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A Tale of Two Toothpicks: How Computers Can Help Manage a Practice

An office manager recently asked, “How can some offices get by with only one or 2 people at the front desk? We have 3 people and we can’t keep up with all the work. We’re drowning! How can other offices be that much more efficient?” Good question! Do the people in the other offices work harder, or are they smarter or better organized? Usually that is not the case. We can find the real answer by comparing 2 companies that manufacture toothpicks.
Toothpick company A and toothpick company B both make exactly the same number of toothpicks each month and sell them for exactly the same price. But A has a 40% overhead and B has an overhead of 110%—they lose money every month! Payroll is the largest expense in both places; A has only 2 employees, both very well paid and happy in their jobs, while B has 15 harried, unhappy people working at close to the minimum wage. So, what do the 13 extra employees at B do? Are they just sitting around collecting their checks? Some interviews with people at both companies are revealing.

Photograph by Nathan Zak

“Our jobs are pretty easy,” says the manager of A. “Every day we go to the loading dock and pick up 2-by-4s delivered there, then run them through the toothpick-making machine. The toothpicks are automatically dumped into the pre-made boxes, also delivered to our loading dock. We just close the lips on the boxes, take them back to the loading dock, and call the shipper to take them to our customers. Then we go to lunch. In the afternoon, we call our customers to be sure they are happy with our product, we analyze our reports to see where our new customers are coming from, we review our marketing, and we pay a few bills. Usually we go home early.”
But the manager at B tells a different story: “First thing, we all pile into our 1955 Studebaker truck and drive to the forest to cut down trees with our handsaws—we don’t have chainsaws yet. If the truck does not break down, we get back to the office a little after lunchtime. We usually don’t have much time to eat because we all have to start carving the toothpicks from the wood we brought back. That used to be easier when we had sharp knives to use, but the knives have all gotten dull and we don’t have any time to sharpen them …we’re way too busy for that! Most of our employees are new because we have such a high staff turnover. I don’t really have time to train them so they are not very good at their jobs. Once they have been here long enough to make good toothpicks, they leave because the pay is so low and the work is so hard. After we get the toothpicks made, we have to fold up the boxes from sheets of cardboard and then hand-write our company name on each box. By then it is almost five o’clock so we have to load our truck frantically and try to deliver the toothpicks to our customers. We are usually late, and our customers are mad at us most of the time, but what else can we do?”
It’s obvious that the problems of B are not due to poor employees; they are due to poor management. Company B continues to try to make toothpicks the way it did 50 years ago. It has not kept pace with the changes that have made its competitor so much more profitable. So, how do the toothpick companies relate to the question asked by the dental office manager?


Because her dental office has antiquated computer equipment—analogous to the 1955 Studebaker truck, handsaws, and dull knives—it cannot adopt more efficient, modern practice management techniques. Its computer software capabilities are 15 years out of date. I have long maintained that the specific brand of dental management software an office uses is much less important than how the office uses that software; it’s the painter, not the paintbrush that produces fine art. But this office is trying to paint with a handful of weeds instead of a paintbrush! As a result, they are forced to use manually generated paper-based lists to track vital things like recalls, referrals, and incomplete treatment plans. Although they use a “computer scheduler,” it does not show booked production or the production value of each appointment they make. They have only the vaguest idea until the day is over just how much was produced that day. This makes it impossible to assess production goals until it is too late!
They use a manual recall system because their computer system is just too cumbersome. They only send one hand-written recall card. If the patient doesn’t respond, tough luck—that’s all they get! The results are poor patient retention and poor patient care. They have few hygiene days in spite of what they think are “lots of active patients.” Neither the office staff nor the doctor knows where their new patients come from or how much each different referral source generates in production. They do an expensive marketing mailer on a frequent basis. It “seems to work,” but they really don’t know. If they get 20 new patients from each mailing, how many of those referrals actually translate into income and how many just come in for the “free bleaching,” then walk out the back door to another dentist? The antiquated computer system doesn’t track that, and no one has time to manually track it. (“No time to sharpen the knives.”) It may be that the office loses money on each patient that comes in as a result of that expensive mailing. No one knows!
Office staff members try to do the right thing by entering the treatment plans into the computer at the time they are diagnosed, and they do attempt to give patients some idea of their insurance coverage before treatment is started. But if the patient doesn’t schedule an appointment, or later cancels an appointment, he or she is usually not followed up with. The computer system does not automatically generate a report of missed or cancelled appointments or unscheduled treatment plans. Lots more patients walking out that back door! Because the office must manually deal with so many different insurance plans, its estimates of insurance benefits are frequently inaccurate. In spite of its disclaimer that “this is only an estimate,” it leads to unpleasant financial surprises for patients. This anger reduces the office collections and engenders ill will among potential referral sources.


Another major difference between our toothpick companies was the use of “outsourcing.” Company A has found it is much more efficient to let someone else harvest its raw material. So how and to whom do you “outsource” tasks from the front desk? One way is to have back-office staff enter treatment plans. The chairside assistant is with the doctor when he or she calls out the treatment, and can immediately make any corrections or clarifications. “Did you say a porcelain crown or a gold crown, doctor?” “How old is the crown we are going to replace, and what is the reason for the replacement?” “Do those anterior teeth need crowns for cosmetic reasons (no insurance coverage) or are there big, old composites with recurrent caries in those teeth? (And should we take an x-ray or photography today while the patient is here?)” The chairside assistant has much more pertinent information available than the front desk person. Why would you cut down your own trees when someone else can do it better, more easily, and more accurately?
Posting treatment and scheduling appointments from the operatory are other examples of outsourcing tasks often done at the front desk. Just as outlined above for entering treatment plans, the chairside assistant is in a much better position to accurately enter what treatment was completed today and to consult with both the doctor and the patient about what will be done and how long it will take for the next appointment. A real advantage of this kind of outsourcing is that it does not transfer work time from the front to the back. It can usually be done without any added time in the operatory if it is completed when the chairside assistant has “dead time”—while the doctor places retraction cord or while waiting for a material to set. In one office that uses a 2-minute double-bite impression technique for crowns, the chairside assistant routinely does all the clinical charting, schedules the next appointment (the patient just has to nod), creates and prints the lab slip, and produces the insurance submission with the appropriate documentation and images attached, all during the 2 minutes for that impression! She knows her job and is very good at it because she is a well-trained, long-term employee—and she is also well paid because she is worth it and the office can afford it. When properly done, front desk outsourcing saves time and produces superior results.



The next question our office manager should ask is, “How do I move my practice from B to A?” Simply throwing money at the problems is not the answer, especially for an office that already has a very high overhead. Is new software necessary? Often, it is not. Current software may have all the capabilities needed for modern practice management, but staff does not know how to use those capabilities. Such an office needs to invest in training and coaching, not spend money on new software. But if the office truly has a “1955 Studebaker” for dental software, it does need to be replaced. The good news is, buying new dental software is a lot like buying a new car—personal preference and the quality of local support are probably the most important factors, not the specific brand of software. (For more on important software features, refer to our Web site, PaperlessDentistry.com.) 
Adopting the principles of modern, computerized practice management tends to produce quick returns in profitability at very low cost. Achieving each step may require some specific staff tutoring. Fortunately, such training no longer requires travel over long distances, except by electrons! Ad-vanced training companies now provide “over-the-shoulder” training using the Internet. The trainer can be in San Francisco and the student in New York! Scheduling is more versatile, and training sessions can be shorter and more productive because there are no travel times. Using these contemporary training methods, it is now much easier and faster to “sharpen the knives” we use every day.


What kind of toothpick factory are you running? To avoid the high overhead, unhappiness, and inefficiencies plaguing toothpick company B, we should all adopt proven, computer-based, easier, and more profitable management. This decreases office stress, contributes to staff longevity and loyalty, improves our ability to provide better patient care, and increases both our monetary and psychological “take home” at the end of the day. Ultimately, the quality of the toothpicks we produce is very dependent upon the processes we use to produce them!

Dr. Stephenson practices in a paperless and wireless restorative small-group practice in San Leandro, Calif. He has been lecturing, writing, and consulting on dental computing and management since 1985. Copies of his articles and other information are available at his Web site, PaperlessDentistry.com. For information about his computer consulting services and seminars, call (510) 483-2164.



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