Your appointment book is full. The clinic still struggles.

Sep 25

6 min read

Dear colleague,

Tuesday morning, ten minutes to nine. The phone rings. It's a patient who has been coming to you for twelve years, and she has lost a crown. She would like to come in as soon as possible.

The receptionist opens the appointment book. The first opening with a dentist is six weeks out. The answer: "I'm sorry, we have nothing before that". The patient says "thank you" and hangs up.

Then she calls the clinic three streets away.

They can see her on Thursday.

You never hear about it. Nobody mentions it at the morning huddle, because from the front desk nothing happened. A patient called, we had no time, she said thank you. A year and a half later it occurs to you that it has been a long while since you saw her. By then she has disappeared into the system and nobody remembers why.

That same week there are five gaps in the hygienist's appointment book.

The clinic had room. Just not in your chair.

The appointment book usually runs on habit

Take a look at last week's appointments in your own book and split them into two piles.

One pile is the work that needs a dentist.

The other is everything someone else could handle with the right training.

Start with the most ordinary thing in pile two. How many routine exams were sitting in your own appointment book? In Denmark that visit pays around 100 euros on average, including the public subsidy and the odd bitewing, and you can fit two into an hour. That's 200 euros for an hour of the one resource the clinic cannot get more of. A hygienist can use the chair too. The hour in your own book is the one nobody else can use.

The usual reaction is to speed up. That's what we were trained to do in the nineties. The books had to be full at all times. Three patients an hour instead of two. I have watched clinics try it, and the first thing to go is the conversation with the patient. The one where she understands what is wrong and why it needs doing. That's usually the exact stretch of time you cut, and it was where she would have said yes to treatment.

So speed solves nothing.

Then take the rest of pile two.

The long checkup on a patient who is doing fine. The follow-up on an aligner case that is tracking. The suture removal. The review where the patient really just needs to hear that it looks sensible. In most of the clinics I visit, pile two is a good deal bigger than the owner expected.

These tasks landed with the owner back when the clinic had one chair and two employees. They never moved, while the clinic grew to three clinicians and four assistants across four chairs. Nobody made a decision about it. The exam has to be done. It just doesn't have to be done by the dentist.

The most expensive way to fix it

When the book is full, the obvious conclusion is that you are one dentist short.

It feels right, and the waiting time points that way.

This is where I want to challenge you. Before you post a job, find out whether you actually turn patients away because you are short of hands. In most of the clinics I visit, patients get turned away because the hours that could have taken them are already spent on work someone else in the building could have done. An extra dentist is often the most expensive way to solve a problem you can see in the appointment book. You pay a salary, you hand over a chair, and the split is the same the next day. Now you just have an expensive clinician twiddling her thumbs in the room next door while she gets steadily more frustrated.

Nobody has written down what the others are allowed to do

A British trade journal wrote last year about new guidance on what hygienists may do without a dentist involved. The rules are British and a bit behind what we are allowed to delegate in Denmark. It did raise a question with me that I have asked in every clinic I have visited since: without looking anything up, can you tell me what each of you is allowed and able to do? If not, we haven't got any further than the British, even after 25 years of being allowed to delegate.

The answer is almost always no. The sheet with the overview of who may do what has never existed. The line is in the owner's head, and it only gets drawn when somebody is unsure and asks.

And they don't ask.

They know the question lands in the middle of your treatment time, that it costs time, and that it can affect the mood. So they do what they usually do.

An employee who doesn't ask looks like an employee who has it under control. She has simply picked the safe version of the task, and the safe version is usually the one where you have to step in. She hasn't done anything wrong. That's what happens when the line was never written down.

The rules are not identical in Denmark, Sweden and Norway, but they are close. In most of the clinics I visit, responsibility for most tasks stays with the owner.

One more thing here. This tends to move tasks, because moving a task feels easy and efficient. But moving tasks doesn't move decisions, and the decisions are what really keep a clinic dependent on the owner.

I thought it was a compliment

Early on, when I had two clinics of my own, I was proud that patients wanted me. The waiting list was long, and I took it as a report card. It took about a year before I understood that a waiting list in my own appointment book is not a mark of quality, but a calculation that doesn't add up.

The clinic could only take as many patients as I could get through myself. The limit is the number of hours in a day, and it doesn't move no matter how good you get.

If I hadn't changed direction and started working as the leader of a business, I would have traded hours for money until there were no hours left to trade. That usually ends in stress, and for some in sick leave. I got closer to that edge than I like to think about.

Try this one this week

Start with the count above, the two piles. It takes twenty minutes and a printout of last week's appointment book. You don't have to move anything yet. You just have to see it.

Then pick one task and the one person who could take over exactly that task. Not five tasks, one. Write down who takes responsibility for it, and what she needs to have seen or tried before she stands with it alone. Put a date on when it is hers.

And then decide who is looking over her shoulder. A task that moves without follow-up comes back to you within a month. A fixed fifteen minutes every other week for three months is usually enough, and then the task is off your plate.

Do nothing, and the appointment book stays full, and you keep believing that's a good sign. The patient with the crown finds another clinic and you never find out.

Do something about it, and you free up treatment time without hiring another clinician. You get shorter waits for the patients you already have, now with room to look at the whole mouth rather than one problem at a time. You get a team that uses what it knows instead of waiting for you, and done properly that always means happier staff.

Think about this:

How many exams were in your own appointment book last week?

What could you have done in those hours instead?

And what would that have turned into in job satisfaction, in patients who don't have to wait, and on the bottom line?

All three questions come back to the same thing.

Do you own a clinic, or are you the person the clinic depends on? (in which case the clinic owns you)

Who is allowed to do what in your clinic

This is one of those places where a leadership question gets mistaken for a booking problem. How you get a team member to take over a task safely and competently, without quality slipping along the way, is what I will be writing about through the fall.

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