Patient Retention
You Made Your Bed, Now Lie in It

Sally Mckenzie, CMC
President
McKenzie Management
sallymck@
mckenziemgmt.com

      Dental teams often forget that when it comes to patient retention they make the bed they lie in. In other words, you may not get what you want, but you will most assuredly get what you ask for. Let me explain. A dentist will lament the fact that patient retention is not where they want or believe it should be. The doctor will pressure the staff to fill open appointments, but he/she has little or no interest in listening to what the current and former patients are saying about the practice. Take the case of “Mary” a business staff employee who recently contacted McKenzie Management

searching for the silver bullet phrase that would convince wayward patients to beat a fast path back to the practice.

Mary deserves a fair amount of credit because she has been following up with inactive patients for some time. Over the years she has heard a number of “excuses” as to why patients don’t return to the practice. The fees are too high, the hours are inconvenient, insurance doesn’t cover enough, the office is too far away, and so on. Mary may not realize it but she has some crucial patient information that the doctor and his/her staff could use to conduct sweeping patient retention reform in the practice. That is if they actually choose to do so.

However, Mary, like many staff members, may be gathering the information and doing absolutely nothing with it. Shoving it in a drawer or simply filing it away in her mind. She assumes that the current office practices – such as hours for appointments, fees, and insurance payment concerns cannot be addressed. In some cases, Mary is absolutely right. The doctor is aware of the patient complaints but doesn’t consider them to be problems for the practice; rather he/she considers those to be the patients’ problems. “Oh that’s just so-and-so complaining. You know there isn’t a thing we could do that would make her happy.” The doctor has no interest in acknowledging the issue let alone being responsive.

Or the dentist wants to make changes but the staff cringes at the mere suggestion of doing things differently. Instead, the team engages in a convenient hand wringing session. They shake their heads, fault the economy, blame the busyness of people’s lives, dismiss the complaints as insignificant and carry on as usual. In other cases dental teams simply dig in and hide behind their rigid “that’s the way it is” policies. “We are here from 8 a.m. until 5 p.m. 4 days a week, and if patients don’t care enough about their teeth to make an appointment well that is just too bad.” Or, “We have our standard financial arrangements – cash or credit card now – and we don’t plan to change those.” Fine. Then don’t complain when patients fire the practice on the grounds that it is too inflexible.

When it comes to patient retention, many of you have made your bed. Next week, maybe it’s time you consider changing the sheets.

If you have any questions or comments, please email Sally McKenzie at sallymck@mckenziemgmt.com.

Interested in having Sally speak to your dental society or study club?
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Tech Tips For Today!

Designed to improve management techniques through your technology platform

Mark Dilatush
VP Professional Relations
McKenzie Management
mark@
mckenziemgmt.com

      Last issue, [see article], I discussed your automated recall system and how to establish and document your recall game plan. You might want to look back at the article and print it for reference by clicking on the link above. Hopefully, you already have a list of weekly (even daily) recall tasks identified, understood, and implemented by someone in your office.

This week I want to keep moving forward with your recall system and discuss the

accountability and reporting responsibilities of the person assigned to the recall system. In your office it may be just the one person at your front desk. Below you will learn “some” of the reporting mechanisms used to show the overall health of your recall system. I am purposely just writing “some” of the reporting mechanisms to make it easy to implement and keep track of on a monthly basis.

Recall System Reporting

Patient flow ratio
The first (in my opinion most important) measurement is your patient flow ratio. Your patient flow ratio shows the total number of new patients for the past year (00150) vs. the total number of patients overdue for recall over the past year. You simply run a production report for all providers for the past year and total the number of 00150’s (or whatever code you post to show a truly new comprehensive exam). Then you run an overdue recall report for the past year and tally the number of patients represented on the report. You don’t even have to print the overdue recall report. Most practice management systems can print it to the screen. Just count the patients per page and multiply that number by the number of pages on the report.

Compare your new patients vs. the total number of overdue patients. Write the numbers down. Finding your patient flow ratio should take no more than 5 minutes. Therefore, there is no excuse not to do it!

Total number of hygiene cancellations in the tickler (unscheduled treatment) files.
Print your unscheduled treatment list (or tickler file). Tally the total number of previously cancelled, missed, or broken hygiene appointments. This represents the number of patients who responded to your recall system but didn’t quite make it into the office. Make a note of the total number. Again, this report should not take any more than 5 minutes to generate and tally. This too is very simple.

Inactivated patients.
Most practice management systems have poor tracking of the inactivated patient. That’s ok, there’s a way around that. I want you to create a treatment code for “patient inactivated”. When a patient goes all the way through your recall system and hasn’t responded within an agreed amount of time, you would go into their ledger and post your patient inactivated code. Some practice management systems have an area of the patient record where you can mark a patient inactive. Do that as well. Posting the “patient inactivated” code in the ledger will allow you to report on patient inactivation by date range. This is an important measurement within your recall system.

Every month, run a production report for your patient inactivation code. Run a production report for the last whole month and another report for the last whole year. Make a note of both numbers.

Accountability
The end result of collecting this data (which should have only taken 10 minutes or so) would be the following. I will use fairly common data results as an example.

New patients in the past year = 450
Overdue recall patients in the past year = 450
Patient growth = 0 (new patients minus overdue patients)
Cancelled or broken hygiene appointments three months ago = 110
Cancelled or broken hygiene appointments two months ago = 130
Cancelled or broken hygiene appointments last month = 150
Inactivated patients in the past year = 300
Inactivated patients last month = 20

Test Questions
Is this practice really growing?
Is the recall system working?
What area of patient retention needs obvious training and focus?

I welcome any and all readers to email me with specific questions, problems, requests and challenges. Who knows? Maybe your inquiry will lead to a new Tips For Today article! Don’t worry, your inquiry will remain anonymous unless you want credit for the question.

Interested in having Mark speak to your dental society or study club?
Click here

HOW TO INCREASE THE SUCCESS OF SRP

Dr. Allan Monack
Hygiene Clinical Director
McKenzie Management
allan@mckenziemgmt.com

         Last year I attended a symposium on “Implementing New Strategies For Treating Periodontal Disease: A Systematic Approach”. The focus was on why periodontal disease happens and how it progresses. The presenters discussed implementation of new protocols to interrupt the disease process. I have known for the past seven years that antibiotics and other chemotherapy enhanced the results of scaling and root planing procedures. The research on the initiation of periodontal disease has greatly

increased our ability to identify specific microorganisms that are involved in the active disease process.

Understanding the symbiotic relationship of the microorganisms in different environments gives us the ability to implement new methods to combat their effects. We now know it is an organized community of bacteria that results in the destruction of the periodontal attachment. Dr. Sigmund Socransky, Head of the Department of Periodontics of The Forsyth Institute, is working to identify the relationship between the microorganism complex and the host cell response. This subgingival microbial complex is called a “biofilm”.

Dr. Socransky has identified different biofilm communities present in a periodontal pocket depending on the depth and proximity to the root surface. For simplicity let us identify the main types as the tooth proximity biofilm (green/yellow complex), interspacial biofilm (orange complex), and the epithelial invasive biofilm ( red complex). His research has shown the more advanced the periodontal disease is, the greater percentage of red complex is present. It has also been shown that at greater depths the more anaerobic is the environment. Research has not identified the mechanism that actually causes the attachment breakdown or why certain hosts are more resistant to loss of attachment. It has shown that there is a direct relationship between the red complex and the disease. The bacteria most associated with the red complex are Streptococcus intermedius, Streptococcus micros, Porphyromonas gingivalis, Prevotella intermedia, Bacteroides forsythus, and Fusobacterium nucleatum. These are both gram-positive and gram-negative microbes. Dr. Socransky presented two theories on how the red complex invades shallow pockets and causes deepening pockets. The first is called the spread theory. The red complex present in some areas spread to noninfected areas and begin to create a destructive process with deepening pockets. The second theory is that red complex is present in the epithelial layers in small amounts and the inflammatory host response triggers the increase of the red complex in that site to cause attachment loss. Dr. Socransky thinks the spread theory seems to be the main occurrence in periodontal disease.

Immediately after scaling and root planing there is a dramatic reduction in red complex. According to Dr. Charles Cobb, who also presented at the symposium, it doesn’t matter if all the calculus is removed, if the root surfaces are rough, or if the scaling is done by manual, sonic, or ultrasonic techniques. The problem is how do we keep the red complex from returning to destructive levels? If we can remove all the calculus and have perfectly smooth roots we can prolong the suppression of the red complex in the pocket. It has been demonstrated that even the best practitioners can’t achieve those results in pockets greater than 4 mm. The problem is exacerbated by restricted access, root proximity, furcations, and restorations. There is a constant race between healing and the reintroduction of the destructive biofilm. Papers presented in the “Journal of Periodontology” have suggested, quoting Dr. Cobb, “The concept of removing all subgingival calculus and contaminated cementum has been shown to be unrealistic and quite likely unnecessary”. There have been many papers on the need to control the supragingival plaque. It appears that the supragingival plaque is the source for both the initial infection and reinfection after scaling and root planing.

In the Journal of Clinical Periodontics in 2001, Serino, Rosling, Ramberg, Socransky, and Lindhe reported that treating patients with adjunctive systemic antibiotics produced significant improvement in attachment gain and pocket reduction over root planing alone. The researchers used a combination of amoxicillin and metronidazole. More than half the patients were stable after three years with quarterly maintenance and 29% of the patients were stable after five years. Since that paper there have been research papers that site specific agents that reduce and suppress the red complex. The objective is to give the host the time to repair the damage caused by the destructive biofilm. In shallower pockets of 4mm or less mouth rinses, such as chlorhexidine, triclosane, essential oils, cetylpryidinium chloride, and other bacteriostatic agents appear to be effective if used regularly after scaling and root planing procedures (JADA, JUNE 2003). Enough, so diligent home care and quarterly office maintenance can be predictable in maintaining health.

What about deeper pockets of 5mm or greater? At those depths, rinses are not effective and scaling procedures have been shown to be inadequate. Obviously, surgical reduction of the pocket will establish a maintainable sulcus with minimal pocket depth and enable the rinses and home care to be effective. Is there a nonsurgical protocol that will work in deeper pockets? There are a few agents available that appear to suppress the red complex and reduce periodontal pockets predictably. They are the new generation of site specific antibiotics. They are not detectable systemically when properly used as recommended by the manufacturers. They are most effective at the initial scaling and root planing procedure. They seem to reduce the red complex for up to 21 days after placement. There is minimal host sensitivity or side effects to the use of these agents. The objective is to place theses agents where the red complex is in greatest concentrations which is the base of a 5mm or greater periodontal pocket.

Ideally, the effective therapeutic effect should be at least 4 weeks. This gives enough time with proper scheduling to treat all affected quadrants. This would suppress the red complex and reduce the chance of spread or reinfection before the therapeutic effect wore off. There is a systemic product that also suppresses the breakdown of the attachment apparatus. It needs to be administered over 6-9 months on a daily dose to maintain its effect.
Once you learn about these products and develop the protocol for your office that will effectively deliver consistent positive results for your patients, you will be able to greatly enhance the success of scaling and root planing procedures. You will be able to maintain your patients in periodontal health with less relapse. There is no magic bullet, but we are getting close to allowing our patients to keep all their teeth for a lifetime.

Hi Sally,
Well, I have a long term and I mean long term hygienist that is moving across country with her husband. Imagine that? And leaving me? Anyway, I have an ad in the paper and have gotten some resumes so feel blessed but…my problem is that I don’t know what questions to ask them to help me determine if they would be a good candidate. Can you help me out?
Dr. Kidder

Dear Dr. Kidder,
Here are questions from my How To Hire The Best Dental Employee book that I think you will find helpful.

1. How often do you think x-rays should be taken?
2. How do you feel about performing sealants?
3. How do you feel about bleachings?
4. What was your daily average production in your previous/present position?
5. What do you consider to be an average patient load per day?
6. How much experience do you have with scaling and root planing?
7. Who do you think should be responsible for the recall system and why?
8. How do you feel about the use of ultra sonic scalers?
9. If you had a broken appointment, what would you do?
10. How do you feel about the use of antimicrobial therapy?
11. Do you prefer to be paid an hourly rate, daily rate, salary, or commission and why?

Hope this helps. Good luck,
Sally McKenzie

For more information, email info@mckenziemgmt.com
or call 1-877-777-6151