Monday, September 2, 2019

45 Days of Practice Ownership


I alluded to it in my last post, but I have officially purchased a dental practice in Greeley, CO.

The name is NorthStar Dental, and you can find me on the web in these locations:

Twitter: @NSDGreeley
Instagram: @NSDGreeley
Facebook: Click here


I've learned a few things in my first 45 days, but I mainly want to discuss the differences between military dentistry and civilian dentistry here.

1. Treatment planning

Military treatment planning is very conservative. This stems from the fact that we are often so booked out, that it's easier to push off that tooth with some visible fracture lines to next year, or do a big filling and hope it doesn't break in the meantime, rather than stuffing the schedule full of crowns.

In civilian practice, you can pitch the option of a crown as soon as you know a filling is a poor long term solution which means your crowns are going to be far more predictable and often not require a core buildup for the patient (which saves them $) if the existing filling is small.

2. Problem solving

The military has a multitude of issues but most of them are small. However, this constant small background annoyance is akin to a constant static slowly invading your work life. There's a lot of problems that you can't fix at all, or that take so long to fix that you just start to ignore them.

In civilian practice, problems get solved very quickly. There's a host of helpful people waiting to service your practice via equipment purchases, financing, supplies, etc. 

Example: It took 8 months to get new curing lights in the military. In my new practice? 4 days.

3. Administrative tasks

One big benefit of the military is that you have a lot of enlisted personnel to help with admin duties. But wait a minute, you also have your own! Writing notes, running programs, the list goes on and on. None of them are that hard, but again, it's like the constant static in the background.

In civilian practice, you have far less that you are "required" to do yourself (treatment notes are an obvious example here). Not to mention you can run your "programs" (referrals, etc) however you want! My admin burden is probably 10% of what it was in the military. My staff is small and efficient and takes most of this load away. Now, I do have a host of new issues to deal with, but with the right leadership background, I have had no problems at all with these new items and I have more down time (yep) than I did in the military.



My overall thoughts after 45 days:

I have been totally surprised at how easy the transition to civilian practice has been. The everyday joy of treating patients that actually chose to come see you cannot be understated. Having a very small team of highly motivated individuals makes you far more productive than having large military teams (ironically) bogged down with red tape and hours of extra non-dental work. The nearly total lack of administrative tasks in the civilian world is a dream. Solving problems instantly means that there's no buildup of stress "static". Being able to actually lead a clinic and have ultimate autonomy is wonderful.

I've loved it so far. If I had to put a number to it, I would say it's about 20% as stressful as I expected, and 2x as fun.


My big caveat: 

If you're thinking of getting out just to associate forever, think twice. The military has such a great end goal for those that can stay for 20 years, and many private offices hire associates too early which means you won't be busy enough. Working for a corporate office might work because they typically have a better pulse on their needs, but you may burn out quickly because you'll definitely be seeing more patients.

So let me encourage those that are considering getting out. Do it!

If... you want to own a practice :)


P.S. If you decide to get out, you *must* use an intraoral camera for *every* exam finding. Showing the patient what you are seeing is far and away the best tool for gaining trust and building rapport. 





Monday, June 24, 2019

The End of the Beginning -- And An Offer for Readers

I started this blog in February 2010 with the intention of chronicling my journey as an Air Force dentist and being a resource to help out people who had questions.

I was "scratching my own itch", if you will. I didn't see anything on the internet like what I wanted to read. So I made it myself.

500 emails, 250,000 page views, and a few phone calls later, I'd say it was quite a success.

After a long 10 years, I am finally in the process of leaving the military and acquiring a dental practice for myself. I can't say really anything more than that, but now you know. I've already learned a ton along the way, and I'm hoping to help military dentists get over the fear of transitioning into practice.

If you're a dentist (military or otherwise) considering transitioning to ownership, please contact me (my email is on the right side of the page)!

I would love to help you better understand if this is the right step for you and even do some help you look at different practice offers, associate contracts, or just brainstorm your next steps.



As for the future of this blog...

I've struggled recently trying to decide what direction to take it, if any, given the facts that:

1. I'm leaving the military (so the title doesn't work super well)
2. It makes me no money (so I can't sell it)
3. It's a very narrowly focused/designed blog (so there's not much else to explore)

However, I think it may be beneficial to continue my story in some way and I haven't quite decided if that will happen here at this domain or on some other blog that is tailored more towards my next phase in life. Stay tuned.

I've received literally hundreds of emails over the last decade and this blog has been a central location for those looking for information about military dentistry, the Air Force HPSP, dental school, and life in the military.

My email is still live, so keep the questions coming! Like I said at the top of the page, I'm welcoming any and all questions from those looking to transition to ownership.

It's been an honor and a pleasure, and I'm excited for the next step in my journey and helping you with yours.

Wednesday, January 23, 2019

Nuts and Bolts - Part 3/3 of Organizing a Military Dental Clinic

Nuts and Bolts - Part 3/3 of Organizing a Military Dental Clinic

Practical tips for making your clinic more efficient. These are actual, real world things you can do to help improve different areas of your clinic.

Post contents:
-Supplies
-Patient Records and Forms
-Meetings

Supplies:

1. Everything has a home

Make sure every single supply has a "home". Some bases have storage areas that can accommodate everything, but some don't. That's ok! Everything should still belong somewhere. NEVER order a supply and deliver it straight to the treatment rooms only and don't just throw the box on a shelf somewhere. You MUST have an area that the rooms are restocked from that itself is a holding area for the clinic. An assistant should never ever ever ever run out of an item and not know where to look for more. The process CANNOT be "tell me when you're low". The item must have a home!

With that being said, this "home" should have standardized labels! NEVER place a box on a shelf by itself unless it's a large box and the shelf itself has a label for that item. Always place the box, or the items in the box, into a standardized container with a label on the front that will allow ANYONE to find that item again later. See #2 for how to do this.


2. How to label item containers in supply areas

Every item must be labeled on a standard container with at least the following information:

-Item Name
-Manufacturer
-Manufacturer Number

These 3 pieces of information are all you need to reorder the correct item. Do NOT just rely on the name alone. Too many products sound similar to trust the name alone! We moved to this system at my previous base and one had 1 item ordered incorrectly in 2 years. At my new base? We accidentally ordered an extremely similar, but extremely wrong, version of the "right" product last month that has wasted money and time, not to mention we have to start over and order the right thing (which we are now out of).

We are working on it :)


3. Have a doctor supply huddle

Every time you get new doctors in the clinic, sit down and go over the supplies. There's no reason that the doctors in the clinic can't compromise on 1 or 2 types of bond. Every single doctor should not have a special bond for themselves. This is ludicrous and adds unnecessary work and strain on the supply chain. Bond is just one example, but it goes for everything.


4. Develop a simple system for alerting the person who does the ordering

Here are some ideas that have worked well --

  • Place a sticky note on the low supply container. The Logistics person sees the sticky note and orders more. When they order more, they write the date the item was ordered on the sticky note and the sticky note stays on the item until it comes in, at which point the sticky is removed and the item is restocked.
    • Pros
      • Eliminates verbal communication 
      • Eliminates Logistics person being notified multiple times about the same item
      • Eliminates the assistants and doctors wondering when an item was ordered
      • Good for clinics with 1 supply area
    • Cons
      • Stickies sometimes fall off
      • Required Logistics person to visually scan supply area
      • Not ideal for clinics with multiple "main" supply area

  • Create a re-order clipboard. The logistics person keeps this clipboard in their area and techs and docs come write down items they need.
    • Pros
      • Centralizes all ordering information
      • Good for clinics that hold supplies in multiple areas
    • Cons
      • Same item might get logged multiple times
      • Handwriting might be an issue
      • Often still required Logistics person to go look for the low item to decide how much to order

  • Create order sheet binders or forms that can go in special areas. Many clinics have supplies that are exclusively held in an Endo cart or Surgery room. Hang a printed and laminated Excel sheet with the applicable information (name, manufacturer, manufacturer number) in the room or on the actual cart itself. 
    • Pros
      • Makes reordering very simple, because the item is identified as being low and the reorder information is right there
    • Cons
      • Make sure the sheet stays updated with new items or item changes

  • BONUS: Same as the "order sheet binder" idea, but just place the info in a relevantly placed Excel document on a shared computer drive. Post the location of the document in the relevant location. This is the same concept as the binder, but more accessible for the person who likes their information digitized. Plus, when you modify it, there's no need to print it off.

5. Consider pre-sterilized burs

I love these so much. Individual burs, sterile from the factory, at practically the same cost as whatever burs you are currently using. 
  • Pros
    • No more nasty looking bur blocks!
    • No more burs running through sterilizers 20 times (or more) before they get used
    • No more "is this rust or blood"?
    • Eliminates entire process for your sterilizer workers
    • Safer for everyone (assistant, doctor, sterilizer techs) due to fewer burs needing to be handled (ie: decreased needle sticks)
  • Cons
    • Takes up more physical space in the treatment room and in the supply area
    • Packages must be opened when needed, stalling your work slightly during the appointment vs having an open bur block with several types of burs
Brasseler and SS White make tons of these. There are other companies as well that should be easy to find with a Google search. Email me if you want some catalogs. I also recommend some magnetic bur holders from Dux Dental to act as temporary bur blocks.


6. Standardized treatment rooms

This is easier if your clinic was built so that all the rooms are the same. This is far harder if you have various types of room layouts in your clinic. Consider at least making all the basics (barriers, suction, etc) standardized. At my previous assignment, we had literally every room standardized, with the exception of the 3rd drawer in a rolling cart, so the doctor could add special things they wanted into that specific drawer.

This made room checks unbelievably simple. Doctors could move to other rooms in a breeze. Assistants knew where everything was in every room. It's a dream come true.

My new clinic was built within the last couple of years, but was actually designed very poorly with little foresight. We have 3 different types of room configurations in the clinic among our 12 treatment rooms (in addition to a severely dwarfed main supply area). I'm still scratching my head trying to figure out how best to serve our patients with these bizarre construction limitations. If I had it my way, we would demo the place and start over! Whoever designed Buckley would have been wise to recall this famous quote: "Begin with the end in mind" -Steven R Covey.

I put this step last on purpose. You must have the previous 5 things accomplished or the standard room will be a nightmare to try to create and enforce.

Note: In order to make this stick, you must have the room photographed so that binders with these photos can be made of what a "perfect" room looks like so the standard you create isn't lost! The binders are used by the techs to standardize the rooms, and used by the docs and NCOs to enforce the standard. 


Patient Records and Forms:


1. Have a weekly record scan program

I wish I thought of this one, because it's so simple. Basically, you have someone in charge of reviewing a set of records weekly.

You have a form on the wall where that person can log the date, the record range they checked, and how many errors they fixed.

Common errors to look for:
Duplicate records
Poor handwriting (rewrite the record)
Misfiled records
Records with missing or incorrect colored tags and papers

This would be in addition to the monthly records review, because that program doesn't hit every record. This does!


2. Put all the forms in the same place on the network drive

Nothing drives me crazier than having a medical history in this folder, the initial charting in that folder, etc.

Put them all in one spot! Here's why:

Makes it simple to train new people (the forms are here)
Makes it easier to update forms (this is the only version of the form, let's update it)
Eliminates redundancies (no more having 3 versions of the same form floating around)


3. Develop a naming system for the files so they are printed correctly

This is how we name our files:

"(BW, Yl, Double sided) Fly Cover Sheet, updated 31 Oct 18"

This naming scheme answers 5 questions:
1. Black and white, or color?
2. What color paper do I print it on? (In this example, Yl stands for "Yellow")
3. Do I print double or single sided?
4. What form is this?
5. When was this form last updated?

No more misprinted forms! Yay!


4. Put the date the form was updated on the form itself

In the example in #3, we would also have "updated 31 Oct 18" printed somewhere on the Fly Cover Sheet itself. This helps us know if a form we are holding in our hands is the most recent version or not.


5. Put physical forms in as few locations as possible

No more forms in treatment rooms. Period. This is where forms go to die and get resurrected 2 years later in a chart out of nowhere.

Find a centralized location, or two, that all the forms can be stocked. This is much easier to replace forms and make sure everyone is using the same version now that they aren't scattered to the 4 corners of the Earth.


6. If the form is part of a program, type the directions ON the form itself

Class 3 forms are standard in the Air Force, but we added a couple things to ours. We minimized some fonts to make room for these instructions:

"Putting a patient in Class 3
1. Have patient sign this form
2. Write up treatment note
3. Assemble completed chart and place chart in Class 3 box in records room
4. Class 3 NCOIC will take chart and... etc...

Taking a patient out of Class 3
1. When treatment is completed, write treatment note
2. Take the blue chart tag out of the chart
3. Take this form out of the chart and place the form in the Class 3 box in records room
etc..."

Now, it's extremely obvious what to do with a Class 3 record! Again, this forces the doctor or tech to go through the proper steps, get the chart to the right person so that person can run their OWN checklist for the Class 3 program. This ensures that all Class 3 charts are handled identically, and HOW to handle them is clear and obvious.

How easy would it be to train a new person on what do to with Class 3 charts using the above instructions? If they can read, pretty darn easy.



Meetings:

1. The length of a meeting is a maximum time limit

Don't feel obligated to stretch the meeting to fill the time allotted. Consider that a "maximum time". If the goal of the meeting is accomplished sooner, leave!


2. Have an agenda for every meeting

This is why people hate meetings. They turn into a circus of confusion and pointlessness. If the goal of the meeting is "let's brainstorm XYZ" then that's great! But set aside time for that type of work, don't make it the default. For everything else, plan it out in order and get to it. A powerpoint on the wall that helps guide the meeting is a great way to keep everyone on task.


3. Don't hate the meeting, hate the chaos

This sort of goes back to #2, but don't hate the meeting itself. If you are prepared with an agenda for the meeting, then implement it use this time to work ON the business/clinic. This is the time to build a better machine! If absolutely no one wants to attend the meeting, you should think very hard about why it exists at all, or how you can make it more efficient (or how you can convince the team that the meeting will result in better outcomes). To gauge interest in the meeting, don't ask a large group. Ask individuals one-on-one.

Don't eliminate the meeting just because you as the meeting leader don't see the purpose. There could be other people looking forward to that meeting for a variety of reasons and they deserve the chance to speak in that setting if they were expecting it.

Most meetings need to happen, but simply don't have an aim and end up running into chaos problems.


4. Be prepared and be decisive

Meeting chaos stems from a variety of places I've already mentioned, but the big one is indecisiveness. Make the decision and move on. "Let's talk about this later" is still a decision. Don't let a group of people spin on a topic forever unless the purpose is to get everyone to brainstorm ideas.

Actually, most decisions are made before the meeting beings (most meetings are a time to disseminate information), unless there is designated decision-making or brainstorming time. If you are prepared for the meeting, a lot of it should be delivering clear and concise decisions to the relevant group, or soliciting feedback from a group to finalize a decision. Once you get the feedback, finalize it. Start moving on it. You can adjust later.

Also, it shouldn't take an entire meeting to decide the theme for the summer picnic so don't let it. Most people won't care anyway, so have a separate conversation later with the group that cares... which brings me to point #5.


5. Don't waste everyone's time

If the decisions in the meeting, or outcomes of the meeting, are only relevant to 1 or 2 people there, consider having a discussion with those people only. The entire clinic doesn't need to hear a discussion about which bonding agent 3 doctors like the best.