NINE

Deal or No Deal: Understanding Patients’ Six Layers of Resistance

The group sat around the coffee table in Joe’s basement, listening to Joe’s replay of his conversation with Tom Pinkerton. Everyone except Rich offered consolation. Rich waited until he thought that Joe was ready to listen and began, “Joe, the school board deal is a great deal if it comes to pass. But I have to tell you that more than once, I have been almost ruined by great deals.”

“Explain, Rich,” Joe’s words came out with a forceful sigh.

“Every time something happened in my practice that brought in unusual money very suddenly and easily, I became complacent about the constraint in my practice. I neglected it. Sometimes, it was OK for months, even a year or two, but then it would flare up and cause problems when I was least prepared. Do you know what my overall constraint has been for almost all of the past 10 years?” Rich asked.

Everyone shook their heads, without even a guess. Rich said, “It’s really obvious. Dealing with internal constraints is not always easy, but it’s still within my area of expertise and control. I learned how to hire really good people. I learned how to let go and empower my people to do their own jobs and help me do mine. When I need more people now, I don’t worry about it anymore. My office manager does almost all the work, including training. My staff has learned how to sell treatment plans with a success rate of more than 90 percent.”

Brian laughed. “All right, so we know what isn’t your constraint. It’s getting late, Rich, and the babysitter clocks are ticking!”

Rich laughed and said, “Sorry, I keep having this fantasy that I’m a university professor and I can talk until the buzzer sounds. My ongoing constraint is in the market. Today, it’s the new patients. What I believe drives this constraint is my poor skill in knowing how to attract enough new patients to our practice to keep a constant flow of increased work for myself and, now, for the other dentist in my practice. It’s only in the past two years that I’ve begun to attack it with success.”

“So what’s your point, Rich?” Joe asked.

“My point is especially for you, Joe, at this stage. You don’t know whether or not you’re going to get the school board deal. That’s the best thing that could have happened to you. Why? Because it forces you, right now, to deal with the biggest ongoing constraint to improving your business. And if you end up getting the school board deal in two weeks, your practice will improve tremendously, almost overnight. If you don’t get the deal, you will still be on the way toward a very lucrative practice; it will just take a little longer.”

“I know you’re right, Rich, thanks,” Joe said. “Honestly, both Brian and I really appreciate hearing your perspective on this. So what do we do now?”

“I’d like to start by reviewing the Five Focusing Steps and applying them to your practices.” Rich began: “Step 1 is to determine the system’s constraint. In my opinion, the dentist should always be the constraint since the dentists and hygienists are the only billable staff. And a system is much easier to manage if you only deal with one constraint, not two or more. The more patients that the dentist is able to see, the more throughput you earn and, hence, the greater the revenues for the practice. Do you both agree?”

“I agree to a point. I need more patients, but it’s also about the types of procedures we’re doing. It’s not supposed to be a factory,” Brian complained.

“I agree, Brian. I’m not into dental factories,” Rich admonished. “This is not just about money but about quality of life. When are you happier—when you’ve had a busy, fulfilling day or when you’ve sat around half the day dealing with billing or bookkeeping problems?”

Joe and Brian both admitted that Rich had made his point.

“If we accept that the dentist is the constraint,” continued Rich, “then step 2, more precisely, is to do everything to ensure that nothing obstructs the dentist from performing his or her work. This means that all documents, lab work, and instruments must be ready when the dentist is ready to work on a particular patient. This is called Total Kit Readiness. If the patient needs medical clearance, consent, medical history update, or financial approvals from third parties, they all must be ready and in the patient’s record prior to the dentist working on the patient.”

“Sure,” Joe offered, “but what does this have to do with our problem right now, of being in the hole financially?”

“I’m so glad you asked, Joe.” Rich said. “It has everything to do with it. What’s obstructing you today from doing your billable work? You don’t have enough billable work lined up. So the constraint’s time is wasted. Step 2 means don’t waste the constraint. Wait—before we finish today, I guarantee that you’ll have some help with this step. Let’s briefly review the remaining steps, so we can put this all into perspective.

“Step 3 is to make sure that everyone is following procedures to allow the dentist to generate throughput. In a few weeks, when your calendars are almost full, we’ll talk about scheduling and how much of a dentist’s time is typically wasted because of poor scheduling practices. But for now, just understand that you both reacted incorrectly to the current economic situation by laying off staff. It created hostility in your staff, which compromised patient care and resulted in patients canceling lucrative procedures such as veneers and crowns. You did the opposite of what you should have done. Tell me what happened.”

Joe answered for both himself and Brian. “For both of us, our staff was not sure who was going to get laid off next, so they started looking for jobs elsewhere. They were overloaded with work, and their stress levels and negative attitudes started to become obvious to our patients. The patients openly complained, but no one was recording their complaints, and our greeting staff was covering up. The crisis hit me when my hygienist quit because she was forced to clean her own room, make her own appointments, and call patients herself. There were holes in her schedule, and I was expecting her to help out with procedures like an assistant. She outright refused. She told me she was trained to do only hygiene, and assisting wasn’t in her job description.”

“It sounds to me like she had a good point. So what did you do, Joe?” Rich asked.

“With the increasing slowdown in both of our practices, Brian and I decided to offer our hygienists commission with base pay. We had heard about profit centers from the last seminar we attended together. The hygienist room and supplies could be kept separate, and the profit was calculated based on revenue allocated according to the number of patients the hygienist saw less the total cost allocated to her department. However, war broke out among the classes when the hygienists demanded that the assistants take the x-rays. In addition, they wanted the dentist to use a different room for seeing patients.”

Rich commented, “This is the perfect example of the opposite of step 3. Instead of everyone helping the dentist deliver more throughput, it was every man and woman for himself or herself. That’s what artificial profit centers do to a practice.”

“In hindsight, we both agree with you,” Brian concurred. “It seemed like our staff members were forgetting about the patient. The patients came for oral health care, and they expected the dentist, hygienist, and support staff to work in harmony to serve their needs and wants. If the hygienist is looking after her commission, and the dentist is looking after monetary gains, what is the quality of care we are providing our patients? Both of us saw a further decline in our practices, with open schedules and increasing stress.”

Rich concluded on step 3: “Given both of your current situations, the correct action is the opposite of what you did. You need more staff to help increase sales, and you need everyone working as a team for the patients.”

Both Joe and Brian had the identical reaction. “Rich, we can’t afford to pay more staff.”

“Follow my advice today, guys, and your practices will reverse the trend/>