Practice management (2)

• Introduction
• Winds of Change
• Changing Scenario
• Management styles in dental practice
• Orthodontic Office design
• Paper less practice
• Financial consideration
• Physical consideration
• Ethics
• Patient incentive and motivation
• Fees & Payments
• Orthodontic support team and Associate
• Partnership
• Relation with general dentist
• Practice acquisition and transition
• Preventing loss
• Retirement
• Conclusion
• References
www.indiandentalacademy.com

INTRODUCTION
• Dentistry :a health care profession
• Two fold role :
– to provide health care & service
– to make profit as a small business.
DCNA 1988www.indiandentalacademy.com

Metamorphosis of the
DENTAL practice
TRADITIONAL TO NEW
• Challenges faced
• Art and Science to Business
• New questions and new answers
WINDS OF CHANGE
DCNA 1988 & JCO 2002,03,04,06www.indiandentalacademy.com

When did dentistry seem to become
a business first and an art and
science second?
Why is the practice of dentistry so
exquisitely sensitive to every type of
fluctuation in the market place?
What is responsible for all these
changes?
DCNA 1988 & JCO 2002,03,04,06
allenges posed to today’s dent
?www.indiandentalacademy.com

SERVICE v/s BUSINESS
• As a health care service: dentistry provides
quality care for the patient, following
standards of care established by government
agencies and the profession itself.
• As a business: an enterprise in which one is
engaged to achieve a livelihood, be
productive & create a profit.

Preferred future through informed choice
• Today’s patients will seek optimal services
from orthodontists who understands and
accommodates their expectations,
• Whereas those patients with low
expectations will have their requirements
satisfied by a provider equipped with to
process large nos. of people.

•CAPTAINS of their fate must
understand the sociological
evolution
•If they are to chart an
appropriate course for their
professional contributions:by
accepting that changes are
occurring they can prepare
themselves and their practices
from the segment of the
population they choose to serveDCNA 1988 & JCO 2002,03,04,06www.indiandentalacademy.com

CHANGING SCENARIO
Up to 1940s:
 Solo practice
 one-on-one relationship
 relatively low key, low pressure, and momentarily
rewarding
 level of dental sophistication
 free to charge
1950 -60 :
 consumer demand
 Population increases and a greater desire
 Technical advances

1960-70’s:
 “GOLDEN YEARS” of dentistry
 Loss of control on patients
 emergence of third party
 indemnity insurance concept
Mid 1970’s:
 Patients were hard hit
 effect of a mini-recession
 Manufacturers faced layoffs
 excessive no. of graduates
 fighting for survival :ERA OF COMPETATION
 Closed panel capitation plans

Late 1970s and Early 1980s:
 proliferation of group practices
 Department stores and franchise
business began
Through 1980s and 90’s
 Alternate service providers emerged
like CPO, prepayment plans and
capitation plans
 Department of health maintenance
organizations (HMO)
 Closed panel with staff and group
model practice and Individual
practice models.
The 21st
century
 change in insurance scheme
 advanced technologies
 Demanding conscious consumers
DCNA 1988

Management styles in dental practices
• Leadership: vital to communication.
• Authorative management
• Free rein management
• Participatory management
AJODO 2004

Establishing practice goals and objectives
• Develop a practice philosophy
• Develop practice objectives
• Develop procedural policies
• Develop business principles
• Develop a practice standard
• Develop a staff recognition programme
AJODO 2004

Desirable characteristics for building
relationships: Big Business
• Self confidence
• Genuineness
• Openness to experience
• Acceptance of others
background and values
• Enthusiasm
• Assertiveness
• Integrity
• Effective listening
• Recognition of other needs
• Sense of turnover
AJODO 2004

ORTHODONTIC OFFICE DESIGN
• SITE PLANNING:
• Office Location
• Areas demographics
• Price of land and overall
cost of the project
• Legal restrictions
• Landscape and greenery
• Type of building
• Parking space
JCO 2000 & 2002 www.indiandentalacademy.com

“TODAYS PRACTICE” - The Paperless Practice
• Difficulty in keeping tract of patient files and
treatment records.
• Demographic (patient information forms)
• Diagnostic (health histories, photographs, models, x-
rays)
• Treatment (charts, plans, notes)
• Scheduling (appointment book)
• Financial (ledger cards)
• Increase practice efficiency
• computerized practice management program

Computer technology and HIPAA
• Health Information Privacy and
Accountability Act (HIPAA)
:influenced the way we gather and
maintain patient data on computers
and thus have had an impact on the
office environment.
• Office Designs must now
incorporate physical and technical
barriers, as well as administrative
safeguards, to protect the security
of patients personal health
information JCO 2003www.indiandentalacademy.com

• Ancillary tools
• Imaging and cephalometrics
• insurance – benefits data bases, credit reporting
• Scanning,
• Inventory and Electronic ordering,
• CD-ROM systems for patient education, case
presentations, and staff training, prediction, etc
JCO 2003www.indiandentalacademy.com

Financial considerations
• Investment in hardware
and software
• The system selected
• Size of the practice
• Paperless practice should
cost 2-5% of gross income
• Investment based to
increase efficiency alone.

Physical considerations
• Office Design:
• “Work patterns determine the floor plan”
• Location and no. of work stations:
– Front desk
– Financial / business areas
– Key areas throughout the operatory
– Chair side units
– Satellite offices
– Doctor’s home
• Location of main sever
• Record storage:
• Storage space

Reception Desk
• Contemporary style :completely open to
the reception room. Helps create a friendly
atmosphere.
• Open desk with prefabricated fiberglass
victratex sound panels on the walls behind
it to mute conversations between patients
and the secretary.
• Computer terminal for appointments, and
accounts maintenance.
JCO 2001

• First visit to the orthodontic office
• Initial impression is critical to case acceptance
• Ambience and design of the examination room
• warm atmosphere and décor go a long way
toward establishing a comfort zone for both
parents and patients.
• Set ups
• Smaller and newer
• Well established
• location and design of the exam/consult room
Examination room

Exam/consultation room
• designed with enough flexibility
• used as an exam room, a treatment
coordinator work area, and a
consultation room
• room in the 150 – square – foot
range
• imaging system and photography
section, impression area, etc
• seating for patient and parents
JCO 2000 & 2002www.indiandentalacademy.com

Business office/Doctor’s private office
• used for education as well as to
motivate patients in a semiprivate
environment
• Payments
• Review records of a difficult case on
the computer before the patients
visit
• The doctor to conduct a confidential
huddle with the staff about sensitive
information during treatment
(HIPAA factor) or to meet with the
treatment coordinator about a
difficult case before the consultation
JCO 2000 & 2002

Operatory Design
“site of real action”
• “Visual Privacy” and
preferably sound proof
• A rear-delivery cabinet with
a mounted computer

Chair side cabinetry and delivery system
• ambidexterity of the operator
• rear-delivery systems to avoid
this potential problem
• Four hand practice.

• Chair side utility centers
• Central islands
• Sterilization centers
:preferable in the most
visible part of the
clinic : due to public
concern
SINK AUTOCLAVEULTRASOUND UV LIGHT
STERILIZATION UNIT
JCO 1988, 2000 & 2002

Working Area
• Primary work triangle formed
by the operator, the assistant and
the primary work area (tray)
• Secondary work triangle based
on the location of sinks, secondary
storage, and mixing areas
• For easy traffic flow of patients.
JCO 2000 & 2002www.indiandentalacademy.com

• “individual non-stress tempos”
• At busy times :doctors and assistant
can step up their ‘cadence a notch’,
but it is not desirable or healthy to
work that way for extended periods
of time.
• Experience :the most efficient way
to handle the volume of patients
DCNA 1988 www.indiandentalacademy.com

Arrangement of dental chairs
• Save or Waste valuable space
in an operatory
• Comfort zone where patients
feel they have their own
territory
• Traditional parallel or radial
designs
• Circular or pinwheel chair
arrangements

Clinical TimeClinical Time
• upgrading and rearranging the equipment
• Procedures and techniques selected.
• Working position
• Four hand practice
• Newer technology
• Placement of instruments and equipments in
the primary working area.

ETHICS IN ORTHODONTIC PRACTICEETHICS IN ORTHODONTIC PRACTICE
• Non-payment of treatment fees
• Breach in Contract or agreement
1. informed verbally as well as in
writing about the delinquency
of the account / missing
appointments/ breakages
2. see the patient at regularly
schedule maintenance
appointments to monitor the
integrity of the braces as well
as the oral hygiene
3. removal of the braces, or
suggest that they find
another practice.
JCO 1999 www.indiandentalacademy.com

• Offer a limited treatment option
– as long as it doesn’t leave the patient in a
more compromised relation, but it is
unethical to do a limited treatment that
could have a detrimental effect
– try to convince the patient
– Plan for all alternative treatment options
along with the level of compromise expected.
• Dr. Birdwell
– “It is ethical to offer a less-than-ideal
treatment because of finances, as long as
the limited treatment leaves the patient in
better dental health.”

Change in Fees
• work, material, time and quality of care,
advertising and marketing
• “The orthodontist didn’t create the
system. He is just trying to survive in
it.”
–Dr. Schudy

• Charge different fees for the same
service ?
• If the same work, material, time and quality of
care are to be offered it would be taking
advantage of the full fee patient to reduce one’s
fee for the managed care patient
• Should one Reduce his Fee if treatment
finished early ?
• Doctor patient relationship?

Getting to your patient:Getting to your patient: Psychological MotivationPsychological Motivation
• When reasons and emotions clash, emotions
almost always wins.
• In getting a patient to move in the direction of
better health, one need to appreciate the
powers of emotional appeal and have certain
attitudes, values and feelings our self.
• Building up a trust that makes it possible to
sense our patient’s real desires.
““People act to satisfy their own needs and desires, not thePeople act to satisfy their own needs and desires, not the
needs of other people. People behave to satisfy their realneeds of other people. People behave to satisfy their real
motives, not the motives they should have.”motives, not the motives they should have.”
- A N Shoonmaker- A N Shoonmaker

PATIENT INCENTIVE AND
MOTIVATION
• Patient behavior through positive
reinforcement for decades
• Rewards such as T-shirts, stickers, fast-
food coupons, and movie passes have been
used to recognize good oral hygiene,
headgear and elastic wear, and on-time
appointment keeping
• marketing strategy

• To be effective, motivation must be internalized
• Rah-rah speeches usually fall on deaf ears
• patient with low self-esteem – the typical non-
complaint patient
RESPONSESTIMULUS
freedom to choose
•Office environment
•Monitoring the treatment progress
•Non cooperative patient.www.indiandentalacademy.com

Positive v/s negative reinforcements
• Positive is always better
• Changing the attitude
• Office environment and staff concern
• Parents and peer group

Orthodontic support team / Associates
• Doctor and his associates, older patients, parents, etc are its
members
• Older members are used to motivate the newer members of
the same group.
• They make reminder calls for headgear wear, elastic wear,
removable appliance usage, and oral hygiene.
• Advantages include
» One-to-one peer contact
» Sharing of experiences and practical information
» Mutual problem solving
» Social interaction

Staff development
• maintain staff longevity
• continuing education and cross-training
• Job satisfaction and level of professionalism
of staff members by giving them the
opportunity to utilize their intellectual as
well as technical skills
• better caregiver, communicator, and practice
builder.

Staff models
• Group Practice:
• Multi specialty care center
• Many highly qualified
doctors working together
• Paid Associates and Un-
Paid Partners
• separate working areas and
a bigger set up
• Separate Assistants,
receptionists, technicians,
hygienists, etc
•Individual practice:
•Doctor, Receptionist/ clerk/ assistant/
technician, etc
•Visiting other specialists
•Assistant lower qualification doctors

Patient communications
• “Communication is the KEY to
success.”
• The orthodontist can only speak to
one patient and parent at a time,
• But staff members can greatly
expand the distribution of
important messages about practice
philosophies, procedures, and
special features.

Paradigm of MotivationParadigm of Motivation
• Primary motivational techniques
orthodontists use - for encouraging
patients to assist in their treatments
• Three main psychological disciplines.
• Humanism, existentialism, or Maslow’s
Third Force techniques.
• Psychoanalytical techniques developed by
Freud
• Behaviorism
» positive reinforces
» negative reinforces
» punishment.

• Do not expect all patients to do things for your
benefit.
• Most patients, except for the deranged and
totally altruistic, do things that benefit
themselves.
• So when people do have the skill but not the will
to do something, look for the following
conditions.
– rewarding to perform as desired.
– punishing to perform as desired.
– simply doesn’t matter whether performance is as
desired.
– Identify and remove the obstacles in performance.

Child orthodontic patient
• Gives children a first-hand, experiential, and
interactive lesson in dentistry and orthodontics.
• Involvement in a worth while community
service.
• Alleviates fears about dental care.
• Familiarizes people with the specialty.
• Introduces to a great number of potential
patients
• Allows to market our practice and the services
provided in a professional manner.
• Newer learning experience

Trait Easy child Difficult child
Activity Low High
Distraction Low High
Regularity Regular Irregular
Approachability Approaches Withdraws
Adaptability Good Poor
Persistence Low High
Mood Positive Negative
Sensitivity Insensitivity Sensitive
NINE CONGENITAL TEMPERAMENTS
THAT MAKE CHILDREN EASY OR
DIFFICULT TO MANAGE

• Behaviors associated with non-complaint
orthodontic patients :
– poor oral hygiene, chronic complaining, easily
fatigued jaw muscles, inability to open their
mouths wide, copious salivation, frequently
broken appliances, refusal to use permissive
appliances, easily provoked gag reflexes,
chronic mouth ulcers, TMD symptoms, and
frequent missed appointments
TURTLES WITHOUTTURTLES WITHOUT
SHELLSSHELLS

• Low profile hyper reactive childrenLow profile hyper reactive children:
– show little inclination to tolerate the demands,
discomfort, and inconvenience of orthodontic
therapy
– broken brackets and bands result from when
they touch, tug on, and damage the appliances
that are discomforting them .
– They cut the wires with nail cutters or wire
cutter.
– break the offending brackets by biting on a
pencil, pen, or block of ice

FEES AND PAYMENTS
• Economic success & profitability.
• Economic equation : costs and fees
• Fixing the fee for service provided.
• Cost benefit ratio:
INCOME V/S SKILL, EXPERTISE, EQUIPMENTS, TIME

Payment schemes
• Direct to doctor
• Via insurance company
• Patient to doctor and then patient claim from
insurance providers.
• Free service
• Robin hood practice.

• Knowledge and Experience
• Cost-per time analysis of the fee-for-service
approach
• Internal audit of the following variables:
– Number of dental chairs
– Hours per week the office is normally open
– Weeks per year the office is closed
– Net income forecast
– Indirect cost factors
– Percentage of occupation of dental chairs
Direct measurement
Approximation

How do people choose an orthodontist ?
• Referral from their
dentist
• Recommendations
from friends and
relatives
• Media

• Initial phone call
– Patients form an immediate impression of the
dentist and his practice before ever meeting or
seeing the office
• Art and Science of the initial phone call:
– Art: the way of talking and expressing your
gratitude and concern for the patient.
– Science: the information to be gathered and
information to be imparted
• The staff member answering the initial call
must have a very pleasing and welcoming
voice and must sound interesting.
Key to patient attraction

Pre appointment phone call:
to Obtain essential information
1. First and last names of the
patient and both parents
2. Addresses of the patient
3. Phone numbers
4. Patient’s Date of Birth
5. The dentist or other person
who referred the patient

THE PERFECT ASSOCIATE:THE PERFECT ASSOCIATE:
COLLEAGUECOLLEAGUE
• The doctor usually spends an increasing amount
of time at the chair treating patients
• Time spent on marketing; with family ,
vacations etc… gets shorter.
• Issues in finding a perfect associate:
• differences in treatment philosophies, competition between
the doctors, money issues, etc.

OLDER ASSOCIATE
• A fresh outlook and avoiding burnout of the
practice.
• experienced and confident
• No Ego hang-ups nor trying to change your
practice philosophy, nor leaving to set up a
competing practice.
• More focused on treatment and provide
exceptional patient care.
• Better holiday and higher education planning.www.indiandentalacademy.com

PARTNERSHIPS
• Importance :
• expanding a practice.
• making the transition to
retirement.
• high cost of a bad decision / miss
diagnosis.

SUCCESSFUL PARTNERSHIP
• A good fit between the personalities of the
partners.
• Similar values
• The ability to be team players
• Compatible goals
• Mutual trust & understanding

Break Ups !
• The process of dissolution can take
months or years and often involves
litigation.

RELATION WITH GENERAL DENTIST
Relationship :based on referrals
• Add new general dentist referral sources or to
maintain the loyalty of existing referrers .
• Internal marketing efforts
• METHODS OF ESTABLISHING RELATIONSHIPS :
• lunch meetings, office-to-office events,
gifts, set up study groups, memberships
to various associations, etc.www.indiandentalacademy.com

PRACTICE ACQUISITION AND
TRANSITION
• Financing :
• Funds
• Self funded/Commercial bankers and loans
• Partnerships
• Fair-market value for the target practice
• After-tax cash-flow projections
• Debt and living expenses.
• Credit-worthiness of the purchaserwww.indiandentalacademy.com

Reasons for failure of practice acquisitions
1. legitimate personality conflicts
2. unforeseeable event
3. insufficient planning
• Valuation of the practice, cash-flow, tax-
efficiency, legal, operational, and a myriad of
other concerns must be addressed before the
parties can proceed with confidence

To sell or not to sell ?
• If the practice is of high or
moderate income in a highly
favorable or favorable location,
then the chances of selling are
extremely good

Green = Go !
Transition Probability : excellent
Yellow = caution !
Transition probability : guarded
Red = Alert !
Transition probability : unlikely
?

Strategy
• start looking for an associate / buyer at least
seven years prior to retirement
• Ample time to choose the best possible buyer.
• Higher the income, the better the chances of
selling
• improve the practice

Every beginner wants to get into profitableEvery beginner wants to get into profitable
existing practice rather than starting a newer oneexisting practice rather than starting a newer one
• Less risk.
• Guaranteed immediate income.
• Continue to build an already
thriving practice.
• work with a mentor.
• benefit from the good will already
established within the community by
the senior orthodontist.
• a high-quality facility that otherwise
would not be affordable for years.
• practice with a well-trained staff.www.indiandentalacademy.com

PREVENTING LOSS
Why do so many orthodontists fall prey to
embezzlers ?
• Leave the management duties to front-desk staffers
• No internal controls or periodic reviews
• Shortcut the hiring process

Ten steps to protect the practice when
hiring an employee
• Reclaim any office keys and building
passes from the terminated employee.
• Change the office locks.
• Revoke the employee’s computer access,
and change passwords.
• Change the burglar alarm code
• Revoke any check-writing or other
financial authority.
• Recover any practice credit cards or phone
cards.

• Have the employee remove all personal
belongings from the office and return all cell
phones, pagers, etc
• If the employee has the power to order
supplies by phone, notify suppliers that it is
revoked.
• Finalize all payrolls and benefit details. Give
the employee the last pay check. Although a
few states have no law governing how quickly
doctors must pay employees who quit, most
require that an employee receive the final pay
check by the next regular payday.
• If severance pay will be provided, consider
having the employee sign a release form to
protect your practice from liabilitywww.indiandentalacademy.com

RETIREMENT
• 1999 JCO retirement survey :
• 92.9% = able to “afford a comfortable retirement”
• fewer than 15% of practicing orthodontists will have $4 million
or more in assets at retirement
NOT PREPARED TO RETIRE.
• Divorce
• poor investments
• poor planning
• limited saving
• enjoy life today philosophy
“Not able to hang up their pliers and ride off into the sunset!”

Strategies
 Plan ahead
 Seek professional assistance
 Monitor your numbers
 Maximize peak earning years
 Develop both personal and practice
budgets
 Increase practice income
 Reduce practice expenses
 Spend less than you make
 Determine the investment rate of return
needed to reach your goals
 Don’t be greedy
 Don’t make foolish investment mistake
 Plan to work longer
 Make sure to sell the most valuable asset
 Protect the loved oneswww.indiandentalacademy.com

• Always know the value of your
practice
• A practice coverage agreement in
case of death or disability
• The value of your practice decreases
quickly and dramatically if you are
unable to operate it
• The longer it can be kept running, the
better the chances that your loved
ones will be able to sell it and reap
the benefits of your years of hard
work.

• Insurance needs : Protect the loved ones
• Life insurance
• Liability insurance
• Home insurance
• Health insurance
• Long-term care
–Auto insurance
• Practice :
• Liability (Malpractice) insurance
• Office overhead insurance

CONCLUSION
• success in an orthodontic office
• team effort
• first, impression is the last impression
• maintain a good rapport with the patient and
associates
• Right fee for right work is our right.
• Cost benefit analysis
• Time for all aspects of life
• Successful & comfortable retirementwww.indiandentalacademy.com

“Managing a practice is an art inManaging a practice is an art in
itself which everybody has toitself which everybody has to
master it so as to lead amaster it so as to lead a
comfortable, satisfied life.”comfortable, satisfied life.”

REFERENCES
1) Hamula Warren (April 2003) “Orthodontic office design”.
Journal of Clinical Orthodontics. Volume XXXVII, Number 4
: Page 213 – 216.
2) Hamula Warren (Oct 2003) “Orthodontic office design”.
Journal of Clinical Orthodontics. Volume XXXVII, Number
10 : Page 533 – 540.
3) Iba Howard (July 2003) “Management and Marketing”.
“Orthodontic office design”. Journal of Clinical Orthodontics.
Volume XXXVII, Number 7 : Page 373 – 375.
4) Iba Howard (Sep 2003) “Management and Marketing”.
5) Iba Howard (Dec 2003) “Management and Marketing”.
6) Hamula Warren (Jan 2000) “Orthodontic office design”.
Journal of Clinical Orthodontics. Volume XXXIV, Number
1 : Page 15 – 18
7) Gottlieb Eugene (March1999) “Ethics is orthodontic
practice”. Journal of Clinical Orthodontics. Volume XXXIII ;
Number 3 : page 145 – 150. .www.indiandentalacademy.com

8. Gottlieb Eugene (April 1999) “Ethics is orthodontic
practice”. Journal of Clinical Orthodontics. Volume
XXXIII ; Number 4 : page 221 – 223
9. Mayerson Melvin (March 1997) “Management and
Marketing”. “Orthodontic office design”. Journal of
Clinical Orthodontics. Volume XXX, Number 12 : Page
153 – 162.
10. Mayerson Melvin (Sept 1997) “Management and
Clinical Orthodontics. Volume XXXI, Number 9 : Page
613 – 617.
11. Mayerson Melvin (Dec 1997) “Management and
Clinical Orthodontics. Volume XXXI, Number 12 : Page
821 – 825.
12. Mayerson Melvin (Feb 1996) “Management and
Clinical Orthodontics. Volume XXX, Number 2 : Page 99
– 105.
13. Mayerson Melvin (June 1996) “Management and
Marketing”. Journal of clinical Orthodontics. Volumewww.indiandentalacademy.com

14. Mayerson Melvin (Sept 1996) “Management and
Marketing”. Journal of clinical Orthodontics. Volume XXX
Number 9 Page 493-497.
15. Mayerson Melvin (Dec 1996) “Management and
Clinical Orthodontics. Volume XXX, Number 12 : Page 699
– 702.
16. FinkBeiner Betty, FinkBeiner Charles “Practice
Management for the Dental Team”.
17. DCNA 1988
18. Keim RG et al. Jan 2006 practice growth and staff data
JCO 40 (1) 17- 26
19. Clark JR facing retirement .JCO 2003
20. O Neil JF Developing , implementing & sustaining
marketing plans AJODO 2003 Dec
21. Berning et al. Vision for Orthodontist CEO AJODO 2003
Dec.
22. Gottlieb et al. Manage to Succeed JCO 2003 Nov

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