47: Is Clinical Quality Assurance Good for the Industry?

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Hello, everyone, and welcome to another episode of DSO Secrets. I'm your fearless host, Emmett Scott, and I'll tell you, I just came off this incredible event. It was the DEO Summer Summit, and I attend a lot of different events and conferences which I actually enjoy just looking for trends and gathering the information and the truths in the industry. And I'll tell you, DEO is one that I think is really leading the pack. This isn't meant to be a total plug for them, but I was really happy with the event. Now I'm a little biased. I was asked to be the master of ceremonies, the MC for the event. So I was like, fully in. It was a great experience. My first time really lead an event like that. I got to meet a lot of you, which I really enjoyed. And I appreciate the feedback that everyone gave me and the kudos, but there's something powerful about getting 600 people in a room all focused on figuring out the truths for this industry. So I do want to give a shout out to the DEO Group, the dentist entrepreneur organization, Jacob Poole over there, CEO, and all of the team and staff that support him. And if you're lucky, you may be able to get a hold of a short video of Dr. Moser, Charles Moser, and myself doing a little bit of dance on stage. We. We had a lot of fun. So anyway, you know, whatever event you might be going to, I just can. I would just encourage continued learning, continued education. I think all of us, no matter what your degree is in, is very clear that getting a college degree or high school degree or whatever level you might be, even a PhD was never enough. Continued learning is a constant. Some of the data points that I'm seeing that I really want to focus on in this podcast and I'd love your feedback over on our Facebook page, DSO Secrets, your thoughts around this. But I'm seeing a change in the industry that I think is super healthy. It's not one that I anticipated, but it's one that's really interesting and it's been super controversial in the past and I kind of want to break down why I think it was. And I think it's going to be everything about the growth, the development and the improvement of this industry in the future. So I'm going to give my perspective of what I think happened historically around this principle and then what I think is happening today. So let me just kind of frame this and I'm going to oversimplify it, but as DSOs, as business experts and support centers started to consolidate this industry and help dentists who wanted to do multiple locations, I think one of the things that stood out to them very early on, because they were the first to really do this, is the difference in standard of care that existed amongst dentists and therefore different practices. So imagine before a dentist wanted to do multiple locations and have all these different associates that really 95, maybe 98% of the industry had never been in another dental practice, though they might have gone to study groups or association things. It's much different to have conversations around standards of care and treatment planning kind of in an arm's length way, in a philosophical way. That's much different than actually owning a few practices together as dentists and having these associates and starting to notice something very early on that the industry probably was somewhat blind to. And that is that standard of care was maybe for an industry wise, industry wide concept, was actually not very standard. Many of you will remember the reader digest research article and I haven't looked into, you know, all the data points that were really used in that article, but it really made waves because apparently this guy or gal went around to, I think it was 20 dentists or maybe more and just got treatment plans from each of them and of course came back with 20 treatment plans, all ranging from a few hundred to multiple thousands of dollars. And the purpose of the article was really calling out really early on, this is an older article 20, 30 years ago that there really wasn't a standard of care within dentistry. And there was a lot of decision points and a lot of opinions that were being made in these disparate dental practices. Now I think all of us can argue maybe pretty articulately why that would be and maybe even why that's good for the industry. I think one thing we could all agree on is that early on as more business people got involved in DSOs and helped develop into structure their multiple locations, they saw this and it created in their mind a financial problem and the financial problem that it created, and I think it still creates today, is strictly just around cash flow and budgeting. I heard an analogy recently that I thought was really great in kind of comparing, like, what standard of care and treatment planning and budgeting all coming together in multiple dental practice locations looks like. And the analogy that I heard, and the context was somewhat similar, somewhat different, but I'm going to use it for this, in this podcast is I want you to imagine that you started a technology retail store. And to really simplify this, it's going to be a really small store and you're only going to sell for this analogy, one product. And that product is a television set. It's going to be the same specs and there's really no difference, but it's really popular and it's hard to find. And so tons of people are coming into your store. Now, from a financial perspective, selling one product, one SKU would make it pretty easy to do budgeting. You just kind of look at volume that you had coming through over time. You'd look at the price that you felt like you could sell that for, and you would determine what your revenue was going to be and you'd match expenses that worked well with that, and you could project out into the future pretty well what you thought your overall revenue and expense and therefore income was going to be. But let's put a little bit of twist on your, your store here. Let's imagine that your cashier, that your cashier has power to determine the price of the television. All right, it's the same television, and there's a long line of people, but the cashier, based on things that they feel are very important, will change the price. Maybe when the person walks up, they look at them and they think to themselves, you know what, I don't know that this person can really afford this television set at this price. And so they change the price accordingly. Let's say it's based on the person's age or how long that they've been in line, or maybe it's determined on what time of the day it is. Maybe at 12 o' clock, they're selling the TV for a certain price, but later on at 5 o', clock, the cashier wants to go home and so they start discounting the television. Or they might just tell people, listen, we're not selling any more TVs, and they close down early. Now, what does this do to your budgeting process? You know, we won't analyze whether this is right or wrong for a second Here. But just from a practical perspective, if the cashier is changing the price of this product up and down, and you really can't figure out why that is, what would that do? As far as your ability to know how much you can spend on marketing, how much staff you can hire, whether you can hire that next executive to help support you, etc. You know, cash flow is now all over the place. And your concern is if it, if it varies down too much, then your cost structure doesn't really work. But if it moves up and the cashier decides that because of supply and demand and everything's working so well for them and it's easy for them, that they're selling them at a new price, a higher price, then, wow, now you've got all of this income and you can structure it out and build more stores. Now, as oversimplified and as crude as this analogy may be, the reality is that is the business of health care and that is the business of dentistry. Specifically. As we see it today, each dentist has their own standard of care, which we know can vary based on a bunch of external factors. Time of day, behavior of the patient, other perceptions of the dentist or staff may change with their treatment planning or ability to provide service to that patient. Is. Now, I'm not really here to argue whether that's good or bad at this point, but more just saying that that is a reality and maybe that complete autonomy of variance, even for these external factors is really appropriate and it's best for the doctor. But early on, and I would say even today, what's difficult about that is how do you do your budgeting and financial planning processes as you have associates now working in your practices, and what is the proper way to think about that? And to do that, then we might have a deeper ethical question, which is, is this right for the customer? Is this right for the patient, that there's this variance based on these external factors? Now, because business people tend to work in spreadsheets, and you have CFOs and others who entered the industry early on, I think that they saw this and tried to solve it with probably one of the worst processes or systems and, and probably now, like the worst slang word that exists in the industry, which is to create this idea of quotas, this idea that we will have a standard, it'll be based on a spreadsheet, it'll be based on maybe some metrics from the past, or even taking a large swath of dentists and saying, hey, it looks like their care per visit is hitting at this number, therefore, everybody must hit this number. Doesn't matter whether they have that treatment plan needs or not. And I think that was damaging and terrible for the industry that that came that way. But you see where the tension was, where the pressure was, where the concern was, is why is there such a variance in standard of care? And I think the business people's approach to that was to create this idea of quota, which I think was wrong. And I think any good DSO now is making sure that the autonomy of the clinician is available, it's open and it's apparent and it's there that the DSO side is truly there. As I talk about on this podcast, as a dental support organization, it is there to provide support and to give, to take off all of the business concerns so the clinician can do the piece that they have been trained to do and that they are most excited to do, which is take care of the patient. So now for the twist. One of the things that I'm seeing is clinical leadership is now stepping in. They are looking at these variances in standards of care across their locations. Now that we have dentist leaders who have multiple locations, and they're really seeing for the first time, maybe, or really getting their arms around the fact that there is such a variance in the care being provided to patients. And first of all, you might say to yourself, well, Emmett, you've already oversimplified it, because what clinicians do is not just sell the same TV to everyone, and it's not just this product that's stamped out in a factory, etc. And I totally agree. But what's interesting is when you look across the law of large numbers, let's say, out of 250,000 dentists, and you took the millions of people that they service, and you take all of that bell curve, there are subsections that you would say these patients are very similar and they have similar concerns, issues, needs. And frankly, if you've been in practice for a long time, you could probably give me 3, 4, 5, 10 sections of people that are fairly similar. They present themselves with similar pathologies and issues that have to be taken care of, and they're in similar age groups, et cetera. And so for them, should their standard of care vary dramatically? Just pretend with me for a moment that there are groups of people across large numbers here that are very similar. And what I'm hearing from clinicians is, why do we have such a variance in the industry? What I love about this conversation is it's not being taken on by the business People, because I don't think they have any business being in it. But what I think is really interesting is listening to the clinicians take this on and ask themselves, what is our standard of care? Now, let me just give my two cents on why I think this is going to change the industry for the better and why I think it's going to help with patient flow and really to professionalize even more, if that's a word. But really take dentistry to the next level from the perception of the outside world. The number one reason is I think that when you standardize things clinically across some group, let's say, of practices, and you document that and you organize that by doing so, you allow people to give feedback and to improve upon it. So, for example, if I come out and I say, I think if A is present, B, C and D should be completed and somebody comes in and says, well, I think X, Y and Z should happen now we can have a really great discussion. And if we're both interested in actually getting to truth, we may create something where there's an A, X, C and D that is created that is actually superior then to either one of our ideas. So by starting to organize and document standards of care, I think that we start to give more ability for people to upgrade standard of care across the industry. I think number two is how great for patients if they started to understand more fully that if A is present, then these are the treatment plans that really should be presented. And I think that we start to show to customers, to patients, that dentistry is actually a science and not some subjective whim created that day by how the dentist feels. And whether you like that accusation or not, the reality is that our customer base and our patients definitely have that feeling. And you say, but Emmett, it's so apparent on this X ray what the needs are and why I chose what I did. And I'd say it's not apparent. And you have the challenge as a clinician that patients are not trained in the diagnostic capability that you have. And so figuring out ways to organize the standard of care better and starting to present that in a more organized fashion to patients is going to be huge across the industry to really upgrade the perception that we're a science. And lastly, I think we actually achieve some of the things that the business people were concerned about early on, which is you're able to budget better by having clearer standards of care and you will know within your group of practices more clearly what your revenue cycle is going to look like and be able to match your expenses. Better to that revenue cycle because over the law of large numbers, you're going to see that standardization really does help to say, hey, this is where things are going. And this is I don't know whether this patient or that patient's going to need these services, but over this number of patients, this many will need it based on the demographics that we work in now, why is this important? So that you can make tons of money maybe, if that's your primary goal. But I think more importantly is you will be able to stabilize your business and service more people. So one of the difficulties that a lot of multi practice dentists face right now is their financials are all over the place and so their ability to impact and support and service more patients actually goes down dramatically. Now what I love about clinicians leading the charge on this, like there's many things, but one big one is the jargon that they're using in standardizing standard of care. I'm hearing words like quality assurance standards. Who among us wouldn't love to have quality assurance in all our clinical standards? I'm hearing things like evidence based treatment planning. Who of us wouldn't like our treatment planning to be evidence based, to be rooted more in white papers and research and data and large number experience than basically kind of the whims of the day for any clinician. And I'm hearing the term standard of care quality assurance. So again, that quality assurance component coming in from a clinical perspective. Now here's why I love where this is going. And again, it's not something that I can be fully involved in as much as just be a spectator watching it happen. But when I look at other healthcare industries and what they've done when they've standardized or begun to standardize the clinical parts of their business, is they've created this huge upgrading of conversation across their entire industry. When we think of Mayo Clinic and we think of Kaiser, these are not groups that just sat back and said, well, we're just going to let healthcare happen however it happens. Our clinicians and physicians have been trained and therefore whatever they come up with is good for us. They actually collaborated at a clinical level and began to set standards and processes around the clinical piece, which you can absolutely criticize. You could go in and look at the Mayo Clinic way or the Kaiser way and say this can be upgraded, this needs improvement, et cetera. But that's my argument on why it's so great is because you can actually see it versus just kind of having this nebulous open system that can't be analyzed and can't be improved upon. And so as soon as you standardize something like that and you document it and you open the conversation up, you create improvements, you also improve collaboration. Right. As soon as I put anything down on paper, we can collaborate on it much differently than if we're just kind of philosophically talking back and forth. Now I've kind of pondered on how I think associates are going to respond to this, because here's what I think is going to happen. I think clinical groups are going to start to create evidence based treatment planning, quality assurance, standard of care, and they're going to start organizing and documenting this and presenting this to their associates and they're going to get feedback and they're going to improve upon it. But over time, they'll have gathered a lot of feedback and they'll say, this is our guidelines, this is the treatment planning methodology that we're using within our group. And it will be presented by a clinical committee, clinical leadership. And what I love about it is it'll be presented and available up front when an associate's recruited. So how great would it be if I'm a new doc and I'm out there looking at where I want to work, if I couldn't get maybe from multiple groups or I could get from multiple groups their standard of care, quality assurance, treatment planning processes, look at those and say to myself, I love how they think about taking care of patients, I love how they solve this problem in the industry and I want to learn how to do that. And so I want to sign up to be with this group of clinicians that are all working towards that. And again, it will always be an evolutionary process in the best businesses, it always is. But how great to compare these different groups to one another to look at their treatment planning, quality assurance and ask yourself, which one do I want to be involved in? And know that up front. I think as an associate right now you don't know what you're walking into because most groups have kind of swung the pendulum so much towards autonomy that they've really decreased transparency. They've decreased transparency on what the treatment planning process is, what demographics that that group is really servicing to. Just a lot of information that I think as an associate I'd actually be very interested in. You know, I've listened to associates with our recruiting team and other associates who are, who call me or Facebook message me and they're trying to make decisions on where to go work and different groups maybe or starting their own practice, et cetera. And so as I'VE listened to them kind of talk this through and I'm always happy to try to help. I hear kind of a bipolar or a dichotomy of needs, which is on one side they really want to make sure they have their autonomy and on the other side they really want over the shoulder mentoring as much as possible. How do you combine these two needs, which I think both have legitimate arguments on why they're needed, but how do you combine these into kind of one process that's really transparent? And I think the answer is having documented evidence based treatment planning documents, having standard of care quality assurance documents to clearly lay out how you do things within your practice and how you think through those. And again, this coming from a clinical executive committee, I think will be very powerful. So as I'm in different groups and conferences, I'm seeing clinicians start to talk about this. And it's really amazing how far some of these entrepreneurial dentists have already evolved this within their own group. I met a dentist who has taken this all the way to the patient. So the patient clearly knows the six different areas of health that they could fall into. And then within those, based on what is presented in their X rays and their exam that what the treatment plan is most likely to be, et cetera, they're really making this a science that's creating transparency all the way to the patient level. Imagine again, as an associate A, I may or may not like how they think about that and organize it, but it's fully transparent. And day one, I can assess that and say, wow, I really want to join this team, or I think this is broken and I don't, I don't want to be in it. So I love where clinicians are taking this. I think it's going to be amazing for the industry. And I think as clinicians develop out these different treatment planning methodologies and standards of care, that you'll be able to even see competing standards of care if you will more transparently. And again, ultimately those will combine and create something that's just at a higher level. That's my futuristic analysis of what I think is coming down the road. So I'd be curious of your thoughts on this. Do you believe that this is great for the industry? If clinicians start to get together and within their groups start to create standard processes for treatment planning and delivery of care, and if associates can see that up front and then be trained on that and be a part of that, do you think that's going to be great for the industry? And do you think having these different groups, each creating their own, and then making those transparent as associates are trying to decide where they want to work. Do you think that'll be great for the industry? Or do you think that creating this open autonomy where every clinician walks in and can make whatever decision they need to that day, depending on a myriad of factors, is that best? Is there something in between that we're trying to achieve where we can make dentistry more predictable, more scientific in our approach with our customers, with our patients, but also allow for pivots and changes and decision trees to be still at the dentist level for that day, for that moment, for that time. Please jump on our Facebook page. I'd love to hear your comments on this episode and keep fighting it out. There's so much to learn in this industry. This is what makes it fun, is we've got a consolidating industry and we're pioneering so many things that have already been done in other industries. But what's the right way to do them in our industry? All right, so open to your feedback. Come on to our Facebook page and until next time, keep smiling.

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