An Interview with Aaron Nicholas on practice efficiency and staff systems – Part 1
Today we’re speaking with to Dr. Aaron Nicholas, a 27 year veteran of clinical dentistry and a master of efficiency. Dr. Nicholas owns and practices in an extremely profitable, multi-million dollar, fee for service dental practice in Burtonsville, MD.
We discuss some of his most popular clinical and efficiency based systems. Any practice can quickly implement his systems to become more streamlined and profitable. Dr. Nicholas’ obsession with efficiency has lead to years of steady growth and 30% in last year alone, despite the new corporate dental practice which recently arrived across the street from his practice. Dr. Nicholas shares how his staff, systems and quality patient care has actually attracted patients from his competitors and helped his practice experience steady growth.
In this interview you’ll learn:
- Why every dental office needs Systems
- Why you need an Instructions Manual
- How a Template can save you hours in a day
- How to implement changes like 100 calls a day
- Bonus Incentives
Personal Background Story
“Practicing dentistry for nearly 30 years, can you speak on your journey, where you where and how you started off. What were major problems you initially ran into and how did you solve them?
In dental school, my main interests was in treating patients, not so much in research or academics. Started looking for a practice to buy during my last year in 1987. Not finding a suitable office, I opened a scratch startup.
Back then advertising and marketing in dentistry was frowned upon. My professors said, “If you’re good, they’ll find you. Good dentists don’t advertise.”
Obviously wanting to be a good dentist, and to do the right thing, I didn’t focus on advertising. The only ad for the scratch start up was an ad in Yellow Pages. I sat back and waited a few months and nothing happened. Then signed up with PPO’s and HMO’s but that didn’t take off either.
Funds started getting tight and had to look for associate positions which were difficult to find. So I had to resort to a temping as a hygienist for that year.
Eventually found some spots to cover older dentists that were injured and taking time off. All the while was working 2 days a week at the startup, mostly sitting around twiddling my thumbs. All the money from the part time jobs were funneled back into the startup. It got to a point where bankruptcy would be eminent within 7 months.
After talking to a specialist who worked in the same office building, I went to a dental consulting group.
They offered a free month trial period. After asking how long it would take to turn my practice around to becoming profitable, they answered, “about six months”.
I replied, “Here’s the deal, I’ll sign the contract and do everything you tell me to do, but in 7 months I’m going bankrupt. So if you’re not right, then you get to be in line and try to get money through collectors.”
So I test drove them for a month, it seemed like they knew what they were doing. Signed the contract, and within 6 months turned the practice around. It was strictly because prior to the consultant, I had no idea how to run a dental practice.
In dental school, they’re trying to teach you at the speed of light and get you up to par on the basics of clinical dentistry, but they don’t teach you how to run a practice or any business. So when I opened the scratch start up, I fell flat on my face. The consulting group got me set up and going on the right path. That’s when I started to understand how the business of dentistry works.
You study so long and hard for Clinical dentistry, thinking it’s going to be the difficult part. But it’s actually the easiest part of running a dental practice. It’s necessary, but it’s not the thing that’s going to make or break you as a dental practice. I know dentists who are just average clinically, but they’re doing fantastic because they know how to run a practice. They know how to manage staff and how to interact with patients well. These are the things that makes for a successful practice.
As long as you do the dentistry in a somewhat competent manner, you don’t hurt patients, your fillings don’t fall out every few weeks, and are nice; people will trust you. People don’t know what you’re actually doing inside their mouth. As long as it doesn’t hurt, your work lasts long, and you seem like an honest guy, those are the minimal requirements in dentistry.
How did that first consulting group actually “open your eyes”?
In a dental practice, there are different areas and systems. There should be protocols set in place for each of these areas. We didn’t have a protocol or system for how the front desk contacts patients, how to schedule properly, what sort of work to schedule at certain times, or how to even greet patients.
We didn’t have any firm financial policy. Before it was, hey come in, we’ll do the work, submit to insurance and you pay us later. However that last part, you pay us, never happened. Or we got paid so slowly that we couldn’t pay our bills.
How do you actually bring in new patients to the office? What forms do you use? Before the forms were bare and basic. Now we have very specialized forms that target how we want to bring patients into our office.
Even answering phone calls are very important. What questions do you ask over the phone? What questions do you not ask? What’s your attitude like?
All of these things are important in forming a perception in the patient’s mind when they walk into your practice. This will affect how they see your practice and you as a dentist. If you have all those things down in a consistent and professional manner, then patients will see you as good doctor and your practice as professional.
But, if you’re sort of shooting from your hip the whole time, it’s a lot harder to impress a patient. Then when you sit down to tell them what work they need, they’re gonna think twice if their experience up to that point has not been good. If the experience has been very good, professional, organized, where the whole staff seems to know what they’re doing, everybody knows what their role is and the whole place is humming along, then they’ll be more likely to say, “Sure let’s go ahead and take care of that”.
Having the right system and protocols set in place can make or break a practice?
When you get down to it, the systems in the office will allow you to work efficiently and get things done on time. Your life well be less stressful and your practice can become successful.
A lot of times, the systems only exist inside the doctor’s head or inside the mind of a superstar staff. Somehow you’ve worked along and reached the point where everything sort of just manages and get by. But if that key staff decides to leave or gets run over by a bus, all of the systems in your practice just went goodbye with that person.
So what we’ve learned over the years is that you must have your system written down. If you have a protocol and written systems, it’s much easier to train new staff. Simple things like, setting up a bur block can be systematized. We have different blocks set up for certain procedures. There is a big picture in the back showing exactly what burs go in each block. As opposed to having someone sit down and tell them, which burs go in what block. They’ll have to remember which bur goes where and for what procedure. How many times will it take them to set up and get it right?
Then when you sit down to work on a patient and realize that bur you need isn’t there, you have to sit and wait for someone to get it, interrupted from the procedure. This also doesn’t look good to the patient, if things constantly have to be stopped and interrupted.
It’s a matter of what makes the office run smoothly. It’s like trying to walk and halting at every step along the way because you don’t have everything you need set up properly.
So it’s like having an instructions manual for the staff.
It’s exactly like having an instructions manual. If you go to McDonald’s and want to learn how to make a hamburger, for sure they have a standard operating procedures manual or something written down that tells you exactly how to make the burger. How long you cook it, what do you do after, each step along the way. All those things are regimented so that it can be done the same way every time. Otherwise a Big Mac would taste different from each McDonald’s, there wouldn’t be any consistency.
In a dental office, it’s kind of the same way. Especially if you have multiple rooms and several assistants running around. If each DA sets up differently from one another, you’ll have to sit there looking around for stuff as you’re going through a procedure, yeah it might be on the 12×18 delivery tray, but you still have to look around for each thing on the tray because it’s not where it’s supposed to be.
Maybe something is missing, but you won’t be aware of it because it doesn’t have a home, a specific place to be.
So you start looking for the thing and then you realize it’s not there, okay so let’s go look in the drawer or call somebody to get it. Each of these steps, are small and don’t seem like a big deal. But if you’re constantly doing this throughout a procedure, it slows things down, it doesn’t make the procedure flow smoothly.
You have a “home” for each specific item?
Let’s say you’re setting up a room for a RCT, build up, and crown. That’s a lot of stuff, there are lots of bits and pieces to set up for those three procedures to be done efficiently.
We have a laminated template for each procedure. The template for that specific procedure goes down, you put the cassette on top of it, each of those instruments in the cassette are set in a particular order. On the template it shows you where each item goes. So you just go and load up the template. If something’s not there, there will be a space on the template showing exactly what’s missing. So X, Y, or Z won’t be forgotten.
Before you even start the procedure, you know that everything you need is there. Now you can sit down and work through your procedure without being interrupted. You don’t worry if you have what you need. You never have to stop for somebody to get something, it’s all there and the whole process runs smoothly.
A lot of the things were developed over the years, invented, or tweaked to solve my own problems. It was always frustrating having to stop and wait for an assistant to go get something. So I needed a system to assure me that everything was there before we started. So that’s how we got the template system we use now.
Your practice has been an evolution of tweaks over the years. How do you get your staff to implement change?
You’re basically asking, “How do I stay motivated to implement new things, because the staff will always be resistant to change.”
Way back my first consultant suggested I go to this CE. I was fresh out of school thinking, “Why do I need to go to this course? I just got out of dental school, I already know everything that I need to know about dentistry.” They just chuckled and told me come along anyways.
I went to that first course and my eyes were opened. That’s when I realized how differently dentistry is practiced from how it’s taught in school. At school they teach the time honored bulletproof method of getting the job done. But there are lots of faster, easier, and more elegant ways of delivering dental care that you really want to avail yourself to.
At that first course, they told me something that stuck. They said, “We’re glad that you’re all here, that puts you above 80% of the profession. But the sad news is, that 80% of you guys here will never do anything with what you learn or try to do something and your staff will talk you out of it. Only 20% of you all here will actually implement what you learn.”
At the time I was facing bankruptcy, being right on the edge, everything I did had to count.
So I took a piece of paper and wrote a list of things to do back at the office. That paper was taped up on the wall next to my desk. Working through the list was met with resistance from the staff. But I kept going back to the list because the paper hanging on the wall was a constant reminder of what wasn’t done.
Each time I saw it would remind me of what I wanted to implement. Even after 4 weeks, it’s still hanging there and it hadn’t been checked off. Not wanting to be like the 80% of guys that didn’t do anything, I just pushed through. I needed to be the other 20% because I was in financial straights.
As far as getting resistance from staff, it happens all the time. First we would have a meeting and I would tell the staff, “This is the situation we’re in, we have to make these things happen.” They’d all agree to do it, but you’re still going to get resistance. People just don’t like change.
Where we’re currently at with the practice now, is that we have changed things so many times, that the staff has lost their knee jerk reaction to resist change, because things are always changing, and they know it will always change.
You have to realize, some things you try will work, some things you try will not work. So I try not to do too many things that will fail. You don’t want them to think, “Here he goes again, this probably won’t work either”.
Every time before implementing something, it was verified with others. I’d call others asking, “Have you done this? Did it work like the guy said it would? Okay great. What were the biggest problems that you ran into in implementing this?”
After confirming with others and finding out the issues, I’d present the new idea to the staff.
I could say, “Hey I talked to these 3 guys that did this, it worked great. But these are the problems we’re going to run into.” That way when we did run into those problems, they would be reminded, “Yeah, he said this would happen”. So they would just work right through the problem.
That was my way of mitigating the resistance I would meet from the staff.
There is this saying,
“You make the right decision,
once the decision is made,
you make the decision right.”
So you make the decision to do whatever it is you’re going to do, and then you just do everything possible to make sure that it works. You just have to.
Your staff makes over a 100 calls a day. How would one implement this?
Well it actually started out that each person would make 35 phone calls a day. We have patients in different categories. With new patient when we present treatment, we always ask, “If we don’t hear back from you in a few weeks, is it okay to call you?” Then we place that tx plan in a separate folder. We also have patients with recently missed appointments and those that have not shown to the office in over a year.
One person is responsible for filling the hygiene schedule. Her 35 calls start with people that recently missed appointments or canceled, because they will be easiest to get back to the office.
Another staff member who will do some hygiene and primarily fill the doctor’s schedule. So if the need is to fill hygiene, she’ll work together with the other person to fill hygiene schedule. If the need is for the Doctor’s column, then she’ll call treatment plans presented.
Then my office manager will do primarily Doctor’s side. But if we get into a situation where hygiene is wide open, everybody is making hygiene calls. That’s the way it’s going to be.
Because in my office, 60-80% of the production will come from the hygiene side. Same day dentistry, previous planned treatment, patients waiting on insurance benefits to renew, or things that got lost in the shuffle.
The way you make sure it happens is to have office manager hold them accountable. Each staff writes down their own To Do List for the day. They have to write down the names of all the patients that they called to fulfill their 35 calls.
But what you don’t want to have happen, is for them to make the first 5 phone calls with no answers or all rejections. Then they’ll get an attitude of let me just plough through the list. You don’t want them to just crank calls out just to mark the paper.
Our general rule is: If you make 5 phone calls and they’ve all been negative, go take a break for a little while. Come back to it later, and let’s do it again when you’re refreshed.
You can’t just lock someone in a room and tell them to go through a long list. They have to be calling with the right attitude and mindset because it will be conveyed to the other end of the phone. If it’s not working, let’s take a break and come back to it in a little bit.
There is an accountability system with one another. The list of calls must be sent to the office manager at the end of the day.
So do you reward positive results of scheduled calls?
The entire office is on an incentive program. So patients sitting in the chair means, work gets done, which means collections, which means bonus at the end of the month.
How long have you been doing a Staff Bonus System?
We’ve been doing it for quite a long time and we’ve done a few different bonus systems.
We had a “New Patient Bonus”. For every new patient that came in, they would get $x. That worked out okay.
Then we had bonus based on initial pay without raises, but as the practice did better, they would get paid more in $/hr. That one blew up on us because we were basing it on production and not taking into account the overhead. They started with me when we were doing $50k per month and now we’re doing $150k/month and it went out of control.
So now we take into account overhead, reasonable amounts of pay, etc. Our current staff salary is at the higher end for a dental office. I want my staff to be the best paid in town, but we can’t have it sink the whole ship.
If we hit our collection goal and stay below 65% overhead, then they get to divide a small percentage of the overall collection equally among the staff. It also depends on the hours they worked. If a staff took a week vacation that month then they would get a lesser portion of the share. It doesn’t include vacation pay sick pay, because it’s your body in the office producing the bonus.
Do you believe every office should have a staff bonus system?
It helps a lot, but it has to be structured right. As human beings, we’re going to only do the work we’re being paid for. If I told a hygienist, instead of seeing 7 patients a day, now you’re going to see 16. They’re not going to be motivated to work at all unless there is an incentive to work harder. But if they get a piece of the pie, they’ll be more motivated.
Before the bonus system, nobody would be willing to stay extra hours to work for last minute emergency patients that walks in 10 min to close. Now staff are on board to do the right thing for the patients.
This concludes Part 1 of the interview. Continue to Part 2 on “Increasing Case Acceptance and Hygiene Profitability.“
You can listen to his full podcast interview here.
To learn about Dr. Nicholas Systems, readers can receive a 10% discount on purchases using the code “AUXO” on his site.
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.