The color of business

Dec. 1, 1997
The interdependent parts of a business must function within a system in order to survive. Dental practices, two consultants say, paint themselves into a corner for failing to recognize this fundamental aspect of business.

The interdependent parts of a business must function within a system in order to survive. Dental practices, two consultants say, paint themselves into a corner for failing to recognize this fundamental aspect of business.

Cathleen Terhune Alty, RDH

The heart, the lungs, and the liver are vital organs that keep the body alive and functioning optimally. Each of these organs function within a body system - circulatory, respiratory, or digestive. Without any one of these organs, the entire body quickly fails, each system shutting down when it doesn`t have what it needs to survive. You can`t have a functioning heart without a brain, or operational lungs without the heart. These body systems all are interdependent on one another. They function as a team for the good of the entire body. If one system no longer functions or doesn`t function properly, the other systems are affected.

It may seem like a bizarre analogy, but a dental practice is very much like the human body in that it requires various systems to operate. Each dental-office system - the business office, the dentist`s operatory, the hygiene department - is interdependent on the others to function. If one of the systems falters, the practice has low production, low profits, and unhappy patients.

A dental practice exists to care for people`s oral health through education, prevention and treatment of disease. It can do this only when the office systems are functioning reasonably. But reasonable functioning usually is not optimal functioning, where every system is performing for the maximum benefit of the whole.

Why consultants `trample on turf`

Many dentists turn to practice-management consultants for assistance when faced with the realization that there is a problem of some kind in the practice. But why does it seem like the first place that most consultants pinpoint for change is the hygiene department?

Hygienists, long frustrated with the feeling that dentists want them to work faster and treat more patients in a day, often feel under siege when the consultant walks in the door. Abruptly, battle lines are drawn! The turf war begins!

"There are several reasons why dental hygienists get upset when the practice-management consultant is brought in," says consultant Dr. Roger Levin, president of The Levin Group. The biggest reason, Dr. Levin says, is that ineffective consulting experiences have given many consultants a bad reputation.

"They make a few changes and then they are gone," he noted. "If the changes are not integrated into all the practice systems, the results are usually not satisfactory. Our company philosophy is that efficient systems are the key. You can only work so fast. So you build the system first, then plug in the people. The system is there to help you succeed. If the system isn`t helping, try a new system."

Another reason Dr. Levin feels dental hygienists may be resistant to a consultant`s input is they often do not feel included in practice decisions or see the need for a consultant. "In many cases, the hygienist is a part-time employee and is not quite as involved in the business decisions of the practice," he adds. "There is a natural resistance to change when a person doesn`t feel that they were a part of the decision. A consultant may recommend staff cutbacks if the practice can`t support a full-time hygienist at the time - an unpopular option and a sure way to find the welcome mat rolled up when the consultant pays a visit."

The hygiene department`s far-reaching role

Another problem between the hygienist and the consultant`s ideas is that the hygienist often doesn`t realize how her department touches every part of the practice. "When office systems are being changed, the hygiene department must change with everything else," says Dr. Levin. A hygienist often doesn`t see that changes in her department, even those she may not think are beneficial, allow changes for the better in the entire practice. Dr. W. Edwards Deming, a noted economist, management consultant, and business statistician who helped the Japanese restore their economy and revolutionize their quality and productivity after World War Two, put it this way: To optimize the whole, you sub-optimize the parts.

Going back to the body example may help make this point clearer. If you optimize the heart, let`s say you get it to pump twice as much blood at twice the pressure. Sounds good, right? Well, the net effect of this optimization is death, either by blowing out a blood vessel or bleeding to death from a cut that can`t clot due to the increased pressure. Although the heart physically may be capable of pumping more blood, the rest of the system can`t handle it - so the body can`t either.

Instead of focusing on the business and operation of the hygiene department, most management consultants will look at the practice as a whole. Their job is to see how all the systems fit together and how they can each be fine-tuned to benefit the entire practice. So when the entire practice is optimized and the various parts are adjusted, everyone should reap the benefits. There is less stress, more income, and it`s just a better place to work.

When a consultant says the hygiene department needs to be optimized, it may not mean five-minute prophys from now on. Instead, it could be a new way of looking at your job or department function and how it relates to the entire practice.

Bill Rossi, president of Advanced Practice Management, says that increasing hygiene production usually is not a function of speed. "It is more a function of how good a communicator she is than how fast she works. Production equals how many people you see times what you do for each patient. How do you increase production? Increase the amount of care delivered. You help more people and do more to help the people you see."

Dealing with the `growing pains`

You can, however, expect some growing pains as these system changes are being implemented and tested. "It always gets worse before it gets better," says Dr. Levin. "Expect more stress and work now to get less later. We find that after one year, the staff consensus is that they were nervous of the changes at first, but now their stress is down and things are going great. It`s worth the effort."

Other kinds of growing pains may include a philosophical change, Rossi believes. "You should never sacrifice patient care for the sake of technical excellence. For example, a patient comes in to have a prophy who hasn`t been seen in three years. The patient has a ton of calculus buildup and has been scheduled for a one-hour, 10-minute appointment.

"Now the hygienist has to make a choice. She can put the patient in the chair and do a perfect prophy, but she`ll probably never see the patient again. Or, she can decide that she won`t do the perfect prophy. Instead, she is going to be more concerned about the relationship with that patient. It`s a formula: patient behavior times your clinical skills equals the outcome for patient care.

"In this case, if the hygienist does the perfect prophy, but the patient won`t come back, the outcome for patient care is mediocre. Or, from the another angle, if the hygienist focuses too much on patient behavior and sacrifices patient care, there`s the same mediocre result. A high-production practice requires a high-touch approach. With high touch, you keep those patients coming back; you build relationships with those patients. It`s a very quality-oriented approach."

"High touch has nothing to do with time," adds Dr. Levin. "What is important is what you do in the time you have."

If a consultant is recommending changes in the practice systems, what sort of revisions might be expected in the hygiene department? Dr. Levin says his consultants look at it all. OCould we schedule her better? Does she need verbal skill enhancement? Is the dentist getting in there to check out the patients in a timely manner? Is she skilled at selling, able to point out what is needed and what may be desired?O Dr. Levin points out that patients today are spending a lot of money on improving their looks above the neck. The average woman spends about $2,000 annually on hair and makeup and men are not too far behind this annual dollar expenditure.

OIt?s good to educate the patient about enhancing his or her comfort and self-esteem,O he said. OWe need to help patients understand what is possible.O

Rossi adds: ONo patient wants to be oversold or pushed. Dentists are perfectionists and tend to want to crown everything instead of placing large amalgams. Some dentists will look at a patient and, depending on his mood, will decide that a patient doesn?t really need a crown because he?s feeling so benevolent today. Or, maybe a wealthy patient will be oversold dentistry that he really doesn?t need because he can pay for it.

OBut every patient deserves the dentist?s best advice and technical skills. A patient should never be pressured into accepting a particular treatment. Give the patient options. If you approach the patient as a salesman, you are trying to win a deal. If you don?t win the deal because the patient won?t accept the treatment, there is a danger of destroying the relationship. By playing the role of an adviser, giving the patient options and allowing him or her to choose the course of treatment, you maintain that relationship.O

What if this hygiene department overhaul doesn?t fit with the hygienist?s ideas of how it should be done? Well, as in the body, all the systems must work together or perish. A person may disagree as an individual, but if it must go that way for the good of the whole, the person must adapt or leave.

ODental hygienists have routines,O says Rossi. OIt?s what has worked for them in the past, so it?s our human nature to cling to these patterns. If a hygienist doesn?t want to make it work, we either get the hygienist replaced or we suggest not second-guessing the patient or pre-judging a patient?s reaction. If the changes lead to more or better care, the patient will pick up on this. And if you are less stressed and more efficient, the patient will pick up on your good vibes.O

OIf the hygienist is unhappy, she can get another job, especially with the shortage,O says Dr. Levin. OIf she?s happy, why should she want to make changes? She doesn?t realize the changes could make her even happier in the long run.O

Cathleen Terhune Alty, RDH, is a consulting editor for RDH who is based in Rochester Hills, Mich.