Increasing Case Acceptance and Hygiene Profitability.
– An Interview with Aaron Nicholas: Part 2.
We were last talking with Dr. Aaron Nicholas on his journey through dentistry and practice management. His current system and practice setup is light years ahead of when he first started, with efficient organized systems being main contributing factor. We’re continuing our discussion on how office systems can impact revenue, increase treatment plan case acceptance and hygiene profitability.
In this interview learn:
- A Combined clinical procedure to Increase production and benefit the patient.
- How Your staff can be major factor to make or break your practice.
- How a hygienist can comfortably produce between $2,000 – $6,000 in a day
- How to increase Case Acceptance
Practice Systems & Efficiency (Clinical)
Over the years, you’ve taken countless clinical courses and figured out what works and doesn’t. What is the most effective clinical procedure you currently do and how did you develop it?
Early on in practice, with root canals, I’d wait a week to make sure everything was okay prior to the crown. Then one day a patient came in to get the crown down after a root canal. She told me, “something is funny, it doesn’t feel right, maybe it’s not healing.”
I took a look and saw that the tooth was split right down the middle. The occlusion was reduced properly and everything was done right.
I had to look her in the eye and say, “I’m sorry, but the tooth is split and we’re going to have to take it out now”.
That was not a good feeling.
I had done all the right things, she did all the right things, yet this happened and here we were.
From then on I started to reflect on why we had to wait a week after performing root canals? Could the crown have been done immediately after doing the root canal had been completed? The same day? After researching, I could not find any downsides of doing a crown and root canal together.
The worst thing that could happen is the treatment isn’t successful, in which case we retreat or extract. But we would still avoid the major potential problem of having the tooth split and break, as well as preventing patients from not returning for the final restoration. We all know that teeth that have root canals, when they don’t get crowns will eventually fail. Either if gets reinfected and they need a retreat or it ends up having to come out.
Root canal, build up, and crown worked out fairly well, but we had to figure out exactly how much time to set aside for it. Anterior and bicuspids can get done fairly quickly, but molars are variable in time to complete. Talking to other guys who did a lot of molar root canals, they always said it took them about 40-60 min to complete.
They said, “You know, we just use those little files, they work great.” I tried it out on extracted teeth and couldn’t figure out exactly how they did it.
Eventually was able to sit down and have someone walk me through step by step exactly what he did. We were both at a course for something completely different, a soft tissue surgery course. He was telling me the same thing I always heard a hundred times. “You know, just use those files.”
I asked him, “Tomorrow at lunch will you sit down with me and go over every single step you do for a molar root canal?” So we sat down and with a piece of paper and pencil, I listed every single step. Went back to my office and gave it a try. His system gave me much more consistent results in completion time. Tweaked a few things here and there and got to where I liked it.
But it still took me 2 hours to do the molar root canal, build up, and crown.
Being an efficiency geek, I learned to do quadrant dentistry in the shortest amount of possible time. When you pick up the handpiece, you use the same diamond or burr on every single tooth that needs work before you change the bur. You want to minimize the amount of time you keep switching between burs or handpieces back and forth. So I had been doing that a lot for other procedures.
Then I realized for root canals, I was going back and forth between burs, hand pieces, files and instruments. Then I asked myself, am I being as efficient as possible doing this root canal procedure? Can I figure out a way to minimize this? I sat down and started to critically analyze each and every step and how many times I kept changing between different instruments. Then I just changed the order of the procedure and all of a sudden, saved a whole lot of time.
Everything became clear. Between that and the tweaks in the order of steps, I got it down to 45-60 min of actual Doctor time of doing the root canal, build up and crown. Everything else was assistant time making temps, etc.
That whole thing was a 10 year journey, it didn’t just happen overnight. In the middle of that journey, endo techniques and instruments got way better which helps us finish root canals a lot faster.
What is Ultimate Anesthesia?
The anesthesia is from picking up different techniques and combining them. An example is the topical anesthesia, you go in there and patients still feel the sharp poke of the needle. So how do we figure out that problem? We got very strong compounded topical which helps that out. But when you give the injection they still feel it. So we tried warming the carpules, trying different ones. They wouldn’t seem to get fully numb. When Articaine came out that helped immensely, as they would get numb really quick.
Then we started timing them. How long does it take for each different anesthetic to get the patient numb. If we get beyond the average time and they’re not numb, then we move onto the next technique. So we had a whole series of steps, to show whether we’re moving along in the right direction or not. So we found a combination that works great.
Also tried doing sedation dentistry for awhile. Lots of my friends love it, but I just didn’t enjoy it much. I would try to refer out patients that wanted full blown sedation, but they wanted to stay in the office.
We had to figure out a way to get patients comfortable with something more than nitrous but not full blown sedation. We figured out a way of working with Valium a little differently to get them where we wanted them to be, and it made the anesthesia work better. Because when patients are stressed, they metabolize and burn off the anesthesia much faster and they don’t get fully numb.
So it’s always good to have a trick or two up your sleeve. We did intraosseous injections for awhile and that worked great. Now I like to give a PDL with a vibraject attached to the barrel of the syringe.
If you’re trying to do same day dentistry, which we do a lot of, and miss a block, you often waste 20-30 min trying to get the patient numb. This can put a lot of stress on the staff as you get behind on the schedule, everybody waiting on you and looking at the clock. That’s not a comfortable situation for anybody to be practicing in.
Aaron has had 30% growth to his practice over the last twelve months and attributes one-third of the production from his hygiene department. Due to his highly efficient hygiene department system, each hygienist produces on average 2-6k per day.
You have a product on Hygiene Profitability?
Yeah that came up during a conversation with a friend on his podcast. I was telling him my office manager expects each hygienist to produce $2,200/day minimum. We had one girl produce over $6,000 in a day. He was amazed and suggested that I create a product for that. So I sat down to examine all the different pieces that make it possible for a hygienist to produce $2-6k a day.
What I realized was, we had done a lot of tweaking over the years to increase the communication between the front office staff, the hygienists, and assistants. My hygienists are on an accelerated schedule, so they have assisted hygiene. There must be clear effective communication between all three groups to make everything work.
Over the years, we developed different systems, bits of paperwork, and communication techniques between the hygienist, staff, and Doctor to make it all flow smoothly.
So little by little, overall production numbers in the practice kept increasing, till we reached the level we’re at today. But to do this, we must have hygienist who are on commission. They won’t be motivated to jump from 7 patients to 14 in a day, unless they start taking home more. It also puts them more in charge of their pay and they won’t be asking you for a raise.
It doesn’t become a matter of up selling this and that to patients. But it’s, “oh we only have 30 min left, but Mrs. Jones who is getting a filling done would also like to get a cleaning today. Would it be okay to squeeze her in?” Well if you’re just getting paid hourly, of course it’s not okay. They want to go home early. But if you’re on commission, all of sudden, sure they have time to squeeze in Mrs. Jones to see and take care of her.
To me that is the right thing to do for the patient, the right thing for the practice, and the right thing to do as a dental provider.
So all the pieces have to work together. If you’re going to ask the hygienist to do that, they must be properly supported with both the clinical staff and front office staff to keep their schedule full. There were a lot of moving parts, but we had gotten it down to a system.
So we ended up putting it into a product. This is how you do it step by step. These are the things you needed to get the right groups talking together, making sure things run smoothly.
We had lots of upsets going on between staff because of inaccurate communication, people getting upset with each other when things were not done properly. So we have systems to make sure that nothing falls through the cracks.
There must be clear communication. To make everything work, my staff wears a headpiece radio to talk between all four groups: front office, hygiene, assistants, and the doctor.
If a new dental graduate or new practice owner asked for your advice and you only had a few minutes to give them your best tip, what would it be?
Make sure that you remember to invest in yourself and invest in your staff. That means training in both clinical and Practice management. Not just clinical, but also staff and office management.
Does that include outside consulting and marketing?
Absolutely. You need the right type of consulting for the exact stage you are in with your practice.
There has always been a practice consultant by my side for the entire life of my office. That has been 28 years of consulting. We’ve had numerous different consulting groups. Sometimes they have been dental consultants, and sometimes they were just straight business consultants. Someone is always looking at it from a business perspective from the outside. Helping to figure out the next step, how to get where we want to be, how to improve.
Think of it this way. Tiger Woods has won a lot of golf tournaments. He’s one of the best golfers in the world. Yet he has always had a coach by his side working with him every day throughout his career.
It’s the same thing with dentistry. There are things you’re too immersed in that makes you blind. When you’re so close to something, it’s difficult to see in it’s entirety. You want to make sure that somebody is looking at it and helping you to see your blind spots. You must work on your practice, and not just in your practice.
As dentists, we are trained on all the clinical aspects, but not the business side. But when dentists have a problem, they just want to focus on clinical stuff. That’s what we know and are comfortable with. “I’ll learn to produce more by taking a CE and start offering a new treatment procedure.”
But sometimes, what’s really needed, is to step back, and take a breather. Then look at what the main issues are and what needs to be changed in the practice. What will make the practice more efficient as a whole to help make the practice move forward?
Marketing is just an essential part of the practice you must do. I’m sure there are rural areas without many docs, but for the rest of us, we must do some type of marketing. You gotta figure out what works. Track your marketing, track the results, make sure it’s doing what you think it’s doing. If you don’t know whether or not it’s working, there’s no sense in throwing away your money at it. Just look for something else. You gotta do the research, track the marketing, and then put your dollar down where it’s most effective.
How does your practice website come into play? Do a lot of patients find you through your website? Is it essential to have a website?
It’s critical. In this day and age, you want to have a presence on the web. Everybody searches online to look something up.
When was the last time you heard of somebody pulling out a thick, old Yellow Pages to flip through? It just doesn’t happen anymore.
When I first started, a direct mail campaign helped a lot. Now we’re seeing the web based marketing pick up and focusing online has helped immensely.
Yet at the same time, don’t get stuck on just one mode of marketing. The only thing that’s certain is change. Things are going to change year to year depending on what’s going on outside. Marketing is how you get people to walk through the door. What brings them in is going to change year to year.
Business is never stagnant. The economy goes up and down, things in the world will change with how people interact with businesses. So you have to be flexible, watching and reacting when things change. So you aren’t wasting dollars here, when they should be going there. That’s the thing that’s going to make you more profitable.
Any favorite books?
It’s essential to work on the practice instead of just inside the practice. One book that helped a lot was the “E-Myth” by Michael Gerber. It talks a lot about systems and protocols. He basically says the bulk of success in any business is in the system. And if you get the systems right, you’ll save yourself a lot of headache and get you closer to success. So work on refining your system.
Also liked book called the “Slight Edge” by Jeff Olson. He talks about just changing things a little bit. Putting in a little bit of effort here and there, just little by little every day, every week, months, and years. Over time, this will make a dramatic difference for you.
It’s just a little tweak here, a little change there. One thing added to another and it just compounds over time causing a huge change over time.
Have you done any practice consulting?
Dentists as business owners, need to step outside the role of top producers and into the role of CEO. We must assess the views of the daily operations from a step outside the practice and look at the practice numbers.
I have sat down with a number of doctors to help them out. It is interesting to look at their numbers and see what the numbers are telling about the practice. You have to start by asking, where are you exactly at in the life of your practice? What’s not working out the way you want it to? Then you have to work backwards. Figure out the things that need be changed and moved.
As a practice owner, it’s essential to know what your numbers. Not just production, collection, and number of new patients a month, which is all that most docs know.
You need to know exactly how much you’re spending on marketing, payroll expenses, lab costs, supplies, and office expenses. All those things work together to create your total overhead number.
You can choose to buy something or not. You always have an alternate option in what to buy and which lab to use. Those things you have a lot of control over.
If you have a Dentist doing over $1 million in revenue, but his overhead is 80%, he’s only bringing home $200,000. The guy producing $1 million with only 50% overhead is bringing in more than double. That’s a huge difference in the quality of life.
We all pay lip service to overhead, but it’s really really important. It’s something to look at and concentrate on as much as the next new procedure to add that will help increase production of the practice.
You can also look at your numbers to figure out your service mix. If you’re doing 500 prophy’s a month and only doing 25 bite wings, there’s a problem.
Numbers really tell you what’s going on in the practice. You need to sit down and take a whole day or two to analyze your numbers. Or have your accountant provide your numbers x times a month. It has to be more than one time a month.
If you only look at your numbers once a month, you’re only looking back on what’s happened. You can’t control it as it’s going on. You have to look at what’s going on in the moment and make adjustments as you’re going through the month.
Since we’re talking about numbers, how can you increase case acceptance and what are your thoughts on offering patient discount specials?
When we did a lot of direct mail campaigns, we would offer a special on exam and cleanings. That’s a good way to get patients in the the door. However, about a third of the patients coming in, most having not seen a dentist in several years, had gross decay in their mouth. Yet they were adamant about only getting the cleaning special done and nothing else.
We began to track the amount of treatment being presented to each patient and who was accepting treatment and not. We looked at the demographics of the locations we were doing the mailings. We researched the median household income of each neighborhood. We looked at the addresses of every patient walking in the door and the case acceptance rate. We found that folks coming in from a neighborhood of combined income of less than X tended not to get anything done other than the low price cleaning and exam. Those that were above the X level, tended to get needed work done.
So we targeted and redirected mailings to certain areas, cutting out the lower combined income and putting more money into marketing at the thresholds above X neighborhoods. This made our case acceptance go up.
Then we looked to see if there was a process that makes case acceptance go up?
If the patient is calling up, and getting a curt, rude answer rather than a pleasant greeting every time, they’ll think twice. Patients must be handled with care. Patients calling our office for the first time don’t know how the whole process works. We need to guide and walk them each step of the way. They come in, are greeted, they’re walked back and they have a good experience. If things flow smoothly, then they’re more likely to accept cases presented to them.
Rather than, “yeah just come on back here” with nobody formally introducing them to anybody. If staff are on their phones, are chatting with one another, things are not flowing smoothly, it affects the patients perception of the practice and the doctor.
If they’re coming in and things are clicking, everything is seamless and smooth. The staff seems to know what they’re doing, the hygienist was nice. Then they’ll trust us to work on them.
It is a matter of the cost of treatment, but it’s also a matter of their total overall office experience. How they’re treated from the first phone call to how they’re greeted and literally walked through the office for the first time. This strongly affects their perception of the office. If the staff is cheerful, talking to and interested in you, happy to help you out, getting you through the whole process. Then they’re going to think, “oh this person is suggesting something to me, I like and trust them. Yeah we’ll give that a try. Maybe we can start with something little and go from there”
Compared to a patient going to a drab office and they don’t really feel any positive energy or competence. Then they’ll think twice before getting any work done that they’re apprehensive about.
Jim Collins, Good to Great said it best. It doesn’t matter what business you’re in. You have to get the wrong people off the bus, the right people in the bus and shuffled around into the right seat. Then you can drive the bus anywhere you want successfully.
How do you get the awesome staff? You have to work with them. Train them, be patient. You can’t just hire someone off the street and expect them to be superstars right off the bat. I’ve done that before, that’s why I know that doesn’t work! There really is no shortcut to practice success.
It’s hard work. You have to look at all the parts and pieces and how they best fit together. It’s always something. You have to be working on improving something continually. Working on making your people better and moving the practice forward.
Finally, how can others learn more about you and your clinical techniques and systems?
They can learn about my products and reach me at Monday Morning Dentistry
(Note: if interested in Dr. Nicholas’s products, mention “AUXO” for a 10% deduction)
Dr. Aaron Nicholas Bio
Dr. Aaron Nicholas is a well regarded author and speaker to the dental profession. His focus is on clinical and management efficiency in the dental office. He helps dentists across the states gain clinical speed and practice efficiency with techniques he as developed over the years. He is a featured speaker of the Dental Success Summit, where he teaches how to achieve maximum practice efficiency.
Dr. Aaron Nicholas is the owner, manager and lead dentist of Nicholas Dental Care in Burtonsville, MD since 1988. After graduation in 1987 from the University of Maryland Dental School, Dr. Nicholas founded his office and proceeded to build it up to a busy nine operatory practice. He and his staff have attended hundreds of hours of professional development courses, both clinical and non-clinical. Dr. Nicholas keeps abreast of current research of clinical and operational management practices and implements them within his own practice.