I’ve never really liked statistical rules, such as: “30% of Doctor production should be crown and bridge,” or, “Hygiene production should be 35% of the practice.” “Perio should be 35% of the hygiene department.”
Clinical philosophies between dentists vary widely. Since I work with independent private practitioners, I have clients that are all across the board, so standardized statistics seem irrelevant and in fact can be counterproductive. The object of the game is not the numbers, it’s the care. Each practice should realize its full potential, given the philosophy, experience, and values of the Doctor(s) and team.
In every practice, there is a gap between what can be done for patients and what they choose to have done. This gap can lead to frustration, compromised patient care, and tens of thousands or even hundreds of thousands of dollars lost per year. The more you close that gap, the better level of care you are delivering, and the more successful the practice. Instead of using standardized percentages as a guideline, why not use your own values?
Countless articles have been written about case acceptance: how to set up and plan consults, sales techniques, and scripted dialogues. It’s been my experience that none of those things work as well as creating a strong ethical foundation. This is where “Clinical Calibration” comes in.
If you’ve ever judged diving or gymnastics, you know that they “calibrate” the judges. That is, whether it’s the Olympics or the high school, the judges have to agree on criteria for a quality performance. As judges clarify their criteria for scoring, they are in effect defining what a quality performance is.
It is not unusual to visit a practice where the hygienists have wildly different criteria for treating perio, fluorides, and X-rays. They may not even be using the same probing techniques and therefore don’t get the same readings. We know that consistency is an important component of quality, so consistency between the patients’ experience in treatment between hygienists is very important.
There are a number of approaches to Clinical Calibration. You can have a “Clinical Protocol Summit” where you go through every procedure you do, from adult fluorides to X-rays, and ask your team questions like, What conditions warrant the recommendation of a crown for a tooth? When do we feel it’s better to save or restore a tooth, or extract the tooth and do an implant or bridge? What are our criteria for doing implants versus bridges? What patient conditions warrant recommending topical fluoride treatment?
You can also look at actual case histories of patients you examined the previous week. A good exercise is to split the team up and look at the patients’ information, X-rays, etc., and each team draw up “optimal” treatment plans, and then compare. Or, the Doctor can lead the discussion using theoretical case histories to open the conversation and test everyone’s thinking.
When you do a Clinical Protocol Summit, you should be able to come up with criteria that are so clear and simple that a temporary hygienist could come into your office, read them, and know what your criteria are. After your discussion, develop a one-page (or less) summary of each of all the major services you deliver. And, if you are keeping up with the science, you want to update your “Protocol Manual” at least once per year.
Criteria Versus Quotas
There is a huge difference between criteria and quotas. Quotas are things like, “Each hygienist should do 35% of their production in perio.” Or, “We must do 35% crown and bridge.”
With criteria, things are framed as, “In situations where we see a breaking down filling that’s covering over half the tooth and needs to be replaced, we will recommend a crown.” Or, “Our criteria for endodontically treated teeth is that if they are in occlusion, we will recommend a crown.”
I’ve never seen a situation where the Doctor and team actually did these calibration exercises that did not experience an increase in case acceptance. That increase was not driven by reaching a certain percentage or dollar amount or number (quota), it was done by clarifying and affirming the criteria. If you know that every patient gets recommendations that align with your protocols, the case acceptance will take care of itself.
Moreover, any technology or techniques you use to increase case acceptance will work better. For example, your hygienists are more likely to use the intra oral camera. In fact, I find it’s much more important to clarify when and why you recommend treatment, than to buy new technology to show patient treatment options that you and your staff haven’t thought through.
As you and your staff clarify your protocols, you’ll find that your discussions with patients will automatically become more effective. Your team members don’t have to be “salespeople.” You are advisors. You are not making pitches; you are having conversations.
So, as you clarify your thinking, you communicate more clearly. As you do this, patients understand your recommendations better. As they understand your recommendations better, they make better choices. Their better choices lead to you doing more of your best stuff for them and you get better outcomes for patients. If you trace the logic of this back, as you clarify your thinking, your patient outcomes improve. These are no small stakes.
Except for fee increases, if you want practice production to grow, you either have to:
1. See more people (statistical indicator: exams)
2. Do more for the people you see (statistical indicator: production per exam)
If you are near full capacity and don’t really want to add more hours, further growth will come from doing more for the people you see. You’ll have larger treatment plans in your schedule. You are not pedaling the bike faster and faster, you’re changing the gears on the bike.
If you’re at capacity and finding that you’re running yourself ragged, yet you’re collecting less than 80% of your gross production – well, it’s time to cut back on insurance discounts (e.g., PPO participation).
If you are cutting back on PPO participation and want to ensure that you keep productive, you’ll get the best of both worlds if you do more for the patients you see and collect your actual fees in doing so! A double bounce. We have seen this approach work very well for our clients through PPO transitions. The average increase in collections is over $120,000 per year. That’s a statistic I like!
Practices with more than one Doctor tend to have unspoken and unclear multiple clinical guidelines. This can be confusing for the staff, and the confusion causes them to default to no substantial discussions or co-diagnoses with patients. It’s not unusual to see Doctors who graduated in the same class or even sat on the same bench, arrive at widely different philosophies, such as when to crown a tooth, build-ups, implants, and so on. This confusion results in less effective communication and lower case acceptance.
I have seen many situations where Doctors will bring on an associate but never have a frank and complete discussion about the clinical protocols of the clinic. Associates are not telepathic! You don’t want them to have to rely on inferring what your clinical policies are. They’ll have plenty of challenges in meeting patients, gaining experience, treatment planning and presentation of treatment plans. Don’t make them start from scratch with no idea of what patients have been told in the past and going forward.
If you have an associate or partner, share some exams. Perhaps do this for exams on members of your staff, their relatives, or your relatives (or any patients that are willing). Tell the patient, “Dr. Smith and I are both going to examine you, it’s an exercise we do in Clinical Calibration. It will help us work together as Doctors.”
After the exams, compare your findings and treatment plans. Work through it. Again, the process will solidify your convictions, and your convictions will lead to good communications.
I grew up in Rochester, Minnesota, home of the Mayo Clinic. Almost every time I visited a doctor, there would be Residents present. I grew to understand that’s how they promoted quality at the Mayo Clinic – the Mayo Clinic really does think in terms of team diagnosis and treatment.
For most Doctors, “Dental Hell” would be doing less and less on more and more people and getting less and less pay for doing so. Close the gap between what you can do for patients and what they choose to have done. Endure fewer insurance write-offs and invest more in practice advertising. One thing is for sure, if you don’t do anything, you’re not going to see any change in the numbers! If you rely on the suits at the PPOs to send you patients and then let insurance coverage dictate treatment, you are headed for (or are already in) Dental Hell!
Your Place On The Patient Flow/Patient Care Spectrum
Although I don’t like statistics to drive treatment recommendations, statistics are a very good indicator of your situation and progress.
Check out your own situation. How many exams are you doing per month (total, comprehensive, periodic, and limited exams)? The average general practitioner does about 150 exams, and in general I’ll see a range from about 100 to up to 300. Most Doctors start to feel pretty maxed out at about 200 exams per month – that’s checking 2 hygienists all the time. Beyond that, the interruptions can really drive a Doctor crazy.
Then, divide the total number of exams in a given period (say, the first half of this year) by the total production. Production per exam for a typical GP in our area (where prophies are about $100 and crown fees are about $1,250) is about $550. The range is from about $300 to $1,000. As you will notice, there can be as great a range in what you do per patient as there is the number of patients you’ve seen.
As you actually do Clinical Calibration, you will see the production per exam go up. If at the same time you are peeling off PPOs, you’ll see the collections per exam go up. That means that you’re getting “more torque and fewer RPMs.” This can be very satisfying and profitable!