Cohen’s Pathways of the PULP

CHAPTER 30 Key Principles of Endodontic Practice Management

ROGER P. LEVIN

Operating a successful endodontic practice requires both excellent clinical and management skills (Fig. 30-1). Endodontists are extremely well trained in their clinical specialty, but most do not receive extensive business training prior to becoming a practice owner. This scenario is beginning to change as more in the dental profession recognize the value of practice management skills and the role they play in an endodontist’s ability to have a successful and rewarding career.

FIG. 30-1 The keys to achieving practice management success.

Endodontists who possess management skills are better positioned to handle the demands of operating an endodontic practice—a business that can generate significant revenue. Historically, there was a time when endodontists could enter practice without strong business skills and enjoy a long, prosperous career, but the business side of endodontics has become more complicated in recent years.

Young endodontists are leaving dental school and residency with far more debt than even a decade ago. The cost of purchasing or opening an endodontic practice continues to rise. In addition, endodontists face increased competition from other clinicians who perform root canal treatments. The success of endodontic practices can also be affected by the development of new clinical techniques or services. For example, some clinicians believe that dental implants are a better treatment choice than root canals, depending on the difficulty of saving the infected tooth. As dental implant procedures become easier and more common, this trend may continue to grow.

To meet these and other challenges, endodontists need to supplement their clinical expertise with the necessary practice management skills. Practice management involves the use of documented systems to achieve superior business results. Effective practice management allows endodontists to provide optimal patient care while creating a highly productive, low-stress office environment. The design and implementation of effective practice management and marketing systems enables endodontists to operate their practices as successful businesses with steady growth and maximum efficiency. Endodontists who can combine excellent clinical skills with strong practice management skills will experience greater practice success (see Fig. 30-1).

Endodontic Management Systems

Written, documented systems are the basic foundation for all successful operations within an endodontic practice. Step-by-step, reproducible systems enable a practice to operate successfully as both a provider of patient care and a business enterprise. Documented systems reduce unnecessary stress and allow endodontists to remain chairside so they can focus on providing exceptional quality of care. As each system is established, every step in that system must be clearly documented and then implemented. Many endodontists fail to establish efficient systems in the early years of a new practice, and inefficient systems can hinder the practice’s growth, increasing stress for the doctor and team.

Endodontists should begin their careers by developing and implementing effective practice systems. This way, when a practice begins to grow, the office has a solid management foundation in place to allow for the achievement of more challenging goals. If the practice waits until it gets busier, there is less time to design effective systems, and the endodontist often becomes less motivated to do so owing to a higher level of “busyness” and other responsibilities in life.

Systems Design

New practice owners have an excellent opportunity to design systems when capacity is available. This type of foresight sets the stage for practice growth in the years to come. However, systems should be evaluated and updated throughout an endodontist’s career. It will be necessary to replace most major endodontic practice systems on a 5- to 7-year cycle to maintain growth and profitability. The reason is that practices regularly outgrow their systems as a result of changes in staff, equipment, technologies, referral relationships, and the economy.

Systems should be designed based on the specific characteristics of each practice. Areas to be considered include:

• Days of operation

• Hours of operation

• Number of staff

• Number of patients

• Number of emergencies

• Average daily patient flow

• Types of procedures offered

• Number of chairs

For example, a practice that sees a higher volume of patients will probably need more staff than a practice that sees a lower number of patients. The same would be true for a practice that participates heavily with insurance companies versus a fee-for-service practice.

Effective management systems can make the difference between a successful endodontic practice and a highly successful endodontic practice. Many endodontists cannot fathom how they could see any more patients, produce any more revenue, or work any harder. Yet, there exist similar practices that have much higher production in the same number of days per week with the same number of staff. It is always interesting to reflect on why one endodontic practice can be so much more financially successful than another practice in a similar situation.

Assuming a sufficient patient flow, the answer always comes down to management systems. It is not about working harder or faster, but creating systems that allow the practice to operate at a specific production and profitability level in a low-stress environment. Key systems and principles for effective endodontic management and marketing include:

1. Vision

2. Mission

3. Goal setting

4. Key performance indicators

5. Staff training and development

6. Scheduling

7. Customer service

The first question endodontists should answer before opening or purchasing an endodontic practice is “What kind of endodontic practice do I want to have?” This question requires the endodontist to take some time and identify a vision, which is a description of where the doctor wants the practice to be in 3 to 5 years. Whereas some vision statements may reflect a longer period, this shorter timeframe works well for most endodontists because it is difficult to predict changes in dentistry, the economy, and other events more than 5 years into the future. In addition, after 3 to 5 years, it is time for the clinician to review what has been accomplished and possibly establish a new vision for the practice.

These are just a sampling of questions that can stimulate the design of a vision statement.

A vision statement clearly articulates where the practice is going. The length of a vision statement can vary between a short, single paragraph and several paragraphs. It is probably counterproductive to have a multipage vision statement; it will be difficult for both the endodontist and staff to fully grasp such a lengthy and complex vision.

The vision guides the long-term development and growth of the endodontic practice. Once the vision statement has been created, it should be shared with the endodontic staff on a regular basis. Good leaders always communicate their vision to their staff. When team members understand where the practice is headed, they are empowered to help the endodontist achieve his or her vision. Sharing the vision inspires commitment and participation in achieving the vision. The following are two examples of vision statements:

Once the vision statement has been created, the next step is the development of a mission statement.

Once again, a strong leader has a clear practice mission and shares it with the team. Because of the similar services provided by endodontic practices, many mission statements resemble one another—they talk about quality, patient care, practice services, and customer satisfaction. It is not important to have a mission that differentiates one practice from another, but it is essential to have a mission that reflects the doctor’s true vision. Here is an example of a mission statement:

One way to keep the mission statement top of mind is to display it prominently in several places throughout the office, as well as on the practice’s website. The most powerful reason for displaying the mission statement is to reinforce to the team that the mission is a living document that guides the practice. An added bonus of displaying the mission statement is the opportunity to let patients know of their importance to the practice.

The endodontist should reference the mission statement on a regular basis. Reinforcing the mission during meetings helps staff members focus on why the practice exists and the difference the team is trying to make in the lives of patients.

Goal setting is one of the most important business activities for endodontists. It is critical to achieving success in a doctor’s professional and personal life. Once a vision and mission are established, annual goals are the method to make the vision and mission a reality. Goal setting is a step-by-step methodology that leads to the achievement of the overall vision. To be effective as a goal, it must be:

Goals that lack these three characteristics cannot be considered goals and are much less likely to be achieved. Be sure that all of the goals are aligned with the practice’s vision and mission to achieve the desired results.

The hectic pace of today’s endodontic practice obliges many doctors to focus on day-to-day operations and fail to step back and see the big picture until many years have gone by. Goal setting and regular goal review can help endodontists manage their practice instead of being managed by it.

Far more than just a motivational concept, goal setting acts as a timeline, benchmark, and directional process to achieve the vision and mission. A vision or mission without specific goals is merely an idea. Endodontists who set goals are much more likely to achieve their goals and ultimately make their practice vision and mission a reality.

Without data, an endodontic practice cannot be well managed. To obtain a clear picture of current and potential practice performance, practice goals must be monitored and measured. Key performance indicators (KPIs) provide an accurate assessment of the practice’s most critical functions, including:

These KPIs offer endodontists a starting point for analyzing their practices. Once the information has been collected, weekly measurement and analysis are necessary. Although this may sound arduous, a weekly review should take only a few minutes. Such frequency of analysis can bring substantial benefits to the practice.

Evaluating KPIs every week allows endodontists to rapidly identify trends or performance deviations that may be difficult to discern otherwise. With accurate practice data, endodontists are then able to take appropriate actions.

Establishing practice systems will only be effective if the team understands their roles in making those systems work. Training the endodontic team begins with the development of job descriptions that list the skills, responsibilities, and accountabilities needed to perform each staff position. Bear in mind that the majority of endodontic staff will be hired without previous endodontic or dental experience and must be trained on the job.

Training is specific to each position so that all team members can perform their duties and responsibilities as independently and effectively as possible. During training, it is critical that practices document training policies and procedures. When policies and protocols are documented, they can be clearly communicated to new staff and regularly reinforced by current team members.

One frequent problem is that many team members fail to fully understand their job responsibilities and are not held accountable for their performance, which means the endodontist will continue to handle numerous responsibilities that should be performed by other team members.

Although this type of behavior may be common in the early stages of an endodontic practice, endodontists who become effective leaders learn how to delegate appropriate tasks to the endodontic team. The goal for every endodontist should be to spend 98% of their workday involved in direct patient care or communication with referring doctors. To reach this goal, it is recommended that endodontists make a list of all activities they will perform and all responsibilities that will be assigned to the endodontic staff. This exercise will allow the endodontist to clearly identify which activities should be handled by the doctor only and which can and should be delegated to the team.

Delegation empowers the team to take ownership of their roles in contributing to practice success. The concept involves giving responsibilities to staff members so that endodontists can concentrate on what they do best. Without delegation, endodontists often carry out numerous responsibilities that can be performed by others. To spend more time in direct patient care, endodontists must delegate appropriate responsibilities to specific staff members. In addition, the team should be cross-trained on systems to cover for any illnesses, vacations, or turnover.

Once all team members have achieved a high level of expertise and independence, the practice can operate at peak performance. Efficiency, professional satisfaction, and quality of care steadily climb to maximum levels. At this stage, endodontists trust their teams to effectively perform their duties with minimal oversight. Best of all, doctors can focus on providing exceptional patient care without distractions and unnecessary stress.

In successful endodontic practices, the doctor focuses 98% of working hours strictly on patient care, interdisciplinary treatment, and referring-doctor communication. These practices will typically reach 90% to 100% of the practice production potential.

Making changes in the area of practice management should begin with a thorough evaluation of the schedule because of its impact on all other major systems. If the schedule is integrated properly with all other endodontic management systems, the practice has the best opportunity to achieve the endodontist’s goals.

Schedules are created to achieve specific practice production in a low-stress environment. This means that an endodontic practice must establish a target for its annual production and design the schedule accordingly. Each year, endodontic practices should complete an exercise of determining the desired level of growth and create a schedule that allows for that growth. The greatest challenge to increasing production is scheduling limitations that make it all but impossible for the practice to grow.

The following principles are essential when designing the ideal schedule for any individual endodontic office.

Design the schedule to achieve a specific production goal. Endodontic practices are typically capable of growing between 5% and 15% annually. Less than 4% growth represents moving into a plateau. There are endodontic practices that can grow by as much as 25% to 30% in a single year as optimal systems are implemented.

Scheduling is a quantitative and mathematical activity because time is quantitative and therefore measurable. The schedule should answer questions like: How many of each service will we need to perform this year? Will those numbers allow for the production goal to be achieved? Benchmark these production goals against the hours and days per week the practice is available for patient care, and adjust the schedule accordingly.

Setting the daily goal is a reflection of the annual production goal. To determine the daily goal, simply take the annual production goal and divide it by the number of days the practice will be operating that year. Then build the schedule around this key number. Front desk personnel should become aware that the top practice management priority is to achieve the daily goal. By implementing an excellent scheduling system, they will have a far greater chance of successfully accomplishing this task.

Many practices are unrealistic about how much time they actually need for procedures. One common example is for root canals to simply be scheduled at one per hour, even though the practice is becoming more stressed and rarely runs on time. Performing “procedural time studies” to determine the exact amount of time needed for each procedure is recommended.

During procedural time studies, each type of treatment performed by the office should be measured approximately 10 times to develop an average procedure time. Once these studies are performed and the schedule is updated, most endodontists will usually be able to increase their endodontic workload by using time more efficiently.

Young endodontists should perform procedural time studies once a year for the first 5 years they are in practice. After that, studies can be conducted at less frequent intervals (every 3 to 5 years) to evaluate whether the endodontist has become faster or more efficient, either by experience, technique, or the use of new technologies in the practice. Procedural time studies play a critical role in building an effective and accurate schedule, which directly affects the success of the endodontic practice.

The schedule should be designed to perform larger and more complex cases in the morning whenever possible. This can be extremely challenging owing to the number of emergencies seen by endodontists during a normal day. By scheduling larger procedures in the morning, practices can avoid the fatigue factor that occurs later in the day for both the endodontist and the team. Of course, emergencies will continue to occur, but effectively managing other appointments will better position the practice to handle end-of-day emergencies. Other recommendations for creating the ideal day include:

Basically, this means that the more difficult or larger cases will occur in the morning when the doctor and team are fresh. As the day goes forward, the doctor and staff have the opportunity to work on less complex cases, such as second visits and patient consultations, with all minor procedures at the end of the day. A highly organized schedule will allow for increased productivity and higher profitability while decreasing stress for the endodontist and the team throughout the day.

No discussion of endodontic scheduling would be complete without a focus on emergency management. Emergency procedures are a frequent occurrence in endodontic practices. Managing emergencies well requires a combination of referring-doctor management, setting patient expectations, and effective scheduling. The result will be a highly productive, enjoyable environment for any endodontic practice.

The first step in managing emergencies is to develop a schedule that allows some flexibility throughout the day. It does not benefit the practice to create a schedule that is 100% maximized without accounting for emergencies. Instead, analyze how many emergencies occur on an average day, and then leave time for that number of emergencies in the schedule. Many high-level endodontic practices will often schedule only 80% of their day, leaving time slots for emergencies. The key is to not ignore the time slots and invite every emergency patient to visit the office immediately, but to manage each situation appropriately.

For example, a patient who is in mild discomfort calls at 10 am. The practice does not have an opening until 12 noon. If the patient is allowed to come in immediately, the office feels a need to work the patient into the schedule, not only causing stress for the doctor and team but possibly forcing already-scheduled patients to wait longer than expected. If the practice manages the emergency patient during an emergency time slot, the opportunity to create an excellent flow for the day and a positive customer service experience for every patient seen is maximized. The main point is to provide optimal care and exceptional customer service without disrupting the daily schedule.

Scheduling is the single most important system, because it integrates with all other systems. When an effective scheduling system has been established and properly implemented, the practice will immediately see an increase in productivity and a decrease in stress. Most stress in endodontic practices is based on poor scheduling methods that overwhelm the doctor and team while lowering customer service. This same type of stress is indicative of inefficient practice systems, which means that even though the endodontist is actually working harder, profitability will be lower. An efficient schedule enables the endodontist to provide a high level of care and customer service to all patients.

Customer service is much more than just “being nice” to patients. It is a system focused on managing the patient experience from the initial referral to treatment to postoperative care. Outstanding customer service is critical to exceeding patient expectations and building strong relationships with referring doctors.

The vast majority of endodontic patients are referred to the practice by general dentists. The growth of the endodontic practice depends on the satisfaction and confidence of referring doctors. General dentists want to know that their patients’ expectations, as well as their own, are being met. When patients receive excellent clinical treatment and superior customer service, they are likely to provide positive feedback when returning to their general dentist. Positive feedback from patients reinforces the dentist’s confidence in the endodontist and leads to continuing referrals.

Developing a customer service system is more complex than simply telling the staff to be nice to patients and referral sources. A customer service system requires that patients consistently receive the same level of responsiveness, caring, and concern from every member of the practice. Consistency and quality are at the core of a practice’s customer service system.

Although the patient’s time in the endodontic practice may be limited, the endodontist must realize that the patient will be returning to the referral source and sharing his or her experience with the referring doctor and/or the clinician’s staff. The patient will also share information about the experience with family, friends, and others. Negative word-of-mouth descriptions about the office will obviously hurt the endodontic practice’s reputation within the community.

Patients want to believe they are the practice’s only priority when they come in for their appointments. Endodontic practices with excellent customer service strive to meet this expectation. If a practice fails to return phone calls in a timely fashion, is running late when the patient arrives, or does not seem prepared for the appointment, patient confidence and trust disappears, as does their perception of quality care.

Practices should manage expectations by making everything about the patient’s treatment plan value based. Do patients fully understand the value of their treatment plans? Do they know exactly what the treatment entails, what the fees are, and why the treatment must be done? Does the patient know the projected outcome? All these questions must be satisfactorily answered before treatment starts.

The business model of an endodontic practice is based on receiving referrals from general dentists and other doctors. There will certainly be the occasional patient who selects an endodontic practice through the Yellow Pages, Internet, or recommendation from a friend, but the majority of endodontic patients will be referred by other clinicians. For endodontic practices to reach their true production and profitability potential, a referral marketing program should be in place. The major challenges with implementing a referral marketing program are:

Referral marketing is a specialized form of marketing. Endodontists are trained clinicians with little to no experience or expertise in this type of marketing; most endodontists typically learn about referral marketing through trial and error. This process can be time consuming and costly in terms of missed opportunities.

Endodontists are extremely busy. They are not only the main producer in the practice but often the only producer. It is not unusual for an endodontist to work 8 hours a day highly focused on providing patient care and managing the practice and have little time to think about referral marketing. This is problematic because effective referral marketing is not a few isolated activities but a complete program that must be carried out in a systemized manner to achieve desired results.

Perhaps the chief reason referral marketing programs fail is inconsistency. Inconsistent referral marketing leads to inconsistent referrals. The typical pattern is that if the practice has slowed down, the endodontist will attempt to increase referral marketing until positive results are generated. Once referrals increase, then referral marketing slows down or ceases altogether. This stop-and-start type of marketing leaves practices more susceptible to the effects of economic conditions, increased competition, and a host of other factors. A consistent referral marketing program is the solution to numerous challenges that face endodontic practices.

Referral marketing should be viewed as a mandatory part of the practice’s systems. Referral marketing has two major components:

Referral marketing differs from traditional marketing in that it is relationship driven. A successful referral marketing program requires positive and consistent contact with referring doctors and offices. It is an investment in time and energy, but when done correctly, it can generate a steady influx of referred patients from dentists and other doctors. Communication is critical to establishing and maintaining strong relationships with referring dentists and their practices. Sharing information about mutual patients throughout the treatment process creates a sense of partnership and teamwork that is essential to relationship-building. To strengthen relationships with their referral base, endodontists should meet regularly (e.g., quarterly) with their referring doctors. These meetings can be formal or informal occasions, but they provide an opportunity to enhance both the treatment process and the referral relationship.

Building a strong relationship with referring doctors requires more than one or two conversations or meetings a year. By implementing a series of consistent, ongoing marketing strategies that reach referring doctors, endodontists create greater awareness for their practices and services while building and maintaining referral relationships. Referral marketing strategies are selected from areas such as professional relationship, clinical education, social activities, and patient satisfaction. For example, hosting a practice management seminar is a “professional relationship” strategy, and going to a sporting event with a referring doctor is considered a “social activity” strategy. An effective referral marketing program encompasses multiple strategies, resulting in stronger relationships with referring doctors and their teams. The more referrals an endodontist receives, the greater potential for long-term growth and practice success.

Leaders possess many skills, qualities, and attributes that are the result of learning, experience, and self-motivation. Many people have great ideas or vision, but true leaders are able to implement those ideas or carry out the steps necessary to achieve predetermined goals. They have the ability to inspire others to do their best. The most successful endodontic practices are guided by strong leaders.

Becoming an excellent leader starts with the desire to have an outstanding practice. Most endodontists are highly motivated to be excellent clinicians. Endodontic continuing education is focused mainly on clinical topics, which is extremely appropriate, given that doctors have an obligation to provide the best possible care to patients. This makes it even more important for endodontists to seek out opportunities to develop leadership, business management, and marketing skills.

As practice owners, endodontists are automatically viewed as leaders by team members. The more leadership skills an endodontist can master, the better leader he or she will become. Though not an exhaustive list, the following leadership skills are critical for endodontists:

Interpersonal skills are the foundation of leadership. Endodontists work with a small group of people in a fairly limited space. Good interpersonal skills are essential for a smoothly functioning office environment. In business, there are many successful “tough” bosses. Even though they may be disliked, they are respected. Unfortunately, being tough or inflexible is not always the best strategy, especially in dentistry. Few endodontists can be tough leaders and still expect to have happy team members and a successful practice. The best practice leaders can motivate their staffs, accomplish goals, and are well respected by their teams. Regular morning meetings and monthly staff meetings provide excellent opportunities to communicate with the team, increase awareness of practice challenges and goals, and build stronger interpersonal relationships with team members.

As the CEO of the practice, endodontists must make business decisions. There are many people who do not progress in business simply because they teeter between two ideas and fail to make a decision in a timely manner. No matter what the issue, excellent leaders make decisions and trust their instincts, based on analysis, education, and experience. Why? Strong leaders believe in themselves and their knowledge base. They are confident and have the ability to make decisions that are in their best interest and that of their teams.

Motivation is one of the most important skills for a leader. The endodontic leader is able to bring together a team of individuals to achieve shared goals and move toward the practice vision. Many people are not self-motivated. Instead, some external force motivates them. In this case, the external force is the practice leader. It is easier to motivate others and work as a team if the leader is trusted and respected.

Practice leaders are usually in constant pursuit of knowledge. They want to excel in the management of the endodontic practice and will read, listen, and learn as much as possible about the subject of practice management. Leaders are typically lifelong learners who do not learn sporadically but tend to seek out opportunities to learn new ideas and strategies on an ongoing basis.

Endodontic leaders never work on their own. They rely on their team to help achieve practice goals. However, many people mistake the concept of being a leader with being a “ruler.” The “ruler” approach is not an effective one when working closely with a team whose performance is tied to the ultimate success of the practice. Therefore, endodontic leaders must remember that they are part of a group dynamic. In fact, the practice leader is like the coach of a basketball or football team. He or she creates a game plan, guides the team, and facilitates teamwork.

Time is one of the leader’s most important assets. Endodontic leaders must not only manage their own schedule but their team’s as well. However, good leaders do not micromanage their team. They educate staff members, provide guidance, set expectations, and hold the team accountable for the results.

Successful leaders effectively and efficiently use their time, creating positive outcomes for themselves, their teams, and their practices. Good leaders also eliminate extraneous items from their lives that take time away from achieving their goals.

The best way to earn the team’s respect is to “talk the talk and walk the walk.” The way the endodontist behaves will have a significant effect on how the team acts. The professionalism exhibited toward patients, the doctor’s attitude and interactions with individual staff members—all of these behaviors send messages to the team. The team is looking to the endodontist for leadership guidance, and the best strategy is to serve as an effective role model. If the team is expected to show up on time, the endodontist cannot stroll in 15 minutes late every day without causing resentment. Good leaders adhere to the rules others are expected to follow.

Leadership is a way of thinking and acting based on desire, skills, training, and specific behaviors. Endodontists who are willing to develop leadership skills will inevitably build better teams with lower turnover and higher efficiency.

Effective practice management involves management systems and referral marketing that allows an endodontic practice to provide outstanding patient care while operating as a successful business enterprise (Fig. 30-3). The #1 source of practice stress is the lack of efficient systems. When an endodontic practice operates year after year without strong systems, the endodontist experiences increased stress and frustration. On the other hand, endodontists who implement documented, high-performance systems enjoy greater satisfaction (and profitability) throughout their careers.

Endodontics is a challenging and rewarding profession. With the right systems, team training, and leadership skills, endodontists can achieve their vision and create a highly successful practice.