Get the right people ‘on the bus’

Core teams should be created deliberately and systematically by the practice, rather than left to chance. The ultimate benefit of a core team is that it allows a practice to reach the highest percentiles of production at a low level of stress, without having to maintain all team members indefinitely. The core team acts as the training organization in all aspects of a new team member's experience in the practice, giving that person the best opportunity to become part of the core team.

Inventory management

As dentistry continues to evolve, the best management systems of the business world need to be incorporated into each practice. As always, my goal in these columns is to bring and modify the best business principles available to readers of The Journal of the American Dental Association. Just in Time ordering and inventory control is one of the best, as evidenced by the fact that top-performing companies worldwide have adopted it.

Collections and financial controls

There is a reason why most businesses manage fees and money very closely with specific guidelines. It is not to be inflexible, but rather to establish excellent financial controls to ensure that the financial health of the business (or practice) remains strong while achieving outstanding customer (or patient) satisfaction.

Employee incentive programs

One great benefit of employee incentive programs is that they connect team compensation with practice performance. Options are always available to keep the incentive programs exciting and motivating. The key is to understand the goal and to put in place the employee incentive program that works for your practice.

Managing time

As you can see from these examples, there are many factors that must be considered in the relationship between time management and practice production. However, it is important to understand that there is a direct correlation among various factors--including how time is used, which services are provided, the volume of services provided and other factors--in establishing a practice with excellent financial results. As always, dentistry is about excellent patient care, but it still is important for the dentist and team to examine the day-to-day use of time and its effect on the business side of the practice.

Return on investment

Return on investment is an excellent mechanism for evaluating large practice purchasing decisions. Whether you are purchasing a new practice, opening an office, building a new facility, recruiting an associate or adding technology, the issue that always should be evaluated is whether the investment will create a positive return for the practice and, if so, in what period. While most dental investments actually provide a positive return on investment within 12 months, larger investments, such as purchasing a practice or opening new offices, may require several years to gain a positive return. They still may be good decisions. At the very least, return-on-investment considerations allow dentists to evaluate options from a business-plan perspective, rather than simply making uninformed decisions.

The correlation between dental practice management and clinical excellence

Efficient practice management is about much more than prof itability. It is about educating and motivating patients to achieve optimum oral health by incorporating the best business methodologies and systems into the management of all practice operations. Effective practice management cannot be accomplished without gaining the over-whelming satisfaction and trust of every patient. This can be achieved only through excellence of care and by achieving the high professional standards that dentistry currently demands.

Creating a viable practice vision

Vision guides the long-term development and growth of a dental practice. It provides focus and purpose to the dentist and team and creates clear goals for achieving practice growth and moving toward realizing the vision.

Action planning and accountability

The truth is that no plan survives its collision with reality. The best plan does not guarantee that the dentist will not go over budget on building a new practice or run into unexpected obstacles in integrating a new software into the practice. The best plan does not guarantee that goals will be met precisely on schedule. What a plan does guarantee is that the dentist has provided the practice with the best opportunity to achieve goals on time and within budget by executive analyzing and charting a clear path toward success. Smart businesses understand the process of vision clarification of vision clarification and goal setting, but do not stop there. Smart businesses define clear AP&A systems that effectively chart a path toward goal attainment, then proceed to implement that plan and monitor progress toward goals. In instances in which information becomes available indicating the plan needs to be revised, corrective action is taken and appropriate changes are made.

The dentist as a leader

Leadership is one of the more difficult business skills to develop. Any dentist can be a better leader and should view this as an essential aspect of his or her own personal business development. Dental practices today are more dependent on staff than ever before, and it is well-known that the number of well-trained staff looking for positions has diminished. To overcome this challenge, we have to increase the skill set, knowledge and commitment of our teams. To do this, dentists will need to be better leaders and continually work to improve these same skills in themselves.

Setting your practice goals

Goal setting is a powerful business technique. Far more than just a motivational concept, it is an outcome of strategic planning. Doctors who set goals are usually more clearly focused on where they want the practice to go and when they want to get there.

The value of new patients

Make no mistake: dental practices are businesses. Dentists as CEOs need to focus on key performance indicators and statistical tracking in order to understand what is happening in the practice over its life span. Average production per new patient is a key factor to be tracked because it is an essential driver of the financial performance of any dental practice. The health of this factor will have a dramatic effect on the financial well-being of the dentist, and on the timing and character of his or her retirement. At the same time, it is essential to balance financial factors with exceptional quality of care for every patient. Without both, neither will be successful in the long-term.

Three basic principles of success

Basic business principles all but ensure success when they are followed consistently. Putting strategies, objectives and tactics in place is the first step toward being able to document systems, initiate scripting and improve staff training. Without the basic steps, systems, scripting and training the practice for performance would be hit or miss, at best. More importantly, applying business principles ensures that limited practice resources are dedicated to the achievement of the strategy. By following this simple, three-step process, a dental practice can significantly enhance both financial success and dentist and staff satisfaction.

The business of dentistry

Dentistry is a rapidly evolving health care occupation that can offer an outstanding quality of life, allowing each doctor to define how he or she would like to practice. Dentistry has a high-income potential compared with many other occupations, and this also contributes to the quality of life of dental professionals. But the profession can be overwhelming due to the variety of procedures performed, the large number of systems in place and the multiple management issues to deal with. While there is no one-size-fits-all system that will work for all practices, KPIs can help each professional evaluate how he or she would like the practice to operate and grow. Using KPIs to help identify the strengths and weaknesses of your practice, you can set and establish the systems that will assure achievement of those goals.

Applying statistics to the dental practice

There are numerous variables in the specific mix of procedures a practice performs. Other practice production variables include the number of patients a practice serves and the number of team members available to accomplish the practice objectives. The majority of practices would benefit by following a model similar to the one above. To return to the McDonald's example, success is measured according to whether each McDonald's sells the optimal product mix for its customers. It doesn't matter what components make up that mix. The same thing is generally true for dental practices. Conducting a "percentage production analysis" to determine how closely a practice follows the above model can be beneficial. It can help in making decisions regarding what changes need to be made to achieve optimal production levels and greater practice success.

Dental business management

Business models and systems do not exist for their own sake. Rather, they are designed to help your practice achieve its goals. Before you adopt any new system for any aspect of your practice, define the goals and write down the specific objectives you expect the system to achieve. Bear in mind that systems need to be easily understood by team members and by those who join the practice later on. It is important to understand that economic changes, governmental mandates and other factors beyond your control may make it necessary to reassess the way each system operates on a regular basis.

Determinants of delayed nephrologist referral in patients with chronic kidney disease

Late referral to nephrologists of patients with chronic kidney disease (CKD) is a major public health problem because it is prevalent and associated with increased morbidity, mortality, and greater healthcare costs. To identify factors associated with delayed nephrologist referral (first nephrologist visit < 90 days before the onset of renal replacement therapy), we identified a cohort of patients with preexisting CKD that progressed to end-stage renal failure. We developed a logistic regression model to measure the association of specific demographic and clinical covariates with delayed nephrologist referral. Delayed referral was highly associated with older age (P < 0.001), race other than white or black (P = 0.002), and the absence of certain comorbidities: hypertension (P < 0.001), coronary artery disease (P < 0.001), malignancy (P = 0.005), and diabetes (P = 0.02). Associations of late referral with male sex (P = 0.07) and lower socioeconomic status (P = 0.09) were of borderline significance. Patients who were predominantly cared for by a general internist were more likely to be referred late to a nephrologist compared with those cared for by a family or primary care practitioner (P = 0.002) or another subspecialist (P = 0.019). These findings suggest that several factors increase the risk that patients with CKD will have the first nephrologist consultation excessively late in the course of their disease. Although timely access to nephrologist services is important for all patients with advanced CKD, this is of particular concern in older patients, those in certain minority populations, and those in whom the absence of comorbidity may provide a false sense of true risk status.

Paradoxical relations of drug treatment with mortality in older persons

Medication use patterns provide popular surrogate measures of disease, yet selective under-use of drugs by elderly patients with potentially unmeasured comorbidity may lead to artifactual "protective" associations between use of specific drugs and mortality. We examined the relation between use of 20 common classes of drugs and mortality among the 129,111 residents of New Jersey 65-99 years of age who had at least one hospitalization during the years 1991-1994 and filled prescriptions through either Medicaid or that state's Pharmacy Assistance for the Aged and Disabled program. Each study drug class was used by more than 5,000 subjects during the 120 days before hospitalization; 41,930 subjects died in the hospital or during the year after discharge. Users of drugs from each of seven therapeutic classes had reduced age- and sex-adjusted rates of death relative to non-users: lipid-lowering agents, nonsteroidal anti-inflammatory agents, beta blockers, thiazides, glaucoma drugs, calcium channel blockers, and anti-anxiety drugs. Adjustment for comorbidity and polypharmacy had little effect on these results. We found similar results in a separate nonhospitalized cohort of 132,071 elderly persons. Much of this observed association appears to be nonetiologic. These findings raise concerns about using observational studies in high-risk populations to infer associations between drug use and outcomes.

Late referral and modality choice in end-stage renal disease

BACKGROUND

We sought to determine whether late versus early referral to a nephrologist in patients with chronic kidney disease influences the initial choice of hemodialysis (HD) versus peritoneal dialysis (PD) or the likelihood of switching treatment modalities in the first six months of therapy.

METHODS

Using New Jersey Medicare/Medicaid claims, all patients who started RRT between January 1991 and June 1996 and were diagnosed with renal disease more than one year prior to RRT were identified. In the resulting cohort of 3014 patients, 35% had their first nephrologist consultation < or =90 days prior to initiation of dialysis.

RESULTS

After controlling for demographic characteristics, socioeconomic status and underlying renal disease, age, black race [Odds ratio (OR) = 0.56], race other than black or white (OR = 0.56), and socioeconomic status (OR = 0.68) influenced the choice of initial treatment modality, but timing of the referral did not. However, patients starting on PD who were referred late were 50% more likely to switch to HD than were patients who saw a nephrologist earlier [Hazard's ratio (HR) = 1.47]. In patients originally on HD, diabetic nephropathy (HR = 1.49) and black race (HR = 0.69) influenced the likelihood of switching to PD, but the timing of referral did not.

CONCLUSIONS

These results refute earlier findings that late referral may limit access to PD. We found that modality choice depends on factors such as age, race, or socioeconomic status, rather than on than timing of nephrologist referral. Late referral does not influence the likelihood to switch modality in patients starting on HD, but does so in patients starting on PD.

The application of the bioelectric recognition assay for the detection of human and plant viruses: definition of operational parameters

The bioelectric recognition assay (BERA) is a novel biosensory method based on a unique combination of a group of cells, their immobilization in a matrix that preserves their physiological functions and the expression of the cell interaction with viruses as a change in electrical properties. A BERA sensor consists of an electroconductive, tube-like probe containing components of immobilized cells in a gel matrix. Cells are selected to specifically interact with the virus under detection. In this way, when a positive sample is added to the probe, a characteristic, 'signature-like' change in electrical potential occurs upon contact between the virus and the gel matrix. In the present study, we demonstrate that BERA can be used for the detection of viruses in humans (hepatitis C virus) and plants (tobacco and cucumber viruses) in a remarkably specific, rapid (1-2 min), reproducible and cost-efficient fashion. The sensitivity of the virus detection with BERA (0.1 ng) is equal or even better than with advanced immunological, cytological and molecular techniques, such as the reverse transcription polymerase chain reaction. Moreover, a good storability of the sensors can be achieved without affecting their performance. The potential use of portable BERA biosensors in medicine, for mass screening purposes, as well as for the detection of biological warfare agents without prior knowledge of a specific receptor-molecule interaction is discussed.