Dr. Rick Steedle describes an effective strategy to plan and implement improvements in your practice to make it more successful and less stressful



In part 1 of this series,1 we learned how to choose the “Right Direction” by committing to excellent clinical care, outstanding customer service, great interpersonal relationships, and sound financial management. In Part 2,2 we discovered how to focus on the “Right Priorities” by deciding which key practice initiatives at this moment will have the greatest positive impact in each of these key areas. In this article, we’ll explore how to have an effective strategy to plan and implement these improvements, following a five-step process to create a more successful, and less stressful, practice.

The wrong strategy
One strategy that doesn’t work is to blame our staff for the problems in our practice. All too often, we believe that if the front desk didn’t put those emergencies in the schedule where they did, or if that slow chairside assistant didn’t take so long with each patient, then we’d stay on time, and everything would be fine. Some think,“If only my staff would improve, then my practice would improve.”

When things go wrong, performance problems are more often a symptom of an underlying flaw in the design and implementation of our systems and procedures. Even good employees can’t be productive with unclear directions or inadequate resources in a poor system with too little training!

Using the “Right Strategy”
Our ability to generate consistently excellent results in any area is determined by five factors: the Direction that we’ve communicated to our staff, the Resources that we’ve devoted to the objective, the Systems that we have in place, the Training that we’ve provided, and then, and only then, the performance of our People.

Therefore, the “Right Strategy” to successfully plan and implement key practice improvements is a five-step process in which we:

1.    Craft and communicate the Vision/Direction—being clear on what we want
2.    Allocate the Resources—deciding what we need to implement the  change
3.    Design the Systems—creating a  reliable way to consistently achieve the desired outcome
4.    Execute the Training—teaching the staff the new system or procedure for achieving our objective
5.    Lead the People—encouraging the staff as they move forward with the change.

Craft and communicate the vision/direction
We reverse-engineer many things in our lives, from going out to dinner with friends to planning a family vacation. We envision the result we want and work backwards to determine what we need to do to make it happen. The same is true to achieve the top priorities in our practice. If we can be clear on what we want by “painting the picture” of better collections, on-time scheduling or a new marketing plan, then we can develop a more reliable solution because we’re focused on a well-defined outcome.
How do we craft a vision-based solution to our most pressing problems? First, we assemble a project team; that is, we set up a series of meetings with the members of our staff who will either implement the change or be affected by it. In a small practice, that may be everyone. In a larger practice (to improve collections for example), it may include the office manager, the financial coordinator, a representative from the front desk, and one from the clinical team. We need the staff’s valuable insight, experience, and perspective to make the most effective decisions.

Next, as a group, we describe the “current reality,” painting a clear picture of the present situation by listing all the related problems. To find effective solutions, this conversation must be a wide-ranging exploration of all of the contributing factors.
For example, at one point, the growth of our practice overwhelmed our capacity to get the patients in and out on time. What once had been a strong feature of our practice had degraded into longer waits, dissatisfied patients/parents, and a stressful working environment.

To describe our current reality in this situation, first we had to “confront the brutal facts”3; that is, acknowledge that our reputation was suffering and honestly answer the question, “What’s not working?” Because we all have a tendency to overstate or understate problems, we had to “get the data,” generating reports of patient wait times to compile an accurate assessment of true wait times. Finally, we had to “think systemically,” seeing this problem not as an isolated issue, but as a symptom of a web of interrelated issues, including staff clinical training, emergency triage and management, scheduling template design, inaccurate procedure times, patient scheduling expectations, and outdated scheduling intervals between appointments.

The next step for our project team was to convert problems into possibilities, listing all the problems and contributing factors and asking, “What would we want instead?” This gave us a preliminary list of what was needed to achieve on-time patient flow. But to get a better vision, we also asked an additional question, “In an ideal world, what else would we want?” This allowed us to dream big, brainstorming ideas that we may not have considered when we focused only on eliminating problems. For example, in order to encourage patients to call and reschedule rather than break their appointment, we wanted “reschedule slots” in the scheduling template so that we could offer a new appointment within days of the original.

Only then were we ready to describe a shared vision of a compelling future. Because we had taken the time to explore the issue fully, we could all now agree on a comprehensive and compelling solution, one that addressed all the related issues and was intrinsically motivating. Unlike most practice initiatives in which change is resisted, vision-based planning allows one to start from a point where everyone is headed in the same direction.

Allocate the resources
In private practice, our most precious resource is not money, information, equipment, facilities, or people—it is time. Nearly all of our time is committed to patient care and the tasks needed to support our clinical operations. But to make significant progress, we must meet to compete, allocating time for strategic planning and meeting together to work “on” our practice rather than simply “in” it.

Weekly “brown bag” lunches and monthly strategic meetings with the project team are essential. Setting limited objectives for each meeting, focusing intensely on the next incremental step, and giving each attendee an assignment to complete by the next meeting are all integral to a successful outcome.

When allocating money to a project, consider the question, “how many patients does it cost?” So, if your fee is $5,000 and the change will cost an additional $10,000, then it will “cost” two patients. Then, decide if this investment will yield two additional patients. For example, when purchasing a demonstration program like Edge™ Imaging, Aquarium or IACT to improve new patient conversion rates, it may require only a short time to realize a good return on the investment. Also, be sure to look for the hidden costs of your present system—how much staff time/salary is being wasted, and how is the reputation of your practice suffering?
Finally, consider other resources that may help—information from books and articles, from specialty organizations, like the AAO, and from knowledgeable people like consultants and other clinicians. No problem is a new problem, and effective solutions are always available from others in the profession and the business literature. Join a business book summary service like getAbstract, Soundview Executive Book Summaries® and GoBrevity™, which can provide a wealth of good ideas from the top business books in 5-8 page condensations.

Design the systems
Because systems are the habitual way a staff performs their duties, there’s always a “system,” whether consciously designed or not. Well-designed systems enable competent staff to consistently achieve extraordinary results. Hap-hazard or poorly designed systems continue to create the same problems whether they are intended or not.

The first step of design is often to adopt and adapt a new system. If you’re experiencing significant problems in any area, you most likely will need a new system rather than trying to fix the one you have. But don’t reinvent the wheel. Someone else is already doing well anything you want to accomplish. Use the CASE principle—Copy And Steal Excellence. Find and adopt an effective system and then have your project team customize it to fit your unique practice situation.

Make the operational design comprehensive enough to address all of the related issues. Use system thinking rather than problem solving. For example, in our practice, the system solution to on-time patient flow was a 9-12 month project that included many core strategies such as documenting the steps for key clinical procedures, staff clinical training to bring everyone up to speed, developing emergency triage and management protocols, revising schedule template design, adjusting common procedure times, modifying scheduling intervals between appointments, and altering patient scheduling expectations with new scripting and handouts.

Next, document the new system or procedure, describing the process in sufficient detail to use as a reference and training manual. These standard operating procedures should be meticulously maintained and updated as necessary. We can’t expect our staff to be “on the same page” when there’s no “page” to be on!

Finally, define the key operating measures and targets. Decide how you will measure progress toward your intended outcomes. Use SMART goals that are Specific, Measureable, Aligned to the objective, Results focused, and have a Target date.

Execute the training
One of the most common reasons that new initiatives fail is that we don’t provide adequate training. Old systems are based on old habits, which need to be replaced by a new system with new habits. Anytime you train, then you’re going to have to retrain until the new way becomes the new habit.

Be patient during this time. Fortunately, because the staff is involved in the development process, they will be familiar with the procedures and more likely be committed to making them succeed. But make sure that the staff is adequately trained before beginning, and provide a high level of support during the early stages.

Lead the people
The staff often becomes discouraged during implementation. We all have an “optimism bias,” feeling that every project we undertake will be easier and will require less time than it actually does. Our role as a leader then is to encourage the staff and remove any obstacles on the path to our objectives.

People who are undergoing change express six predictable concerns:

•    Information concerns–How will I remember what to do?
•    Personal concerns–How will this change affect me personally?
•    Implementation concerns–Who will help me manage  all the changes?
•    Collaboration concerns–How will my coworkers feel about what I’m  doing?
•    Refinement concerns—How do we  refine if it doesn’t work as planned?

Listen to and address those concerns. Focus your energy on making it easy for the staff to achieve the goal by removing any obstacles that impede progress. To encourage the staff, measure the progress and celebrate short-term wins. Use these milestones to generate momentum towards the ultimate objective.

Always anticipate problems. It is often useful to pilot test the new process so oversights can be discovered on a small scale before full implementation. All new initiatives are based on a series of assumptions about what will work. As you test the ideas in the real world, meet frequently to resolve unexpected issues, and be prepared to adjust the process as needed. But understand that new systems don’t eliminate all of our problems; they simply give us a better set of problems, ones that are more manageable and less troublesome to our practice.

Taking the “Right Actions”
The success of any practice-improvement project depends on maintaining the momentum during both planning and implementation. Taking adequate time to meet and to make effective use of that time requires extraordinary discipline. Here are some important principles for taking the “Right Actions” to move any project forward.

•    Have a “bias for action.”6 Don’t wait for the perfect plan. Be willing to experiment as good ideas emerge from the project team. Learn by doing, moving quickly from the drawing board to implementation. Start with “quick fix” adjustments while you’re working on the long-term solution.
•    Identify the key 80/20 actions. The Pareto Principle states that 20% of your actions will yield 80% of your results. At all times, separate the “must do” items from the “would be nice” items. After all the “quick fix” actions have been taken, implement the elements of the plan that will have the greatest impact on achieving the key objective. Because time is limited, good things will always be left undone, so don’t expend energy on things that won’t yield significant improvement.
•    Focus on the next step. To avoid being overwhelmed by large projects, focus all your attention on successful completion of the next step.7 In doing so, stay flexible in your approach. Each step of planning and implementation will produce new information and greater insight.
•    Keep score. Metrics are the foundation for any business-improvement project. Develop key operating measures that are tied to the strategic objective, track your progress, and celebrate the milestones. Early on, create “small wins” for your team. During the long journey of implementing major changes, encouragement comes from measuring how far you’ve come.
•    Finish fully. Don’t stop short of your objective; follow through to completion. The full benefit only comes when the system is refined, the project is complete, and the key objective is met. One project “finished fully” has more impact than three projects one-third complete. Achieving your stated objective builds momentum and establishes credibility with your staff. It’s tangible proof that you are determined to always make things better for your staff, your patients, and the practice.

Conclusion
The work of leaders is change.8 With great leadership, the truly exceptional practices don’t just “manage” each crisis as it arises. Rather, they continually improve by choosing the “Right Direction,” focusing on the “Right Priorities,” and having effective strategies to plan and execute improvements. Effective leaders are committed to a quality improvement process that identifies key issues and problems, work together with staff to formulate effective solutions, and implement reliable systems to consistently achieve outstanding results. In the same way, with discipline and focused effort, you too can reliably lead your practice through such a transformational change, creating a more successful, and less stressful, practice.

Bio
J. Richard Steedle, DMD, MSEd, MS, received his dental degree with honors from the University of Pennsylvania, concurrently completing a Masters Degree in Education. He received his Masters Degree in Orthodontics from The University of North Carolina at Chapel Hill, where he was awarded the Morehead Fellowship in Post Graduate Dentistry and an NIH research training fellowship. After orthodontic residency, he served on the faculty of the Wake Forest University School of Medicine for 4 years before entering private practice. During the next 20 years, he and Dr. Bruce McLain built a three-office orthodontic practice with a staff of more than 25 employees in Winston-Salem, NC. In 2005, Dr. Steedle joined the part-time faculty at the Department of Orthodontics in Chapel Hill. Since then, he has developed a 3-year curriculum in Practice Management for the residents, complementing the work of Dr. Robert Scholz there. UNC now has one of the most comprehensive Practice Management residency courses in the country.

References

1. Steedle JR (2011) Becoming the successful, not stressful practice. Part 1–Choosing the right direction. Implant Practice US online: http://www.implantpracticeus.com/web/home/practice-management/13-practice-management/248-becoming-the-successful-not-stressful-practice-part-1-choosing-the-right-direction.html.

2. Steedle JR (2011) Becoming the successful, not stressful practice. Part 2–Focusing on the right priorities. Implant Practice US 4 (4): 52-54.

3. Collins, J (2001) Good to Great: Why Some Companies Make the Leap...and Others Don’t. HarperCollins Publishers, New York.

4. Gerber ME (2001) The E-myth Revisited–Why Most Small Businesses Don’t Work and What To Do About It, 2nd ed. HarperCollins Publishers, New York.

5. Hall GE, Loucks S (1978) Teacher Concerns as a Basis for Facilitation and Personalizing Staff Development. Lieberman and Miller, eds. Staff Development: New Demands, New Realities, New Perspectives. Teachers College Press, New York.

6. Waterman RH Peters TJ (1982). In Search of Excellence: Lessons from Americas Best Run Companies. Harper Collins Publishers, New York.

7. Allen D (2001) Getting Things Done. The Art of Stress-free Productivity. Penguin Books, New York.

8. Kouzes JM, Pozner BZ (2008). The Leadership Challenge, 4th ed. Jossey-Bass, San Francisco.