Picture this: You’re enjoying one of those exceptionally good days. Things are moving along pretty smoothly. The schedule is full, you’re running on-time, the patients are happy, they’re paying, no major upsets or snafus, life is good. Yes, this has all the makings of one of those rare ideal days management consultants dangle in front of you at dental meetings. 

Then, without warning, staff member Carol corners you in the hallway. “Doctor, I have to talk to you about a problem.” Noooo!” you’re thinking, “What kind of problem could possibly taint this positively perfect day?” As if reading your mind, she snaps, “Kathy is at it again.” That sinking feeling sweeps over you. Ideal has turned to I-dread because the last thing you want to deal with is an interpersonal tiff. 

Disagreement, conflict, strife, consternation whatever label you want to give it, one thing’s for sure, it’s the stuff sleepless nights, emotional eating, and Maalox moments are made of. Hate dealing with conflict? Welcome to the club. A number of surveys indicate that people in all occupations report the most uncomfortable, stress-producing parts of their jobs are the interpersonal conflicts that they experience on a daily basis between themselves and co-workers or supervisors.

It is estimated that more than 65% of performance problems result from strained relationships between employees -- not from deficits in individual employees' skill or motivation. Then there are the findings from the Center for Creative Leadership. The organization’s long-standing research into executive derailment of U.S. and European managers shows that problems with interpersonal relationships, including the inability to manage conflict, is the number one cause of managerial careers going off track. No wonder all you want to do is the dentistry! Even the experts have trouble with this one.

Conflict arises for numerous reasons, but the most common contributors are poor or lack of communication, different values, personal agendas, lack of resources - both human and financial, and poor employee performance. The result: negative attitudes, unresolved misunderstandings, and low morale.

Getting back to the employee who has just derailed your ideal day. What do you do about Kathy? According to Carol, it seems that Kathy is slipping in late, not cleaning up after herself in the break-room, and is making very little effort to use the new computer system correctly. You promise yourself and the complaining staff member that you’ll address the problem at the appropriate time.

You know you need to confront the issue, but you don’t want to anger or embarrass Kathy.  And, truth be told, you simply don’t know how to tackle this matter straight on. So you opt for the indirect route. At the next staff meeting, you announce to the team that everyone is expected to arrive on time, cleanup after themselves in the breakroom, and carry out their responsibilities fully. There. Done. You’ve addressed the issue and everyone can just move on.

Well, you certainly didn’t embarrass problem-employee Kathy. In fact, she may not even realize her behavior is the problem. The other staff members, meanwhile, may be wondering why they are being reprimanded publicly for behavior they don’t engage in. They begin gossiping amongst themselves in an effort to ferret out the real perpetrator. While you might think you’ve done what you can to address the issue, unfortunately, you’ve probably only stirred the pot.

It’s much easier to ignore these undercurrents of discontent or halfheartedly address the issues, cross your fingers and hope the problem will just take care of itself. After all, people have disagreements and personality differences everyday. It’s just the way it is, right?  Such thinking is certainly comforting until you experience the direct impact of unresolved conflict, which manifests itself lost productivity, absenteeism, increased cancellations, lower treatment acceptance, costly mistakes, etcetera, etcetera. The only way to manage this subversive enemy is to tackle it head on.

The process need not be painful or particularly difficult, but it does need to be clear and direct. Take charge. Yes, it’s easier said than done, but implementing clear conflict resolution strategies can significantly reduce differences among the team and keep the practice firmly on track.

Next week, specific steps to walk you down from the cliffs of conflict.

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When a new patient comes into your office and is identified as having a dental problem, the patient may have doubts about the validity of the diagnosis. Particularly, if the patient has been going to another dentist regularly for a long time and nothing has been mentioned in the past.
 
Therefore, you want to be prepared when that patient sits in your chair for the first time. It is recommended that the provider look at the current x-rays that were sent to your office prior to the patient’s appointment. This will allow the provider to note any areas of concern before that patient even sits in her/his chair. When the patient is in the chair, the health care provider will do a visual exam and probe the entire mouth in order to determine periodontal health. Make sure to explain the probings, and periodontal disease to the patient before you start. This will allow the patient to co-diagnose their disease status. It is also best if you ask the patient an open-ended question before you actually start probing, “Mr. Jones, What questions do you have before I begin?”   

The operator has finished probing and the patient now has:

• Pocketing in all four quadrants
• Bleeding upon probing 
• Taking medications for diabetes and heart disease
• The x-rays show bone loss
• The tissue is red and inflamed

This patient really needs to be root planed. What do you do? This patient has never been told they have periodontal disease by their former doctor, and the patient thinks they are only in need for a cleaning. Or, let’s say the patient was diagnosed with periodontal disease years ago and had root planing, but has not been told recently that their disease has progressed further. You don’t want to loose their trust immediately, and ethically you cannot slight the other doctor. Here is a sample of what the doctor may say to the patient. “Mr. Jones, now that I have been able to examine your mouth along with the x-rays that Dr. Black’s office provided to us. I am observing a lot of infection in the gums. I am seeing that you have active periodontal disease and will need further treatment. We want to get your gums in good health. To accomplish this in a conservative manner, we would use a non-surgical approach. The interceptive therapy will take approximately four visits, at no more than a week to ten days between appointments.  It is best to start with root planing, and then we will evaluate your gums again to determine if even further treatment is needed by a Periodontist.”

This is the perfect time to allow for silence. There are many times that a patient may be encouraged to talk and by providing silence this gives them that perfect time. Working with silence is a talent that takes time to acquire. The provider must learn when to talk and when to allow the patient time to gather their thoughts and wait for an answer. Being patient lets the patient know that what they have to say or question is important.

What if the patient replies “Did this just happen since my last cleaning? I have been having my teeth cleaned every three months, why do I need periodontal treatment now? Why didn’t my old dentist tell me about this?” The provider may then reply, “I cannot answer for Dr. Black, but as you can see from our examination there are pockets present today that are not normal in a healthy mouth. The advancement in periodontal diagnosis and treatment in the last few years enables us to treat this disease earlier and with less surgery. Fortunately, we discovered the gum disease and we may possibly be able to improve your condition without surgery. By having your teeth cleaned every three months at Dr. Black’s office they were trying to prevent the progression of the pockets in your mouth. We will be using a method that may reduce the pockets without surgery. Not all pockets will totally improve with root planing treatment, but there is evidence that the procedure has great success! If you do not have any further questions, it’s best if we get started as soon as possible.”

At this time the Financial Coordinator will come in and go over the treatment plan and the cost to the patient. It is always nice when there is time in between the two appointments to go over financials with the patient. However, if there is not time in between, it is imperative that time be made at the chair. We all deserve to be paid for any services rendered. Going over financials before treatment is started will help with educating the patient on office protocol and policy. This may help increase patient acceptance, because they are more informed.

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This case study is an illustration of a family dental practice maybe similar to yours. The names have been change to protect the guilty!

Dr. Sam Shafer’s Story:
The e-mail read:

“Help!   I am busy but it seems that my practice revenue isn’t covering my expenses!  What is the problem?”
OK – This doesn’t sound good.  Where is my Inspector Clouseau hat and a plane ticket to visit Dr. Shafer?

Office Facts:

• 5-year old start-up practice
• Dr. Shafer works 5 days a week out of two operatories
• He has 1 hygienist working 3 days a week
• All PPOs are accepted – no HMOs
• Daily Gross Doctor Production is $3,500
• Daily Gross Hygiene Production is $1,100

Dr. Shafer needed patients when he opened his doors 5 years ago.  He signed up with every PPO plan that he received in the mail with expectations of the phone ringing timelessly from families wanting him to be their new dental provider.
And came they did!!  Can an influx of new patients be detrimental to the future of the practice?  Absolutely.
“Dr. Shafer, did you have an exit plan to terminate your relationship with the PPOs at some point? I inquired.
He looked puzzled asked, “Why would I want to do that?”

In-office Observations:

• The practice had a patient base of 75% PPO patients.
• “Usual and Customary Fees” were being charged out and the PPO adjustment was posted when the insurance payment was posted.
• The staff was receiving bonuses based on gross production
• Dr. Shafer did not review his computer-generated reports
• He felt secure with his gross production dollars

Recommendations:

Using  “UCR Fees” is correct.   However, certain systems must be in place in order to generate the proper practice statistics:

• Patient portion estimation set up properly in the computer
• Proper PPO adjustment codes are applied to the patient ledgers for the PPO write-offs
• PPO adjustments must be posted to the proper provider
• Knowledge of the average PPO adjustment per month based on previous months
  • Scheduling for a daily gross production goal per provider must be established based on the “adjusted” production from the previous six months.   Not only are the PPO adjustments taken into consideration, but also the courtesy adjustments, cash adjustments and other adjustments that are posted monthly.  Determine what the average adjustment dollar is per provider per month and increase the gross production goal to include these write-offs.

In order to determine what the average production adjustment dollar is, run the computer’s Adjustment Report that lists all the production adjustments that are posted for the previous six months and divide by 6. 

• If bonuses are being paid to the staff, it should be based on the “bottom line” by reviewing the staff overhead as a percentage of collections  - not on gross production.
• Develop an exit plan to reduce the number of PPO plans that are being accepted. 
  • Marketing to a target group of non-PPO patients
  • Schedule a certain percentage of your patients per day for PPOs to allow more appointment time for your non-PPO patients. 
  • Run computer-generated reports that indicate the dollars of income for the various PPO insurance plans to help determine which plans will be eliminated first.  It is vital that you are aware of the possible effects from dropping a particular plan.
  • Notify all your patients that are in a plan that is to be eliminated by an informative letter and announce the change in your practice and invite them to stay with you. 

Conclusions:

PPO plans can be an excellent avenue to “jump start” your young practice.  Keep in mind that when you elect to provide quality care at a reduced fee while your monthly expenses are equivalent to a practice that is not reducing its fees, more patients and higher dollar-per-hour production must be provided to “make up” for the dollars that are lost with reduced fees.

You must have tried and true business systems in place to maximize your services, such as Accounts Receivable Management and Scheduling.  Know how much you need to “net” produce per hour in order to maintain a healthy 55-60% overhead. 

Remember….working hard and seeing 20 patients per day doesn’t guarantee profitability.  Understand the difference between “gross” and “net” production.  Your income is based on the “net” production of the practice – not the “gross”.  Friend or Foe – Feast or Famine?  Examine your practice to see where you are.

If you would like more information on how McKenzie’s Practice Enrichment Programs can help you….. email info@mckenziemgmt.com.

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