Universal and Enduring Systems of a Dental Practice: Part 1

Feb. 12, 2008
Cindy Ishimoto, CDPMA, says the common threads that tie a practice together and weave the tapestry of a successful practice are the universal and enduring systems.

The common threads that tie a practice together and weave the tapestry of a successful practice are the universal and enduring systems. To quote my friend, mentor and coach, Cathy Jameson, "The success of your practice will be in direct proportion to the success of your systems."

The efficiency and effectiveness of a dental practice is directly proportional to the time and effort you are willing to "invest" in fixing, changing or enhancing the practice systems. I am told that there is nothing new under the sun in practice management systems, and basically I would agree. Everything has universal and enduring principles that form a foundation to build on. In dentistry these are represented by the systems that support patient care. Every era changes the way the systems impact the patients, how they are received by those patients, how technology impacts those systems, and more.

Scheduling is still basically reserving an appointment for a patient, collecting is basically getting the money from the patients for services rendered, and continuing care (recare) is still helping patients visit regularly so they can maintain their oral health. Learning how to go beyond the basics and refine the universal and enduring systems is really what takes practices to new heights and leads to extraordinary success.

In this series of articles, I will go back to the basics and beyond for many of the critical systems of the dental practice, providing recommendations that can improve your outcome and enhance your practice.

Scheduling may very well be the heart of the practice. Your scheduling strategies define your ability to:

1) Have a smooth flowing day, one that is as stress free as possible
2) Provide excellent care for your patients in a timely, well organized manner
3) Produce the necessary amount of dentistry each day

Scheduling has always been assumed to be the responsibility of the scheduling coordinator, and certainly ultimately administering the integrity of the schedule is a part of this team member's duties. However, scheduling is actually the responsibility of the entire team, and everyone should understand how it works, how to reserve appointments, how to change appointments, how to interpret the pre-blocking, and have knowledge of the daily production goals. In other words, this system must be one that everyone can use, understand and master.

The creation of the day comes from the treatment that is provided to the business team from the clinical team. The art of creating the perfect day lies in having enough beautiful puzzle pieces to fit together and craft a masterpiece. The clinical team must diagnose carefully, design a comprehensive treatment plan, and then provide a strategy for the patient to complete that treatment. This time with the patient is critical: value for the treatment and the benefit of doing this treatment must be clear and concise, and then the patient must understand the urgency of completing the process. This motivation propels the patient to do what will help solve the dental problem, which is to reserve an appointment for the treatment.

Universal and Enduring Principle No. 1 for Scheduling: Establish a daily goal

The ultimate scheduling goal is to create evenly productive days, rather than some highly productive days, some lower productive days, and a lot of so-so days. I recommend that each practice consider the following factors to determine their monthly production goal. Add the following: monthly costs to run the practice, doctor's compensation and salary needs, and the percentage of planned profit. This will equal the amount of production needed monthly.

Next, count the number of days available to produce dentistry, and divide the production needed monthly by the number of days available. This establishes the daily production goal to schedule. Keep in mind that the monthly goal will not change, as the bills and salaries will still be due no matter how many days your practice is open. The daily goal will change monthly. I recommend you set the goals for the year and then evaluate the next six month's scheduling goals at your team meetings to ensure that your goals are corrected if days available to treat patients change or the practice financial picture changes.

Universal and Enduring Principle No. 2 for Scheduling: Determine doctor time, assistant time and clean up time

Plan at your next team meeting to evaluate, analyze and design your templates for each of your major procedures. The entire team needs to develop the procedural analysis forms and discuss why each unit of time is so important. This process educates the entire team, and they will then be able to respect the time needed for each procedure. The scheduling coordinator will be more effective at scheduling when he or she understands the procedures.

The simplest approach is to use a 4x6 lined index card. At the top of the card list the type of procedure, and on the lines write the time of your schedule and break each line into one unit of time. Write the types of tasks done in each unit of time, and leave a space next to your time unit to list who is in the room providing care at that time. (Example below)

Crown Prep (Molar)
Asst & Dr-5min
Greet, seat, review health history, topical, anesthesia, opposing model, shade, intra-oral photo of pre-prep



Pack Cord, Final Impression




Dismiss Pt, decontaminate, clean up, prep for next patient's procedure

For each additional crown add 1 unit of prep time and 1 unit of temp time.

This translates into your appointment system according to the computer system that your practice uses. In many systems there is an open box available to represent business team time, a single slash to represent the assistant's time, and the second slash creates an X to indicate the doctor and assistant are in with the patient. Use your system and what you have available to schedule with symbols, and indicate what you have designed in your templates so that you can create a schedule that flows and doesn't double book doctors.

There will be one card for each major procedure. You can then note at the bottom of the card how to add time and where to add time for multiples of this procedure. It is important to note that ultimately, the goal is to have the doctor doing the things that only a doctor can do, and all other procedures and tasks should be delegated to the clinical team. Verify what things are legally possible for a clinical assistant or hygienist to do in your state. Once you have this information it will be important for the team members to feel confident, and become competent and comfortable with their new responsibilities, which will come from providing a high level of training.

This is only the first step to creating a schedule that maximizes each provider's time. You must take the analysis sheets to the clinical area and complete a "time in motion" analysis. Adjust the cards according to actual time, not "proposed" time or "we-wish-we-could-do-it-in-that-amount-of" time. After the cards have been analyzed and the timing is working out to what you have written, you can give them to the scheduling coordinator to begin designing the appointment system to meet your needs.

These analysis sheets are not cast in stone. They must evolve as the practice care advances, procedures change, etc. It is important to evaluate these sheets on an ongoing basis.

The scheduling coordinator's role is to take the procedures that are given to him or her, look at them as puzzle pieces, and then place the puzzle pieces in the appropriate places, ensuring that the production adds up to the goals established and that the doctor is not double booked.

Universal and Enduring Principle No. 3 for Scheduling: Designing perfect day scheduling

An important piece of this puzzle is to schedule a variety of procedures into every day. In scheduling a variety of procedures, boredom, chaos, and stress will be reduced. The energy output and cash flow of the days will become balanced.

The variety of procedures needs to be a mixture of primary, secondary and tertiary procedures. Primary procedures are those that have a higher dollar value. Secondary procedures have a smaller value. Tertiary procedures are those that have no productivity but absolutely must be done, such as seating of crowns and bridges, suture removals, etc.

The key to unlocking the balanced productive schedule is to design a template, otherwise known as pre-blocking the perfect schedule. Pre-blocking is effectively reserving specific times in each day for primary procedures. Remember that a primary procedure is not a specific procedure, but a high dollar value procedure. Pre-block your days for approximately half of your production goals. You will then fit the secondary and tertiary puzzle pieces around those primary pre-blocks to create a balanced, well-scheduled picture.

Establish a practice guideline and hold on to the open primary blocks until two days before. If at that point those blocks have not been filled with primary procedures, then fill it with things that will help your schedule down the road. I recommend that you first move up new patients and consultations. These will be the appointments that provide you with primary procedures to continue balancing your days. If there is available time remaining, move up secondary and tertiary procedures. Patience is important. Don't give up on the primaries too soon, follow the guidelines, and you will make the transition to more balanced days.

Universal and Enduring Principle No. 4 for Scheduling: The entire team has a role in successful scheduling

The goal for everyone in the office is excellent patient care. This mission must be reflected in the way you focus patients on their entire treatment plan and accomplish the completion of that treatment.

Broken appointments are a disease in a practice that can be prevented by practicing excellent communication and education with each patient. The team needs to focus their final communications with patients on establishing the value for what was just completed, answering any questions, discussing the next recommendation in the patients' treatment cycles, what needs to be done, why it needs to be done (advantages and benefits), what might happen if they don't proceed (create urgency), and finally ensure that before the patient leaves the office they are handed off to the scheduling coordinator to reserve their next appointment.

The patient's clinical portion of the appointment is not complete until this communication has occurred. If this is done consistently, more patients will reserve their next appointment, and no shows, changes and broken appointments will decrease.

The scheduling system is one of the most difficult and challenging management systems of a dental practice. It requires ongoing evaluation for success, discussions on how to fine-tune things, and the commitment to support the goals, guidelines and communications that will keep the system healthy. The ultimate goals are to remain productive, see fewer patients, do more dentistry per patient, and see those patients in fewer visits. By continually working on the universal and enduring principles for scheduling you can create productive, service-filled, less chaotic days that will help you be more profitable than ever before.

Cindy Ishimoto, CDPMA, brings energy and powerful information to dentists and teams every day. With 30 years of experience, she is a well-known speaker and management consultant. Cindy has been a featured speaker at international, national and state conventions. Her lectures are focused on helping practices establish systems that balance serving patients, profitability, and enjoyment of profession. As a member of the Jameson Management consulting team, she works in offices with clients all across the U.S. and U.K. For more information on her programs, contact Cindy at Cindy Ishimoto or (808) 244-7344.