall as we look at running a super successful practice. It should make more sense to give each of you more useful numbers to measure instead.
With this in mind, we spent a lot of time early in the journey diagnosing where you were currently along with what each number means in the overall picture of a healthy practice. Today, we add a little more depth into an altogether different area that significantly affects those fundamental numbers you are currently following.
There is nothing worse than having a perfect day scheduled at 8:00AM and by 9:00AM, 20% of the day has cancelled. What’s even worse is that cancellations and no-shows seem to affect the most productive procedures (Crown and bridge for the doctor and soft tissue and new patient appointments for hygiene). Therefore, a 20% cancellation rate may mean an eighty percent reduction in production. It is never just a 20% reduction in production. Cancellations and no-shows are much like a chronic infection that never goes away. It keeps an otherwise good practice from becoming a great one. It is the difference between a profitable practice and a very marginal one. Take this system and do not wait to share it with the rest of the staff. Remember: There is no learning without application. It is not enough to just share this information with the office. It has to be tracked and measured, and there must be consequences for your staff not following it to the letter. They are either doing the system and getting results, or falling back on what they have always done, and failing to meet goal. There are two types of staff: Good staff that need some more training or poor staff that need their future freed up. You will never go any further in your practice than the staff member with the least commitment to your vision and goals. It is the weakest link. It is no longer good enough to have good staff. You must move to the level of excellent staff: The right people in the right seat on the right bus. Do not delay. (Don’t miss the “PS” section at the end.) Make the hard decisions you know you need to make and reap the rewards of a new level of profitability and production. (Surely every one reading the 180 Degree Dental Journey has a copy but just in case, get your free copy of The Super General Dental Practice at www.supergeneralpractice.com and refer to our philosophy and systems of the Purpose Driven, Doctor Led, and Staff Owned Practice Model.)
Expectations versus Reality
Cancellations and No-Shows (C/A & NS) are a fact of life. They will always exist. Statistically, 15% to 20% of your patients will try to cancel or no-show. Zero percent C/A & NS is not a reasonable goal. We should shoot for less than 8-9% and, of those, I would shoot for a 95% plus filled or replaced goal. In other words, they will still try to cancel but someone has the responsibility to replace almost every one of them. You can ill afford the ripple effect of the loss of even one patient.
Below you will find a chart of “One More per Day”, or if you would like, “One Less per Day”.
ONE MORE PER DAY
|ONE LESS PER DAY
|Adult Prophy $75
|Sealants (4) $140
|Quad (SRP) $225
There are seven procedures listed. Four of these are performed by a hygienist and three by the dentist. These procedures, if added each day to an existing schedule, would create the production, and in this case added profit, of over half of what an average dental practice collects. That’s right: Just add these seven procedures each day and you have added the production of 50% of another entire dental practice to your schedule, and it is virtually all profit. Since your current profit percentage is what it is, adding this to your production has a multiplying effect on your money-in-pocket profit. For example: Assume a dental practice is open 200 days/year. Add one more crown per day at $1000/crown, and you have added $200,000. The opposite is true also. Let one person who is scheduled for a crown cancel each day and you have lost $200,000 for the year. Every day it is “game on” all day long. The doctor and each member of the staff must be dedicated to making every day the best it can be. There is no margin for error. No “do over’s”. No way to go back and redo that day or make it better. Far too many offices operate under the misconception that they can make up for today next week or next month. We all have the same amount of time. Great practices take advantage of the time they have.
Why do patients fail to keep their appointments?
According to the ADA, patients listed time, money, and fear as the main concerns they had at the dental office. I would agree, but would add a couple more areas in order to eliminate failed appointments.
- Time. “Consumerism” is the new buzz word in business today. For dentistry this means we are a small consumer driven business. Patients frequent our business and buy based on emotional decisions and not logical ones. The best clinical dentist does not necessarily have the best practice. You will be judged on your people skills more than your clinical ones. Patients vote with their feet and wallets as they have the sole discretion to decide with whom they buy services and products from. So, if you are constantly seeing the back of your client’s heads, you are doing something wrong. Convenience is a huge draw for most patients. When do patients want to come in? Usually from 7am-9am and 3-6 pm, and on Saturdays. We call these peak demand times. Times when our patients want to come in are consumer hours. When are most dental offices open? Monday-Thursday from 9-5: Where did this come from? Probably from the 1950’s when there wasn’t a dentist on every corner. These are not consumer hours. Are there any doubts about why patients cancel and no show in an office with standard hours? Time is important and you need to respect what your patients ask for. Be there when your patients want to come in, and your productivity goes up and C/A & NS go away. We were always open 6 days each week and this translated into an average of 10-15 new patients a week just because we were there for them on Fridays and Saturdays and our competition wasn’t. Another area of concern will be new patients who call in and are forced into taking a time that is either too far off, or during an inconvenient time of the day. They know immediately that they never plan to keep the appointment, or use some lame excuse or saying they will call back, or need to check with their spouse. I might add one more thing about time, and even money. There is a double standard in dentistry. We moan and complain when our patients don’t show up or are late, yet we never are on time. Because of my obsession with time, I can say I never ran late, never ran into lunch or past closing time. That was only for 40 years, so maybe I will slip one day, but I doubt it. By constantly running late, you are marketing your practice. You are telling the consumer (always remember: that’s the person who pays your overhead) that you do not respect their time and that you are more important than they are. Not a great message to give your clients. Is it any wonder why you do not get the number of direct referrals you think you should? As long as I am wound up, there is a double standard on money. You doctors can’t afford the dentistry you present. You fail to pay your bills on time, yet get upset when patients find it difficult to afford your case presentations or want to frequent a doctor who is in network with their dental insurance. Once again, a double standard from a dentist who always buy a PPO medical plan for themselves and family. Our Summit clients are required to pay us by credit card kept on account because we know that they fail to pay their own bills in a timely fashion. Even with that safeguard we routinely find that their credit cards are denied (over the limit). Isn’t it about time for all of us to walk the walk?
- Fear: In today’s marketplace you must be “Painless”. Every patient should be offered nitrous oxide, premeds, post op analgesics, anti-inflammatory injections, head phones, oral and IV sedation, Intraflow syringe, x tips, Septicaine, Dexamethasone, Stabident, (if you don’t know what I am talking about, start searching on Google or call me) video and a caring and concerned staff that understands their role: serving the patient. Guess who gets to vote on whether you are painless? One guess, and it doesn’t include you or your staff. That’s right. Only the patient gets to decide if you removed their fear and were painless. You can’t afford to pay for the type of marketing that tells everyone that you are painless and that costs nothing. Be on time and look “remarkable” to your patients. Hurt one patient and everyone in town will know about it.
- Money: We have got to figure out a way to help our patients afford the kind of dentistry they need. You have to show concern about making dentistry fit into your patient’s budgets. If you want the dentistry more than the patient, then you have crossed a line that you will never be able to get back on the other side of. You cannot appear needy or too assertive in pushing treatment. Always happily give them what they want and tell them what they need. Do this, and fit it into their budget, and you will have a patient for life. Most of you use Care Credit. While it is an ADA recommended company, it does not have the highest acceptance rate of all the healthcare finance companies out there. It also is a credit card company rather than a bank and can raise their interest rates over 20% if someone misses their payment. You need to add layers of companies to direct your patients to. One is not enough. You can even use a couple of companies to get a single case financed by having each company cover a portion of the cost. If you do not fit the cost of treatment into your patient’s budget, they will always cancel and no show. It is always about money. Think of it this way.
You have a system to finance their treatment, but with money or any other blockage that we are discussing, you are also reading the patient. You are looking at body language and what is not being said. The job of the financial secretary is to identify any hesitance on the part of the patient that might prevent them from keeping their commitment to the office. If you do sense this, then go back, ask a question and probe deeper and identify where you lost the patient. There is one other important note to make. Always, always, make sure you only give them an estimate for the dentistry they want first. They will always pay for what they want. They will always show up for what they want. Once you deliver the service with no pain, faster than they expected and it looked good, felt good, and lasts a long time, the rest of the treatment that they need will move over to the “wants” side. Send them out of the office with a super bill produced by your software with every little thing on there and you can be sure your treatment success rate will plummet.
- Lack of Trust. This is huge. If you are not willing to find a way for them to fit the cost of dentistry into their budget, be there when they want and need to come in, and show compassion and caring, then you become the donor practice for your area. The donor practice is the one that continues to quietly drive off patients for lack of consumerism while blaming it on the economy, poor demographics, and lack of dental IQ of the patient. I have said many times that the best external referral source I had was the two dentists down the street that unknowingly sent me patients because they failed to inspire them. Trust occurs when we master serving (not service).
The lion’s share of this falls to the staff. From the first phone contact thru the final payment, your staff represents the practice. They control your future success. We need to understand what each patient is worth to us. Divide the number of new patients you have into the production per month. This number is the amount of production per new patient (not on each new patient). In an average dental practice in the U.S., it is about $1,400. In a well-run general practice, it will get to about $2,500-$3,500. Anything over this will put you in the boutique style of practice and will usually be with older doctors who see only adult patients with a high percentage of crown and bridge. Add to this the lifetime value of a patient and you need to see each new patient as a $5,000 – $10,000 dollar bill. While I know that money is not the point, it is a measure of the amount of service you render to your patients. Another way to look at it is to measure the number of new patients who are directly referred to you by existing patients. If it is not at least 50% direct referrals you are not inspiring your patients. Loyal patients do not cancel. Think of it this way. If you are not currently growing, you are not inspiring your patients. Your systems will ultimately determine the range of patients you will be able to inspire. It is impossible to get better at giving patients what they don’t want. Learn to create trust and you will inspire your patients, direct referrals and new patients will increase, and cancelations will disappear.
NOTE: Each of you needs to go back and read or listen to our article (www.summitpracticesolutions.com has a quick link to all of my articles) on “How Patients Judge a Dentist”, or go to chapter 25 of the Second Edition of The Super General Dental Practice. This one topic can forever change your outlook on how you practice dentistry. We have had clients completely turn around their overhead, production, and new patient numbers. This is the cornerstone for every system we have developed over the last 35 years. Get this right and you will not be able see all the patients that will want to come in. You cannot afford to start another year without implementing these strategies.
We will take the next step after you have time to actually quantify where you are on case acceptance, recall, and your current cancellations and no shows. Take the time to research this before we move to the next level of eliminating this silent killer of profit.
Michael Abernathy, DDS
PS. Re: moving toward excellent employees.
“Initiative is more than the act of doing something that needs to be done. Initiative prompts you to tackle the task before you are told, before you are asked, and before the last minute.
For example, good employees do what they are asked to do.
Great employees see what needs to be done and do it before they are asked.
Initiative makes the difference.”