Taking care of business
Held on the eve of the Scottish Dental Show, the latest Scottish Dental Round Table evening focused on quality management and a unique new piece of software.
Drs Andy Toy and John Barry hosted the event and Andy set the scene for the evening with a short presentation on the benefits and challenges of adopting modern standards of quality management into general dental practice. Referencing Professor J Edwards Deming’s research on Total Quality Management, Andy established how this business model enables dentists to provide ethical, high-quality dentistry, while still making a profit.
Total Quality Management can be distilled into the phrase, ’doing the right thing right, first time, every time’. Dental practices should focus on being effective, efficient and consistent if they wish to increase the quality of their service and raise their profits. Andy explained that in his experience, it is the development of consistency that can provide the most improvement in a practice team’s performance. This requires an initial investment in the creation of practice systems, with written procedures to improve quality control and practice communication and, crucially, enable the business to evaluate its performance.
Andy went on to report Deming’s research which showed that 85 per cent of all business problems were due to inadequate or missing systems, and only 15 per cent were the result of poorly performing workers.
He said: “This is a wake-up call for those dentists who have a tendency to blame their team if something goes wrong. It is often easier to blame someone else rather than take the time and trouble to build a really good system.”
He continued: “Successful practices develop practice systems that place the patient at their centre. This enables the whole team to understand the relevance of written procedures and audits to their daily work. Quality management becomes central to their work and essential for high-quality dentistry, not an irritating extra imposed by management.”
Once practices have understood this, he said, they then face the challenge of making their quality management systems accessible to the team.
“A system held in folders on the practice manager’s shelf is unlikely to be at the forefront of the mind of even the most well-meaning team member,” he said.
At this point in the evening, Andy revealed the revolutionary, new quality management system known as SUSAN (Simple to use, Unique to your practice, Systems driven, Always updated, Never absent). He described how this cloud-based information software platform’s intuitive and powerful design allows every member of the team to quickly access a wealth of quality management tools – including interactive procedures, training videos, audit and reference materials (such as COSHH, financial and HR). “Having SUSAN at hand to help every team member allows the dentist to put quality management at the heart of their practice and to raise both quality and profits,” he said.
Following Andy’s presentation, the conversation quickly turned to business and the business of dentistry. Dr John Barry posed the question as to why there is no business element on the average dental schools’ curriculum.
Edinburgh GDP Hew Mathewson said: “In some schools they have tried business stuff on the curriculum, but it is not examined and therefore it has taught the students not to turn up because they are not interested.
“It is not a subject that the NHS tends to invest money in and that’s because it does not recognise that you don’t do good dentistry in a badly run practice.”
David Foster, managing director of Braemar Finance, explained that he has been involved with dental finance since 1984 and he has spoken regularly to final year students and VDPs in that time. He said: “Through experience, it is obvious that speaking to newly qualified dentists about how to run a business is not relevant as most will not even consider starting their own practice for at least five years after graduation. Many will simply switch off.
“Instead I have found that a general appreciation of the world of finance as well as understanding and managing money is of greatest relevance at this early stage in their careers, and I have tailored my talks to reflect this.”
Hew Mathewson then said that he never ceased to be astonished at the ignorance of the profession on financial matters, both professionally and personally, to which Andy Toy responded: “You have got to understand that education is not about filling an empty vessel. When they are ready to learn the teacher arrives, and you just hope it’s the right teacher.”
John Barry said: “I’ve seen people who are in real trouble, but it really frustrates me when I see guys who are earning £100k a year and have not got a penny and I know people who are on £15k a year who have savings. That frustrates me about the level of, I don’t think it’s ignorance, I think it’s incompetence.”
Alan Walker, director of general dental practice education for the west of Scotland, said: “It is absolutely true they will only go to the well if they are thirsty and when John is saying that someone calls him in when they are in trouble, that is because they have a need. They can contextualise what you are telling them at the time and that could be at quite different times. Tax might be their focus this
year, appraisal might be in two
“We have to start with the kids in dental schools, or am I wrong?” asked John Barry.
To which Hew Mathewson responded: “The dental school curriculum is grossly crowded and is increasingly badly taught in overcrowded dental schools by overworked academics.
“My own thought is that there should be a compulsory module and the moment you want to own a
practice then you have to do this module and pass an online assessment. It needs to be there, but what happens is that people sail into buying and owning practices without that basic business skill.”
Jill Taylor, president of ADAM, said: “The biggest difficulty I found as a practice manager was that you didn’t know where to turn. You think you are doing the right thing but you’re fumbling about in the dark. If there was a resource that you could go to then I would certainly have welcomed it in practice.”
Hew Mathewson then brought up the issue of government cuts in dentistry. He said: “We know there are cuts coming, you don’t have to be a genius to see that there are more and more dentists in Scotland and a fixed budget.
“I think unemployment will really bite after 1 August. I advertised a job which went on the BDJ website two weeks ago tonight and I have had 60-plus applicants.”
The conversation then turned towards training and Charles Ormond, a GDP from Falkirk, asked about SUSAN’s online training components, commenting that: “I don’t think that there is any substitute for hands on training of a practical procedure in the practice, rather than watching it on a video.”
BADN president Nicola Docherty agreed, stating that NES has a DVD for medical emergencies training but that they are still recommending that dental professions do at least one face-to-face training session. John Barry responded by explaining that the training on SUSAN is best used to supplement face-to-face training. “Learning doesn’t happen in one event, learning happens by
repetition,” he said.
He said that he would rather his staff look at something like medical emergencies four times a year including a face-to-face session, something that SUSAN can facilitate and record to make sure that the staff member has done the training.
Hew Mathewson then remarked that some colleagues complete much or all of their CPD online. “It becomes very easy to hide away, fill in a questionnaire and get it all badly wrong and still get the CPD,” he said. “It is only when you are exposed on a hands-on course that you are challenged.”
The question of dentists supporting their staff members’ training, in terms of money and time, was then tackled. Nicola Docherty said: “We have actually got dental nurses who have to pay for their pre-registration training.”
And David Foster responded by saying: “Out of a hundred sets of accounts we would probably see two where training is a recognisable item in the expenses column. It just doesn’t appear.”
The table then turned their attention back to dentists as businessmen and women with John Barry saying: “The dentist is an accidental businessman. What gets in the way of dentistry is money. If the dentist wants to do dentistry, they will do the best treatment they could possibly conceive for every patient that walks in the door. But that is not reality. Reality is we have to have this debate about what somebody can afford. Even on the NHS.”
Alan Walker then asked: “Are we slowly moving away from the situation of the dentist being the sole business manager, towards them delegating things?”
John Barry commented that some practice managers are simply not allowed to do their jobs by a dentist who “doesn’t know what he doesn’t know”. To which Jill Taylor responded by saying: “Quite often they are given the title of practice manager and they are dumped out onto reception and expected to be a receptionist with a practice manager’s title.”
“If you are not in charge of a budget, you are not managing,” said John Barry.
“You are just given a title and the blame,” agreed Hew Mathewson.
Nicola Docherty then asked: “Is it a control thing though? A dentist I worked with called me his practice manager, but it was just a title. You can appreciate that it is his business…”
Hew Mathewson agreed, but said he believed that dentists have to
delegate to somebody and this is where leadership skills are called into question. He said: “A dentist is supposed to be a leader of a team. That is misleading, they should be saying at dental school that you are training to be a leader of the clinical team, not the whole team and that is part of
Andy Toy agreed, saying that he says to young dentists: “The only reason I need to employ a dentist (over a DCP) is to be a leader and if you haven’t got leadership skills I don’t need you. I need a leader of a clinical team – that is the only reason I need a dentist right now.”
Ian Matheson, managing director of Wright Health Group, then said: “A friend of mine has just retired after being in practice for more than 30 years. He said you are not a truly qualified dentist until you have been mentored in good disciplines and methodologies in a practice for five years. This emphasises the key role of the mentor within the practice and the broad experience factor
in order to become a proficient practitioner.”
Andy Hadden, dento-legal adviser and board member of FGDP(UK), returned to the earlier point of dentists not having enough financial knowledge by saying: “We also see some entrepreneurs coming through who want to run dentistry very much as a business and the main aim, not surprisingly, is to make money.”
John Barry expanded on the point: “Can I draw a distinction Andy? A business is something that is
sustainable. What you are describing, and I understand it exactly, is exploiting the cash cow until you
kill it. And that’s not business. A dental business has to run on
ethical lines and make a profit to be sustainable.”
To which Andy Hadden said: “But the type of treatment that some people do is almost unethical. You may well joke about what in the past would be called the amalgam free practice, well we are going to be heading for the enamel free practice soon, with some of these people.”
Andy Toy then turned the attention back towards the practice managers, asking Jill Taylor and Nicola Docherty what the level of support is for them in the average practice. Both agreed that it is changing for the better with Nicola Docherty saying: “It is about education, it is about educating the practice owners to trust their practice managers and to allow them to gain a qualification.”
And Jill Taylor then said: “Going back to what we were talking about earlier, with the current economic crisis, I think for practices that can’t afford a practice manager, SUSAN is the next best alternative.
“A lot of practices are having to make cut backs and this is a way for them to have everything in place but without a full time or a part time member of staff.”
John Barry then explained that the more people using SUSAN, the ’smarter’ the software becomes, creating a “resource that is going to be unbelievable”.
“When people see all of the things that SUSAN can offer – all the training resources, all the CPD resources, all the information, all the tools, there is something in there for everyone that makes it worthwhile. There is enough in SUSAN to excite everybody.”
Andy Hadden then asked: “How would you sell this to the practices that already have all the systems in place?”
“They don’t,” replied John Barry. “Some of them have a lot, but SUSAN fills in all the gaps.”
Andy Toy said: “If they recognise the importance of systems then this makes it all the more accessible, powerful and with the added extra of regular updates.”
Ian Matheson then brought up the question of internal quality audit, asking Andy and John how SUSAN can help “close the loop”?
Andy replied by saying: “I am one of the most experienced dentists involved with audit in the UK. Over the last 15 years or so, I’ve advised more than 1,500 dentists with their audits.
“I personally believe that audit is probably the most powerful management tool there is. We can make it easy for people to carry out audit using SUSAN, because we can provide them with the resources that they need, not just the procedures but then the ability to audit those procedures. We are already building that in.”
And John said: “The great thing is that we can close the loop. There is nothing that we can’t do with this product in terms of its versatility. And as we grow it will become even easier to make it even better.”
“That’s the message,” said Andy. “That is absolutely the message – we build a community.”