September/October 2014


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A Growing Role
As DSOs expand, so too do the responsibilities and opportunities for office managers

From The Publisher.

Treatment Protocols
The importance of implementing, and maintaining, treatment protocols

Cross Training Done Right:
Maximize Efficiency and Profits

Office Managers and Case Acceptance
Three steps to get patients to say “Yes”

Effective HR planning

The Sell Side
For dentists thinking of selling or affiliating, peace of mind is just as important as selling price

A Perfect Match
Great Expressions Dental Centers values growth, but chooses its partners carefully

Best Practices in Infection Control

Taxed Later
It’s important to maintain a proper balance with taxed later investments




Aspen Dental Management promotes Dr. Arwinder Judge to chief clinical officer
Aspen  Dental  Management  Inc.  (ADMI),  a  dental services  organization  that  supports  more  than  450 Aspen  Dental  practices  in  communities  across  28 states,  announced  Arwinder  Judge,  DDS,  has  been promoted to chief clinical officer. Since joining ADMI in 2008 as Vice President of Clinical Support Services, Dr. Judge has been instrumental in the development of ADMI’s Doctor Orientation, Doctor Development and  Practice  Execution  programs.  In  his  expanded role,  Dr.  Judge  will  continue  to  enhance  support systems for clinicians. Prior to joining the leadership team at ADMI, Dr. Judge founded and spent 11 years as president of a dental group practice, during which he  established  six  de  novo  dental  practices  in  New York and Texas. He currently serves as treasurer of the Dentists for Oral Health Innovation and has been a member of the American Dental Association, New York State Dental Association, Fifth District Dental Society,  Empire  Dental  Political  Action  Committee, and Indian Dental Association. Dr. Judge was also a member of his society’s Peer Review Committee and has  been  recognized  twice  by  the  New  York  State Dental Association for his dedication to the profession and patient care.

Heartland Dental announces new offices, affiliations
Heartland Dental recently announced several new openings  and  affiliations.  The  following  are  new  full-service, state-of-the-art family dental offices:

  • Atlantic Family Dental in Delray Beach, Fla.
  • Little River Family Dental in Woodstock, Ga.
  • Sugarloaf Family Dental in Lawrenceville, Ga.
  • North Pointe Dental Care in Fort Wayne, Ind.
  • Rivers Dental Care in Murfreesboro, Tenn.
  • Family Dental Care of Owasso in Owasso, Okla.
    Affiliations include: Ben  G.  Williams,  DMD  and his  team  members  at  Rolling  Ridge  Dental  Care  in State  College,  Pa.;  Norman  D.  Peets,  DDS  and  his team at Green Street Smiles in Gainesville, Ga.; Deno Chrysostom,  DMD,  his  associates,  Mallory  Northcutt, DMD  and  Virginia  Fadeley,  DMD,  and  their  team  at West Columbia Family Dentistry in West Columbia, S.C.; Stephen  Foster,  DDS  and  his  team  at  Pleasant  Grove Dental in Mt. Juliet, Tenn.

Smile Source joins forces with The Academy of Comprehensive Esthetics (A.C.E.)
Texas-based dental alliance, Smile Source, has signed an agreement with The Academy of Comprehensive Esthetics  (A.C.E.).  In  this  agreement  Smile  Source will  continue  to  offer  strategic  marketing,  growth tools  and  services  to  empower  independent  dentists to  reach  their  full  potential,  and  now  has  increased their offering to member dentists with a more robust educational platform and an extensive online community. Both organizations are dedicated to sharing best practices and providing signature dental care to their patients by some of the top, independent dental clinicians  around  the  country.  Smile  Source  and  A.C.E. will collectively account for an online community of over 11,000 dentists, dental professionals, and dental auxiliaries with over 400 dental locations in the United States, making them the largest independent alliance of dentists.

National Children’s Oral Health Foundation welcomes new board
National Children’s Oral Health Foundation: America’s ToothFairy (NCOHF) (Charlotte, NC) welcomed a new board of directors for fiscal year 2015 under the chairmanship  of  Henk  van  Duijnhoven,  SVP  at  Danaher Corporation  (Washington,  DC).  Other  Board  officers include First VP Avi Reichental, president and CEO of 3D Systems (Rock Hill, SC), second VP Allison Farey, president of Wells Fargo Practice Finance, treasurer Paul A  Guggenheim,  president  of  Patterson  Dental  Supply Inc  (St  Paul,  MN),  and  secretary  Robert  Size,  SVP  of DENTSPLY International (York, PA).

California approves dental telehealth program
California  passed  a  new  law  expanding  the  Virtual Dental  Home  (VDH),  a  program  that  uses  telehealth technology to bring dental services directly to patients in community settings, such as schools and nursing homes. The bill was the outgrowth of a demonstration project established  in  2010  by  Paul  Glassman  DDS,  director of the Arthur A Dugoni School of Dentistry’s Pacific Center for Special Care (San Francisco, CA). The law expands the scope of practice for dental hygienists and assistants and provides payment for telehealth-enabled dental services under California’s Medicaid program. It uses dental hygienists to screen patients and send data electronically to dentists at clinics or offices who advise the  hygienists  which  preventive  and  routine  restorative  care  should  be  done.  Services  provided  include cleanings, sealants, fluoride, X-rays, chart preparation, oral  hygiene  instruction,  nutritional  counseling,  and placement of interim therapeutic restorations. Patients requiring  more  complex  care  are  referred  to  dentists who review the records before an office visit.

Air Technique’s Monarch CleanStream Evac System
Cleaner gets high reviews in peer-to-peer evalAir Techniques Inc’s Monarch CleanStream Evacuation System Cleaner was given a 4.1 rating (out of a posible 5.0) when evaluated by 13 dental professionals who had a  combined  228  years  in  practice.  This  Peer-to-Peer product  evaluation  was  conducted  by  Dental  Product Shopper. The evaluation process included a four week trial where each evaluator used the cleaner in their practice.  The  final  score  was  calculated  by  combining  the evaluator’s  individual  criteria  average  with  their  overall satisfaction  average.  Monarch  CleanStream’s  unique, non-foaming formula cleans and deodorizes lines for all brands of wet and dry vacuum systems and features an easy-to use dispenser system that makes mixing simple. For more information, visit

VA proposes increased pay for its dentists, physicians
The  US  Department  of  Veterans  Affairs  (VA)  (Washington, DC) is proposing increased salaries for incomingdentists and physicians as part of its recruitment efforts to hire more clinicians and expand veterans’ access to care. The updated pay ranges propose increases of $20,000 to $35,000  annually  for  dentists  and  physicians  who  care for  veterans.  They  are  also  proposing  the  expansion  of the loan repayment program, as included in the recently passed Veterans Access, Choice and Accountability Act. Not only is the VA the second largest national employer, it is also the largest employer of healthcare providers. More than 70 percent of all US doctors received training at the VA; VA facilities train 62,000 medical students and residents, 23,000 nurses, and 33,000 trainees in other health profession fields annually.

3M ESPE unveils Filtek Bulk Fill Posterior Restorative
3M ESPE’s introduced Filtek Bulk Fill Posterior Restorative, a one-step placement bulk fill material that delivers stress relief, wear resistance, and the ability to place up to five mm in one increment. It eliminates expensive dispensing devices, additional layers, and multiple steps, saving valuable chairtime  and  offering  improved  productivity.  The  technology was  co-developed  through  collaboration  with  Professor Christopher  Bowman  from  the  University  of  Colorado (Boulder, CO), with the financial support of the National Institutes  of  Health  (NIH)  (Bethesda,  MD).  For  more product information, go to

Patterson Dental introduces newest members of its Special Markets team

  • John Adams, Special Markets – Northeast Territory Manager
    John Adams will focus on managing and growing DSO and government and institutional business in Patterson Dental’s Northeast Region through technology, products, services and after-sales training and support. Adams brings nearly 15 years of experience in dental as a corporate account manager and senior manager, professional field sales. Adams earned a bachelor’s degree from Towson State University in Maryland.
  • Rhonda Durante, Special Markets – Southeast Territory Manager
    Rhonda Durante will be working with customers and manufacturer partners to identify growth opportunities and drive sales growth across multiple markets in Patterson Dental’s Southeast Region. Durante has spent 24 years in the dental industry, managing all aspects of customer accounts, while building relationships with customers and business partners. She studied dental assisting/hygiene and radiology at the University of Kentucky.Brooke Hilzendager, Special Markets – Technology Sales ManagerBrooke Hilzendager will manage the technology sales segment of Patterson Dental’s Special Markets Division, specifically in the areas of digital imaging, CAD/CAM and digital sensors. In addition to her technology product expertise, Hilzendager brings experience in the healthcare field that includes sales and territory and account management. She also has a bachelor’s degree from the University of Minnesota.
  • Joe Techar, Special Markets – Equipment Sales Manager
    Joe Techar will oversee nationwide sales of basic dental equipment for Patterson Dental’s Special Markets Division, working closely with manufacturing partners and Patterson branches and equipment specialists to provide a best-in-class client experience. Previously Techar was a territory sales representative with Patterson Dental’s Omaha Branch, serving clients in Nebraska, Iowa and South Dakota. His prior roles in healthcare include director of national sales, account manager and division manager. Techar graduated from Creighton University with a double major.

Taxed Later

It’s important to maintain a proper balance with taxed later investments

By Jared Thompson

Editor’s note: The following is part II in a series on understanding and effectively using Time-Tax Buckets

You can pay taxes now, later, and never. Proper use of this knowledge will transform the way your future investments look.
In the July/August Efficiency article, we built the foundation for what could be considered a well-diversified method of accumulating assets in the most tax efficient manner. Dentists can implement these simple principles right away to help avoid shocking amounts of taxes and fees. To review, the three buckets dentist clients of PersonalCFO use to accumulate assets are:

  1. Taxed Now Bucket
  2. Taxed Later Bucket
  3. Taxed Never Bucket

The Most Popular Bucket – What if it’s the Wrong One?
Our last article focused on the “Taxed Now” Bucket. I want to delve into where we see the lion’s share of the doc’s dollars accumulating: the “Taxed Later” bucket.
By far, the Taxed Later Bucket is the most popular place to accumulate savings. Do you have a Traditional IRA, 401(k), a SEP, a SIMPLE, a 457 Plan, a TSA, or 403(b) – to name a few? If so, you have money in a Taxed Later Bucket.

The plans available in the Taxed Later Bucket aren’t inherently bad, but they are very often overused and funded at levels that may be dangerously high. If you’re putting money away for retirement, you’re probably using one of these investment tools.

You may be asking, “Isn’t this a good thing?” Well, it can be. But, just like the first bucket, it is important to maintain a proper balance.
Some have too much of their retirement funds in a taxed later bucket

First, there are two strong virtues of this tax-deferred bucket:

  1. 1. A tax deduction. Most often the dollars you and I place in this second bucket give us a tax deduction. Great, right? That means if you pay yourself $200,000 a year but placed $15,000 in your traditional 401(k) plan, your taxable earnings would only be $185,000. CPAs generally love these accounts most because it helps them to lower your taxable income, thereby helping you pay less in taxes today. But what if paying too little in taxes today is a bad thing? More on that concept below.
  2. 2. A match. Often times, if you place money into accounts from Taxed Later Buckets you may receive a match from the company – your own or the company you work for. This is a great incentive. If you placed 3 percent of your earnings into a 401(k) and received a 100 percent match on that first 3 percent, this is a 100 percent rate of return on your contribution!

So if these are the virtues, what are the vices?

  1. Tax rate hikes. Are your tax rates heading up or down? For high income earners, there is a high probability that the amount of tax saved today by using these accounts could mean paying higher taxes on those dollars (and their potential growth) at retirement, when taking the funds out. In other words, you may be saving on taxes now, but potentially paying more later.
    You know many accounting professionals that claim when you retire you’ll be in a lower tax bracket. But let’s consider what that implies. Do you want a simpler or more lavish lifestyle when you retire? Do you really want to assume your only option in retirement is a downgraded standard of living? Such an assumption is the reasoning behind the belief that you’ll be in a lower tax bracket in retirement.
    But even if you are in a lower tax bracket during retirement, is it possible that the percentage attached to the tax bracket will still be higher than the one you saved tax on when you put the dollars away?
    My prediction is that for many, those exact dollars will be taxed higher in the future than they would be today.
    We’re still enjoying some of the most historically low tax rates this country has seen since the 1920s. If tax rates are truly on a cycle, where do you think rates are going?
  2. Lack of control. Are you really in control of these accounts? You may be able to sock away lots of money in the second bucket, but when can you use it? There may be stinging consequences if you pull money from your IRA before you’re 59 ½: you could be taxed at your highest marginal tax rate plus a 10 percent penalty. With current tax rates, this could be as high as 49.6 percent total – almost half of what’s drawn!
    What about forced disbursement?
    Here is the reality: at 70 ½ you are forced to pull money out of your IRA. The IRS calls this mandatory pull a Required Minimum Distribution or RMD. Currently, the amount you have to withdrawal at age 71 is about 3.6 percent (increasingly higher if you’re older) of the total amount of dollars in the tax-deferred bucket. So if you have $500,000 spread between IRA-like accounts, plan on taking out $18,000 – whether you need it or not. If you don’t take the withdrawal, you’ll be penalized with a 50 percent excise tax of what you should have taken out and didn’t…
    Did you catch that? A $9,000 penalty if you don’t take out enough from your Taxed Later Bucket while you’re in retirement.
    You and I basically have 11 years (between 59 ½ and 70 ½) to do what we want with these dollars as long as we pay the tax. Before or after this time period could mean severe penalties.
  3. High fees. Are you paying higher fees? Many Taxed Later Buckets are referred to as Employee Contribution Plans. These typically come with higher fees than similar functioning accounts which can be obtained privately. Watch out for advisory fees, sponsor fees, platform charges, transaction charges, administration fee, custodial fees, sales loads, expense ratios and 12(b)-1 fees.
    That’s a lot of jargon, but the simple truth is that the wrong tools in your Taxed Later Bucket can be horribly expensive.
    Private accounts may provide a good back-up to use in concert with company plans. A good rule of thumb is to place enough into a 401(k) to obtain the maximum match. More than that should be carefully analyzed to be certain excessive fees and future taxes are minimized.
  4. Limited choices. Are your investment choices limited? The narrow scope of available investment choices is one of the most frustrating issues for some of our dentist clients – and for good reason.

Numerous plans are confined to 8 – 15 fund choices.
I often see that half of the available funds are the “retirement date” funds like the 2025 or 2030 type funds. With limited offerings, your portfolio may not be truly diversified.

PersonalCFO helps its dentist clients put together the right mix of funds based on the individual and the individual plan. Where possible, we can also help to expand the plan offerings.

Now that we’ve covered your Taxed Now and Taxed Later Buckets, you may be seeing the delicate balance that needs to exist between the various types of savings vehicles.

In the next issue of Efficiency, look for the final article of this series on how we may help you to transform your future wealth with proper management of the last bucket: The Taxed Never Bucket.

In the Taxed Never Bucket, we’ll uncover the surprising strategy that can propel your wealth more quickly than nearly any other. It just may change your perspective and your future net worth!

For questions or for expanded information, write Jared at:

Any tax advice contained herein is of a general nature.
Please seek specific advice from your tax professional before pursuing any idea contemplated herein.
Securities offered through ValMark Securities, Inc. Member FINRA, SIPC
Investment Advisory Services offered through ValMark Advisers, Inc., a SEC Registered Investment Advisor
130 Springside Drive, Suite 300 Akron, OH 44333-2431* 1-800-765-5201
PersonalCFO, LLC is a separate entity from ValMark Securities Inc. & ValMark Advisers Inc.

Best Practices in Infection Control

By Dr. John Molinari and Peri Nelson

Editor’s note: Efficiency In Group Practice is pleased to announce a new feature, Best Practices in Infection Control, with THE DENTAL ADVISOR. Dr. John Molinari and Peri Nelson will address common concerns related to Infection control in dental practices. Questions can be submitted at, under the Ask The Editors tab.

Q: Due to the volume of patients in our practice, I am washing my hands constantly and have developed small red bumps on my hands. Should I be concerned I am developing an allergy?

A: While it is possible that you have developed an allergy to the hand wash agent in your practice, it is more likely that the condition is a non-specific irritation dermatitis. This is not an allergic reaction. Instead, it is a gradual worsening skin condition which is caused by improper washing and/or care of hands. Repeated use of hand hygiene products can occur over 20-25 times per work day in most healthcare facilities. When water-based soap or antibacterial products are used, this can result in excessive removal of skin oils which are essential to keep epithelial tissues lubricated. Products that are too harsh or used inappropriately can cause some healthcare practitioners to experience the scenario you presented. Adoption of a mild, liquid soap (i.e. lotion-based soap) can be helpful in maintaining epithelial integrity. Water-based hand wash agents are not the only potential problem here, as early studies reported the drying effect of alcohol sanitizers. This problem has been resolved to a certain extent by the inclusion of emollients in these alcohol-based hand antiseptics. These specialized hand hygiene rubs are different from the products available at your local grocery store, so ask your sales rep for a list of acceptable options.

Q: It seems that the new gloves our practice is buying are very tight across the palm area. I’m concerned they will rip when I’m working. They are the size I normally wear but don’t seem to fit right. Are there differences in the way gloves are made? How can I find the best fit for my hand?

A: It is important to first note that people’s hands come in a variety of sizes. Not only are there differences in the lengths of fingers, but also the widths of the palms. Many people talk about gloves not fitting their fingers, but few are aware that the palm width can be equally important in glove selection. There are different glove widths available for various types of gloves. What you may have to do is try a number of samples to find a comfortable width. For example, when you put the glove on the palm shape should remain the same as without the glove. If the palm is constricted the width is too small and may cause muscle stress and damage over time.

Dr. John Molinari and Peri Nelson train dental professionals worldwide on Infection control products and procedures. The course “What’s Bugging The Dentist?” is a popular hands-on, interactive program designed to assist in the selection, assessment, and use of infection control products in practice. Contact to schedule your event.

A Perfect Match

Great Expressions Dental Centers values growth, but chooses its partners carefully

For Great Expressions Dental Centers, each affiliation with a dental practice or group is unique, says Kurt Harvey, vice president of business development. Even though the dental service organization is focused on growth, it moves forward with an affiliation only if the doctor(s) and Great Expressions are in agreement on what each hopes to accomplish. In most cases, that means the dentist is interested in letting Bloomfield Hills, Mich.-based Great Expressions worry about the business side of dentistry, while the dental professional focuses on patients’ oral health.

“We have a systematic approach built on years of experience and feedback from affiliated doctors,” says Harvey. “That said, every affiliation is a bit different from the last, so we try and tailor the process to help them feel as comfortable as possible. We understand it is a big decision and want them to feel comfortable every step of the way.”

Founded in 1975 as a single practice in Dearborn, Mich., Great Expressions has grown primarily through affiliation ever since. Today, it comprises more than 200 practices in nine states: Connecticut, Florida, Georgia, Massachusetts, Michigan, New Jersey, New York, Ohio and Virginia. Harvey has guided much of that growth since joining Great Expressions in 2006 following a career in public accounting.

Growth is good for the organization and for the dentists whose practices affiliate with it, says Harvey.

“I do feel that there is value in critical mass,” he says. “Healthcare costs, benefits, labs, drugs and supplies, facility costs, technological advances, and several other costs or capital requirements are increasing, yet patients are demanding — more now than ever before — to get both quality care and having it affordable. Our goal is to do just that – provide access to affordable dental care without sacrificing quality or convenience.”

Scale helps doctors handle the pressures that they and their patients face today, he says. “It seems like everything is rising in cost these days, and that includes the healthcare industry. Consumers are becoming even more price-conscious.” In that environment, independent dentists or small groups can find it difficult to keep up with patients’ demands for affordable care and still have money left over to re-invest in the business, or give themselves a fair value for their own services.”

Commitment to communities
Much of Great Expressions’ expansion has occurred through affiliation with groups, ranging from four practices to 40-plus practices. “We believe no other DSO has as much experience successfully integrating groups as GEDC,” he says. “We embrace any group that has a hygiene and general dentistry focus as its core. If they already incorporate orthodontics and specialists into their group as well, that is always welcome.”

Many groups are interested in Great Expressions because of the dental group’s commitment to geographical markets and their communities. “If you look at us on a map, you’ll easily see that we have clusters of GEDC offices within a few miles of one another,” he says. “That is one way practice owners know we will continue to invest and grow in that community with them and ensure that their legacy lives on. We are not simply focused on affiliating with the group and then moving to a different area.”

The regional density of its practices enables Great Expressions to provide a full suite of services in the markets it serves, says Harvey.

“This allows us to have all services within a few minutes of each office, sometimes under the same roof. Our goal is to make it as convenient for the patient to get the care they need from a doctor they can trust. It also gives our doctors confidence that when they refer a patient, the doctor they are referring to is within the GEDC network, so they know their patient is getting the best clinical care possible, and they can be up to date on the patient’s progress.

Its experience with groups aside, Great Expressions has significant experience with affiliating — and will continue to affiliate — with solo practices, says Harvey. “When affiliating with a single-practice location, we tend to look for a general dentist or an orthodontic practice. We work together to understand what the dentist would like to accomplish with their affiliation.”

Typically, if the doctor is looking to transition or retire, he or she has little desire to broaden the services they offer. “In that instance, we offer the ability to take away several business administrative headaches after affiliation, and then begin the transition of new doctor into the practice over a one-to-three-year period,” says Harvey. “This allows for a smooth transition, and ensures their legacy continues on.”

On the other hand, if the doctor wants to shed the administrative headaches of running a practice, and instead wants to see more patients and/or broaden his or her services, Great Expressions can accommodate those goals as well, he adds.

Worry less, focus more
The speed with which an affiliation is consummated depends on the doctor, says Harvey. “If they’ve just started thinking about affiliating, it could take up to one or two years before they are ready to move forward. We move at the doctor’s pace to ensure they are truly comfortable and ready.”

For group deals, an ideal affiliation is one that is similar culturally to GEDC, he says. “If the group affiliation opportunity is in a new market for GEDC, an ideal affiliation is one with a strong leader that has a great base of practices in that market already. If a solo practice, an ideal affiliation is with a reputable general or orthodontic practice within, or a natural extension of, our existing markets.

“Any doctor or group that is reputable and provides great clinical treatment, but wants to be relieved of the administrative headaches of the business, is a great candidate.”

Regardless of whether one is talking about a new graduate or a doctor with 20-plus years of experience, Great Expressions offers them the opportunity to “worry less and focus more,” says Harvey.

“We know that being a successful doctor requires education, commitment, time and dedication. And if you own an individual practice, you are constantly required to be on top of the business of dentistry, such as managing an office, paying bills, checking dental claims, handling team member issues…just to name a few. This is the same for a new doctor who started their own practice or a doctor with 20-plus years owning their own practice. Our goal is to affiliate so the doctor can focus on patient care. Their motivation is to get back to being a doctor.”

New graduates may be more focused on career growth. Great Expressions can accommodate that desire with its doctor study clubs, GEDC University and a well-vetted, formal career path, says Harvey.

“For doctors with 20-plus years, they too are looking to learn and grow, but more important, they are looking to get back what they invested, and possibly transition into retirement. In either situation, doctors are always looking out for their team members, and we understand that 100 percent.”

Great Expressions offers all of its doctors membership to the American Dental Association and their respective state dental associations. All orthodontists are offered membership in the American Association of Orthodontists.

Misconceptions and fears
Some dentists have fears or misconceptions about dental service organizations prior to affiliating, says Harvey.

“The preconceptions are the typical myths about DSOs,” he says. “Unfortunately, some students are taught that DSOs are not about patient care and are about revenue only. This is unfortunate, because our model makes patient care affordable for everyone, we participate with all insurances, and even have a discounted dental plan. [O]ur talented doctors and team members put the patients’ needs first.”

Some doctors fear that Great Expressions will dictate clinical treatment following affiliation. That’s not true, says Harvey. “Every state’s dental laws delineate between matters that are ‘clinical’ and ‘non-clinical.’ How the dentist-owner of a practice chooses to handle administrative needs is left to that doctor. The doctor could choose to manage the non-clinical aspects themselves through several sources as they have been (their own time spent directly, managing several various vendors themselves, etc) or outsource those to a single management source, like a DSO. Regardless of how a dentist chooses to address the administrative needs, the decision has no bearing on how the dentist addresses patient care in the practice.”

Nor does Great Expressions have any desire to “clean house” post-affiliation, as some doctors may fear. “GEDC provides business support to practices, thereby allowing doctors and their teams the ability to focus on better personalized patient care,” says Harvey. “As such, we help the doctor understand that his or her team is as important to us as they are to the doctor. Our affiliation process ensures we agree with the doctor on the plan to ensure the team continues to drive the practice with the doctor, and our added support helps sustain the doctor’s legacy.”

Perhaps the biggest fear facing doctors contemplating affiliating with a dental service organization is that of change itself, says Harvey. And that’s understandable. “Many doctors are entrepreneurs in nearly every sense of the word. After operating in that environment for 20 to 30 years or more, switching from managing several functions themselves to outsourcing many of those non-clinical functions in their entirety to GEDC is a ‘change.’

“[W]e understand that change can sometimes make people uncomfortable, so we openly solicit the doctor’s particular concerns up-front. Then we work with the doctor to help alleviate their particular concerns and show there are not roadblocks, but actually opportunities to agree on the best plan forward. Each doctor or group and situation is unique, and we have had success adapting and executing under numerous varied circumstances.”

Sealing the deal
If the doctor or group has been exploring affiliation for awhile and is mentally prepared to move ahead, the deal can be consummated is as few as 30 to 90 days, says Harvey. Key steps in the GEDC affiliation process include:

  • Initial call or contact to understand the doctor’s goals.
  • Initial face-to-face meeting, which often includes touring the practice(s) and community, and providing the doctor with more in-depth information about GEDC to ensure their combined goals will align.
  • Continuous contact until the doctor is comfortable knowing that Great Expressions will help achieve the doctor’s goals.

Once the doctor is comfortable, Great Expressions requests detailed financial and other operational information, and performs its initial analysis, explains Harvey. “We provide an indication of value letter with potential terms, and solicit feedback from the doctor in order to discuss openly any areas that need further alignment.” Once the two come to an agreement, Great Expressions provides a formal offer letter or letter of intent outlining the terms and economics of the transaction.

“Once signed, we perform final diligence, draft formal agreements, and finalize with the doctor the best post-affiliation transition plan. Finally, we affiliate and execute together on the agreed plan.”

Ideally, the practice undergoes a transformation in the first year following the signed agreement, says Harvey. “The simplest way to put it is this: The doctor and team have asked us to provide all the business support side, and the transition from that standpoint has been implemented and integrated. The office itself will feel they have time, more resources, and more support to focus on patient care, vs. having to deal with the payables, cash posting, equipment maintenance, even small things. The doctors themselves realize they don’t have to be the go-to person anymore for the administrative tasks.”

Mustering the forces
Dental service organizations face a key challenge: Ensuring that affiliated practices stay focused on the mission to provide affordable patient care without sacrificing quality or convenience. Great Expressions Dental Centers has built the infrastructure to support its growth, says Vice President of Business Development Kurt Harvey. This includes:

  • National Doctor Panel, which oversees and trains the DSO’s nationally recognized dental professionals.
  • Affiliation onboarding process, which addresses everything from benefits and how doctors will get paid, to new systems and whom to contact for operational support.
  • GEDC University. “We put a premium on continuing education, and we want to ensure dental care professionals stay on the cutting edge of their respective fields,” says Harvey. “For example, last year we introduced Invisalign®, and are continually holding training seminars to assure all doctors are comfortable with the technology.”
  • In-market operations support. Given its density in given markets, Great Expressions offices have operations support that can help them through the affiliation process, and help them manage their day-to-day business, says Harvey.
  • Marketing. “Since we are commonly branded, people in the community know GEDC,” he says. “That concept is working its way into office design – enhancing the patient flow and helping support the mission and culture of GEDC, both in the office and in the community. We want to solve patients’ problems by making dental care affordable and convenient.”
  • Clinical partners, who hold daily office huddles and are a resource for any clinician who needs assistance

The Sell Side

For dentists thinking of selling or affiliating, peace of mind is just as important as selling price.

Used to be, many private practitioners wouldn’t consider selling to groups, believing that groups were not good for dentistry, says Anthony Stefanou, DMD. That is starting to change.

Stefanou is founder of the Dental Sales Academy and “How to Sell to Dentists” workshops, and president of Connect the Dents, a company focused on dental-industry mergers and acquisitions. He recently shared his thoughts with Efficiency in Group Practice about the individual practitioner’s perspective on selling his or her practice, or affiliating with a dental service organization.

In the past, many individual practitioners felt that groups targeted, or mainly serviced, lower income patients, and cut corners on doing quality dental work, he says. “That has changed significantly, as many of the groups now are offering state-of-the-art services and using the latest in technology. They can run practices efficiently, they have the financial resources and business plans to market effectively, and can leverage good deals with dental companies to keep overhead reasonable and also keep staff/office team personnel happy and offer attractive careers for them.

“There are many good reasons for individual practices to seriously consider groups.”

For the solo practitioner, there is only one not-so-good reason for pursuing a sale or affiliation with a dental service organization – believing he or she will get a significantly higher price for their practice than if they sell to another individual.

A fair offer
Though the private practitioner can’t expect a much higher price selling to a group, he or she will generally receive a very fair offer, says Stefanou. “[He or she] can usually be assured that, financially, it isn’t an issue from the group’s side, and the overall package to stay on is usually very solid.”

For younger dentists who are good clinically but who dislike the business side of running a practice, selling to a group is a no-brainer, he says. “Groups offer the best of both worlds – the ability to practice long-term and have the power of the group’s business acumen behind them.”

But Stefanou has a word of advice for dentists who are considering pitting one DSO against another in hopes of driving up the price of his or her practice: Don’t.

“That rarely works, and even if it does, it is uncomfortable and can start the relationship off in a bad way,” he says. “If a practice is attractive and being actively pursued by more than one DSO, my suggestion is that the dentist look to really examine each of them to see which offers the best fit in terms of philosophy of patient care, how the practice is managed ‘corporately’, and how their role will be defined.

“While dentists certainly deserve – and want – to get a fair market price for the practice they built, in some cases, for decades, it is VERY important that they feel ‘peace of mind’ that their patients will be well taken care of,” he adds. “This is true regardless of whether they are selling and retiring and ‘walking away,’ or whether they will be staying on.

“Dentists truly care about their patients. They’ve often been treating entire families for several generations, and have watched kids sit in their chairs from kindergarten through college. Every group is a bit different. So my advice is that selling dentists closely examine which [potential buyer] will be best in taking what they’ve accomplished and making it even better than they could do themselves. When they communicate that to the DSO, even though it’s a ‘business,’ the DSO appreciates the concern the dentist has for his or her patient base, and it creates an even more desirable purchase for them, which, of course, can then help the negotiating and package offered.”

Preparing the practice for sale
Generally speaking, the same things the dentist should consider when selling to another individual apply when he or she is considering selling to or affiliating with a group, says Stefanou. ”This means putting your practice in a position where its overall worth is at a maximum, so you truly get ‘fair market value.’” That means decreasing accounts receivable, increasing collection rates, getting new patients in on a consistent basis, and having an assumable/assignable lease (both) with option years.

Often overlooked is the hygiene department, which is now recognized as a true vehicle that can maximize the “goodwill” factor of a practice’s value, he adds. “The higher the overall percentage of collections that comes from the hygiene department, the better. Work on increasing productivity and the overall point of sale – dollars per patient appointment – within hygiene. This can include retailing home care/prevention products.”

Preparing the staff
Preparing one’s staff for the sale can be an uncomfortable part of the process for the practice owner, but it doesn’t have to be, particularly in those situations in which most of the team can stay on, says Stefanou.

“My advice [to the doctor selling his or her practice] is short and sweet, and involves two points: First, be very positive. The office team needs to understand the good reasons as to why the decision was made, especially around how patients will be taken care of for the future and also how efficiently the practice will operate. Plus, if there are options for them to stay on, the long-term benefits for how they will be taken care of is also emphasized.

“Second, don’t wait until the last second. This happens all the time, and then, even if it’s good for all involved, the shock value and timing isn’t appreciated and it becomes a difficult thing to accept psychologically.”

‘Impressive groups out there’
“There are some very impressive groups out there that truly understand that dentistry is different from other healthcare disciplines, and are developing plans to make sure they offer an excellent environment for patients,” says Stefanou. “These groups aren’t going to cause the ‘death’ of the solo private practitioner, as many doomsayers are predicting. I firmly believe we will, for a long time, still have both out there, as some dentists will always want to be doing things on their own and some patients will want that. Others will become part of a larger, corporate environment, which offers other advantages that the individual can’t. It’s all good.

“One final point for those dentists thinking of selling: Just because you have more options doesn’t mean the DSOs/groups are going to want you,” he says. Dentists still have to position their practices in a way that offers value and is attractive to potential suitors.

“If you are cutting back on your hours and collections are going down, you’re not getting new patients in, and you’re letting the office become run-down, unless you have the absolute BEST location in the world and a lease that is way below market value, the groups aren’t going to be interested,” he says to dentists. “In today’s dental world, groups – just as banks – don’t care how much your practice did 10 years ago. It’s ‘What have you done for me lately?’

“So, continue to do what needs to be done to increase the value of your practice, and those options will be there for you when you are ready to sell.”

Effective HR planning

Provided by DANB and the DALE Foundation

Dental office managers have a demanding job, overseeing many different aspects of a dental practice to keep it running smoothly. Personnel issues can be one of the most time-consuming areas, particularly for large practices with several locations. However, one way to more efficiently manage multiple practices is to implement uniform hiring and training standards.

The Dental Assisting National Board, Inc. (DANB) and the DALE Foundation have several resources to streamline your practice’s operations. This simple guide can help you get started with standardizing your office’s protocol.

Plan for future human resources needs
Effective human resources initiatives are vital to your dental practice’s success. By following HR best practices in your office, you can increase employee satisfaction, reduce turnover, improve your recruitment efforts, and ensure compliance with state and federal employment laws.

Important areas that HR and office managers should be knowledgeable about include: developing job descriptions, implementing protocol for the interviewing and hiring process, evaluating job performance, ensuring employee compliance with federal and state requirements for their positions, and maintaining employee records.

If you’re looking for HR resources for your practice, the DALE Foundation offers interactive, online courses that can help you analyze and plan for current and future HR needs. The DALE Foundation’s HR Fundamentals for the Dental Office covers all of the topics listed above and more. In addition, the course includes examples and templates you can use in your practice.

Understand state requirements for dental professionals
When operating multiple practices, particularly in different states, it’s important to be familiar with each state’s dental practice act. DANB has a free tool that links to each state’s dental practice act, so you can easily find state statutes, regulations and administrative rules governing the practice of each member of the dental team.

Dental assisting requirements, in particular, can vary widely from state to state. To learn more, visit DANB’s free search-by-state map, which includes dental assisting job titles, requirements, and allowable and prohibited duties.

Make sure to check these resources along with the state dental board websites regularly, as rules and regulations frequently change.

Standardize hiring practices
Hiring decisions can often be subjective, and many HR and office managers say that personality fit can be as important as – or sometimes more important than – experience and skill, particularly for dental assistants. However, applying some type of standardization to the process can help eliminate ambiguity and gray area in the decision making, as well as minimize any legal risk.

Employing DANB Certified Dental Assistants (CDA) can benefit your practice in numerous ways, including reduced staff turnover, increased patient trust and greater office efficiency. DANB is recognized by the American Dental Association as the national certification board for dental assistants. Currently, 38 states, the District of Columbia, the Department of Veterans Affairs and the U.S. Air Force recognize or require DANB exams. Since each state has different dental assisting requirements, encouraging or requiring all dental assistants to earn national certification can help you streamline your office’s protocol and create a baseline for hiring decisions. To assist with preparing for DANB certification, the DALE Foundation offers online, interactive review courses and practice tests for many DANB exams.

By streamlining your approach to managing staff, you can improve operations and create greater efficiencies. To learn more, visit and

Office Managers and Case Acceptance

Three steps to get patients to say “Yes”

By Richard Moore

With first-time case acceptance rates for dental procedures as low as 35 percent for some procedures and providers, implementing strategies to increase the acceptance rate result is an immediate financial benefit to any dental group.

Although the dentist is responsible for development of a treatment plan and most often explaining the benefits of treatment to the patient, all team members play a role in case acceptance. For example, an office manager’s implementation of processes and tools that support financial discussions are critical to a patient’s decision. This financial component is especially important as patients are often fearful of the dollar sign behind their care. To ensure all team members have access to information that can overcome a patient’s concern about the affordability of treatment, there are three key steps office managers can take to increase the likelihood that a patient will say “yes” before leaving the office.

Step No. 1: Consider the patient’s perspective

The first step to improving case acceptance is to evaluate the encounter from the patient’s perspective. While the patient may have come to the office seeking treatment for a dental problem of which they are aware, sometimes the need for treatment is discovered during a routine hygienist visit – when the condition is asymptomatic. By providing systems that enable staff to access benefits information, office managers have the unique opportunity to make sure patients have all of the information they need to accept treatment recommendations seamlessly from exam room to front office. This extra support in offering information around proposed treatment helps a patient feel that the choice is in their hands, which helps them be more comfortable with the overall approach.

Step No. 2: Relieve financial concerns

Financial barriers are tricky, which is why they are the second – if not sometimes the primary – reason patients don’t accept treatment. Once the dentist has presented the need for further treatment and explained the benefits versus consequences of no treatment, financial counselors can help patients reach their decision to proceed by providing accurate information about the total cost of treatment and the patient’s portion of that cost.

Although benefits verification is a challenging and time-consuming process in any practice, the volume of patients seen in a group practice increases the need to streamline processes to verify eligibility and benefits. Implementing technology that enables automatic verification of benefits to produce accurate estimates at the time of the patient visit improves the team’s ability to educate patients and answer questions about the cost of their care.

Because few people make major decisions without considering financial implications, and many must choose among a variety of financial responsibilities, be ready to offer options that can make the cost of treatment more affordable to the patient. In addition to flexible payment plans or financing, group practice teams should also be able to identify scheduling opportunities that maximize benefits in a coverage calendar year. For example, when dental team members have information that shows how arranging treatment earlier rather than later provides the most insurance coverage because the deductible is met for the year, the patient is more likely to schedule the next visit before leaving the office.

Step No. 3: Communicate confidently and effectively

Getting patients to accept treatment recommendations requires consistent communications between the group practice team and patients throughout the process. The dentist presents the plan, the hygienist and dental technician reinforce the recommendations and offer to answer additional questions, and finally, the financial counselor sums up all of the information – clinical and financial – while presenting patients with options and offering to answer more questions. Conversations with a variety of people are necessary to reinforce the validity of the treatment recommendation and reassure patients that they are making the right decision to proceed – office managers being the backbone for ensuring each piece happens as smoothly as possible. While a consistent approach to conversations with patients improves case acceptance, it is up to the office manager to ensure the process is designed to produce the best results.

“One way office managers can identify best practices for their specific practice is to monitor case acceptance rates for team members,” says Lisa Blair, operations manager for Inspire Dental Group. “Reviewing data to determine which team members excel at patient conversations and converting treatment recommendations into case acceptances, supports process changes throughout the practice.” This enables the strategies that work well to be shared through specific examples and tips from co-workers in training sessions and workflow and patient communication strategies to be standardized to create cohesive, patient-centered conversations that lead to case acceptance.

In addition to technology that streamlines workflow to verify benefits and produce accurate estimates, processes or tools that prompt follow up with patients who want additional time to think about treatment recommendations is necessary. “With multiple providers and a variety of dental team members working with a high volume of patients, it is easy to lose a patient in a busy practice,” says Blair. “Setting checkpoints or alerts and auditing follow-up activities on a daily or twice-weekly basis ensures that all patients receive a timely telephone call asking if they need more information or are ready to schedule their treatment.”

While there are several factors that contribute to case acceptance, an office manager can set the foundation for success with technology and processes that make sure team members have the best financial information. Combining technology with consistent, caring communications throughout the patient encounter ensures the patient receives the most complete information – clinical and financial – to support a decision to accept the dentist’s recommendations.

About the author
Richard Moore is president of OneMind Health, @OneMindHealth.

A Growing Role

As DSOs expand, so too do the responsibilities and opportunities for office managers.

By Laura Thill

To say that dental office managers have a lot riding on their shoulders is an understatement. Particularly as group practices and dental support organizations (DSOs) have expanded, so, too, has the role of the dental manager. “In dental support organizations and group practices, the office manager supports many of the administrative duties carried out in a dental office,” says DeAnn McClain, vice president of operations, Heartland Dental. In addition, the office manager is often the primary contact for other DSO support professionals with regard to supporting the office’s marketing needs, team training, patient relations and more, she says. “In a DSO-supported office, office managers generally have support in such areas as accounting, payroll processing and bill paying,” she adds. “Therefore, they have more opportunities to partner with affiliated dentists and focus on supporting patients and team members, rather than focusing strictly on administrative responsibilities.

“At Heartland Dental, affiliated offices are each supported by several administrators, including a regional director, regional administrator and practice administrator, as well as an office manager in many cases,” she continues. “All of these roles strive to support affiliated offices in operating as effectively as possible. With our ever-evolving industry, it is important for managers and administrators to stay current on advancements in technology, marketing and effective leadership standards.”

As the dental industry advances – and dentists have a greater impact on their patients’ health – dental office managers have played an increasingly important role, notes McClain. “In providing the best patient care possible, today’s offices have very high operational standards. Office managers and administrators need effective leadership and communication skills to meet these challenges.”

Given the expanding role dental office managers play, one might consider them more of a CEO than a manager. “The role of the office manager has drastically changed with increasing duties and responsibilities,” says Lorie Streeter, FAADOM, CTC,vice president, American Association of Dental Office Managers (AADOM). “Our office manager members report [overseeing] almost CEO-type roles, where they are handling all dental business in the office. They are true partners to the dentist in some cases. A well-rounded dental office manager must be a human resource expert, an OSHA expert, an accountant, a software guru and, in most cases, do the research for larger technology purchases in the practice. He or she must be a true mechanic for the practice – one that knows every nuance of the vehicle that drives patient satisfaction success.”

To do so, dental office managers must be better educated and more dedicated to their profession than ever before, Streeter continues. And, in her opinion, they are up to the task. “It is almost shocking how much ownership their roles require to ensure they successfully juggle all the moving parts of a well-run practice,” she says. “This is why I have loved working with AADOM. We provide the resources and tools that office managers need to succeed.”

Indeed, dental office managers who are willing to do what it takes to meet their growing responsibilities are most likely to succeed at their profession. “Depending on their personality, I believe most office managers and administrators do embrace growth,” McClain says. “These individuals do have more responsibilities to take on, but this will only help them develop personally and professionally. Heartland Dental supports many continuing educational opportunities for managers and administrators, which help them advance their knowledge and abilities. Many take advantage of these opportunities and are excited to advance themselves like never before.”

Multiple offices, multiple responsibilities
Although office managers may have similar responsibilities whether at a single-office practice or a large group practice or DSO, in a large group practice it follows that they have “more team members to coach, more administrative tasks to handle and more patient issues [to address],” says McClain. “An individual managing multiple locations will need to be even more organized, confident and positive.”

The office manager’s responsibilities might vary somewhat from one group practice to the next, notes Streeter, but as a general rule of thumb, she offers the following model:

  • Standalone practice. The standalone practice requires an office manager to adhere to the owner’s guidelines for success and job execution.
  • Multi-location practice. The office manager at a multi-location practice often acts like a CEO. He or she usually heads the administrative staff at all of the locations and oversees the success of multiple doctors’ production. “We are seeing more examples of this model emerge across the country,” she says.
  • Large group practice. Office managers at large group practices/DSOs adhere to a model built for them by the DSO. Generally, their training is methodical and perfected. The office manager requires a consistent message, in order that the vision for the entire group can be executed at a local level. Today, some groups/DSOs hire managers outside of dentistry and train them on the dental piece from the ground up.

Likewise, office managers in large group dental practices or DSOs may report to different individuals/titles, depending on the organization. “In the DSO model, most office managers report to a regional type – a level between ‘mother ship’ operations and the practice,” says Streeter. “The challenge with this is that the regional [supervisor] is not involved with the day-to-day [functions] at each practice. We are encouraging groups to utilize the AADOM group forum so that they can stay connected to one another and have daily access to those within their group to share challenges and solutions. The office manager should operate within the team, but the structure of accountability is usually well placed such that ultimately, the entire practice wins together, which trickles up to the DSO system requirements.”

“As dentists are the leaders of offices, many managers are given guidance and direction from them,” adds McClain. “At Heartland Dental, office managers and practice administrators uphold a specific job design and report to their regional administrators and regional directors. But day-to-day, their most important function is supporting the dentists in their office(s).

“Compared to a few decades ago, patient needs have changed, technology has changed and the industry has changed,” McClain continues. “Therefore, office needs have changed. Group practices and DSOs need to stay conscious of this ongoing change and support managers and administrators accordingly, through education and communication.”

“What we are seeing at AADOM is the pressure to keep up with all of the new and existing regulations,” says Streeter, referring to changes in HIPAA and OSHA guidelines, as well as new trends in human resources and marketing, and the integration of new dental technology. “The best thing about a DSO is the top down support of [its] teams. By comparison, a single-location practice must seek out extrinsic education resources, viable outsourcing and internal coaching. No longer can the single practice tackle these topics passively. There is just too much to know.”

That said, it makes sense for the industry to consider office managers the nucleus of the dental practice, she continues. “They sustain so much and touch all aspects of the practice,” she says. Increasing patient retention is but one example of the value office managers can bring to a practice, whether single- or multi-office, she adds, noting that the most successful office managers – as well as group practices and DSOs – are those “that embrace the patient as a long-term investment.”

Nor is the importance of office managers likely to diminish in years to come. They will continue to play an increasingly more comprehensive role in response to the increased needs of dental offices, notes McClain. In addition, she expects the number of group practices and DSOs within the industry to steadily increase, expanding the need for managers and administrators to support multiple offices. “So, as time passes, managers and administrators will need to become increasingly adept at supporting the needs of dentists and team members,” she points out.

Supporting the office manager
As the role of dental office managers continues to expand, it becomes increasingly important for group practice and DSO leaders to offer support and ensure consistency throughout the organization. “As the role of office managers advances, group practice leaders and DSO leaders must support this advancement,” says DeAnn McClain, vice president of operations, Heartland Dental. “This is especially important for DSOs with hundreds of affiliated offices. With so many managers and administrators to support, leaders must ensure all of them are continually prepared to handle the day-to-day office responsibilities they will encounter. The correct education and support systems need to be set in place so that managers and administrators have the tools needed to continually succeed.”

Key to supporting – and empowering – office managers is through education, notes Lorie Streeter, FAADOM, CTC,vice president, American Association of Dental Office Managers (AADOM). “Retention is key and a well-educated office leader is priceless to retain,” she says. “The disconnect often is in recognizing the difference between a job and a career. How can the corporate leaders let their office managers know they are making a difference, and that they not only value them but their career potential as well?”

Furthermore, how can leaders at a large group practice or dental support organization ensure consistency among all office managers across all locations? “Certainly not every dental office operates exactly the same way as others,” says McClain, “but there are specific skills and methods all managers and administrators can adopt to carry out their roles effectively. This goes back to supporting the right education and operational systems in order to create consistency across multiple scattered offices. Heartland Dental supports a variety of education opportunities and helpful information to keep managers and administrators up to date.”

Streeter finds that while many group practices and DSOs have systems in place to track performance and practice standards and ensure consistency across the group, an improvement might be to focus more on the development of office managers. “Group practice and DSO leaders should train their office managers for the long-term, with their advancement in mind,” she says.

Cross-Training Done Right: Maximize Efficiency and Profits

By Dr. Sami Bahri

At a lean management conference, I met a Toyota executive whose business card said “Jamie B…, Vice president of X.” He had another business card: “Jamie B…, President of Y”. I wondered why he occupied two different positions. “It is very usual for us to have several jobs at Toyota,” he said. I learned later that some Toyota employees go through four different jobs every day – they are cross trained for every one of them.

Imagine the difference between Jamie’s situation and the way my office functioned before we applied lean management. We had one assistant per room. If her patient showed up, she would work; if not, she would wait for the next one. She would help with the other assistant’s patient, only if we asked – and that was not considered part of her job. Assistants, hygienists and front desk personnel were three different groups that never mixed.

The situation was not that extreme all the time, but we certainly went through periods where functions were firmly separated. From an organizational standpoint, having a clear function separation certainly feels neatly organized. But it has a flaw that makes it very costly.

Why is the clear separation of functions very costly?
That separation makes equalizing the work load among employees almost impossible. Unless the workload is equalized, however, some people will be idle when others are busy. The busy ones feel that the rhythm is hectic; but if we can pass some of the load to the idle ones, everyone will be working slower.

However, passing some of the load is not a manager’s spontaneous reaction to overload. The natural reaction is usually to hire more assistants if the assistants are too busy, or more office employees if the front office is too busy. As we will see, hiring more people makes things worse.

How can hiring additional employees harm productivity?
Let’s say your assistants became overwhelmed. You hire a new assistant to alleviate the pressure, which in fact reduces the load on the rest of the assistants and they feel relieved. After some time, however, you find that the excess demand has been absorbed, and you are running out of work for the extra assistant. You also find that the increase in overall production was proportionately smaller than the amount you paid for her salary.

The new assistant has now some time on hand and all the team members start looking for a solution to her idleness. Fairness is on their mind! And to them, fairness means that her workload should not be smaller than theirs. We have experienced the following scenarios over time:

  • The newcomer tries to look busy in order to justify her presence at the office. She then starts doing unneeded work. She spends recourses that otherwise would have been available to treat patients.
  • The office manager gives everyone less work – she distributes the idle time. Everyone slows down and gets used to a slow pace. Then, when demand picks up again, it will be difficult to bring the team back up to the previous speed.
  • The “hide and seek” game: If you have one assistant and one task, she will manage it properly. However, when you have two assistants and one task, they will play “hide and seek” until one of them is caught. As soon as she starts to help a patient, the other assistant becomes more visible. Again, when work goes back to a normal pace, it will be difficult to bring the team back to speed.

As you see from those examples, an excessive number of employees can cause a large amount of process waste. As you added a new employee, the percentage of production devoted to salaries increases and you realize that giving salary raises will become more difficult. Consequently, keeping employees for a long time will become more challenging.

Therefore, it is in everyone’s interest to find solutions that improve efficiency by reducing the load on the actual team members. This is achieved through waste elimination. Such solutions will allow the current team to handle increased productivity without hiring new employees, and without having to work harder.

How to handle increased demand without hiring additional employees?
Two of the most effective solutions to absorb demand increase are leveling and cross training. Leveling was covered in a previous article, so let’s talk about cross training.

Not every employee needs to become an expert
First, let us make it clear that we are not trying to train every employee to the point where they are all experts at every job. In football, for example, we would not try to make every player a quarterback; that would be time consuming, unnecessary and even counterproductive. What we are trying to do can be explained by this example from Toyota.

Imagine a U-shaped cell when you plan the flow of an operation
One of the priorities in the Toyota Production System (TPS) and in Lean Management is flexible staffing – matching the fluctuations in demand by changing the number of employees involved.

As one way to attain that flexibility, Toyota’s engineers have arranged the workstations in U-shaped cells where machines are organized in the sequence of work. If demand is low, they use one employee to assemble the product by walking it from station to station until the product exits at the end of the cell. If demand increases, they will bring in additional employees from a different section to help with the load, until the production pressure is dissipated.

As you imagine a U-shaped cell, you can certainly see how the beginning and the end of the process are located in the same area. You can place one expert in that area, who will control the entire assembly process, from entrance to exit. That expert should have the knowledge and the skills to make decisions and execute them. The rest of the stations in the cell are filled with newer employees who are not able to make decisions by themselves, but have received enough training to carry out instructions given by the experts.

That is exactly what we try to achieve (it is also the main point of this article): We try to have one expert in each area of the operation, and train the rest of the staff until they can execute the solutions suggested to them by the experts.

How does that apply to dentistry?
The easiest example is probably how assistants in our office file insurance claims from the operatory. Sometimes they stumble on a complex case where they need help from the insurance coordinator. They just ask her for guidance; when she gives them the answer, they can apply it because they have received enough training in that field.

What is an easy way to cross train your employees?
Some cross-training techniques have worked for us. They will not necessarily work for you, but once you learn the following principles you will find your own way.

  1. Standardize to eliminate the need for cross training. While we advocate cross training, we advocate eliminating the need for it. That’s because cross training is a tool – a means – not a goal. The goal is cost reduction through waste elimination. Any effort, cross training included, not directly involved in patient treatment, is a candidate for elimination. Every time you plan a process, one of your main objectives should be to reduce the amount of labor it requires. The goal is to keep the staff available for value-added work. We standardized the room replenishment process, for example, until a person who received no training at all could replenish the supplies very quickly and accurately.
  2. Keep formal training to a minimum. Adults learn by doing. Classroom training has little effect and a small return on investment. In a classroom setting, we prefer to teach only the basics that allow for a common language.
  3. Intensify on-the-job training through coaching. You certainly know the difference between a teacher and a coach. A teacher gives you the information; a coach will make sure that you know how to apply it correctly. We need to become coaches, watching over people as they are performing their work, guiding them to avoid mistakes, helping them to develop their thinking and working habits. Are you worried that you might teach them and they might leave? Well, as my friend Orrest Fiume, author of “Real Numbers” said: “You shouldn’t worry if you teach them and they leave, you should worry if you don’t teach them and they stay!”
  4. Make every moment a coaching moment. As I am treating patients, I explain what I am doing and why to the assistant, and sometimes to the patient. Sometimes patients think that the assistant should already know what we are doing and they would lose trust if I explain it to her. In those cases, I give the patient a mirror and explain to them what I want the assistant to hear. This way, the assistant gets the training without the patient even noticing.
  5. Manage busy times differently than slow times.
    a. Busy times: When you are busy, you have less time for training. You want to give a task, to the most qualified employee.
    b. Slow demand times: When the schedule slows down a little, you can call your newest assistant to help you so you can train her. A good idea would be to have the experienced assistant stand behind her and coach her with every step to make sure she gets a quick and precise training.

The main goal from cross training is to equalize the workload among the team members. That equalization allows performing more procedures with the same number of people. This, in turn, guarantees that you won’t need to hire more people and that you will keep your current employees longer. If you like to research the subject of equalization, it is called Shojinka in Japanese, and the word was adopted by English speaking lean leader.

Shojinka is the equalization of the load that remains after leveling the schedule. While Shojinka means distributing the work evenly among people, leveling means distributing the work evenly over time. Leveling assumes that you have control over when to schedule an appointment.

However, no matter how hard you try to level – distribute the load evenly over time, you might find that the schedule gets uneven from time to time. That is when Shojinka – equalizing the workload among people – comes into play, allowing you to utilize your resources with flexibility. If you would like to research leveling for yourself, you could also research its Japanese name, Heijunka. Heijunka has also been adopted in English. The combination of Heijunka and Shojinka is very effective in boosting productivity.