by Lori Garland Parker

The advantages of tracking clinical efficiency

When checking the financial health of an orthodontic practice, it is common to examine data about production and collection statistics, such as the exam-to-conversion rate and the percent of total receivables that are delinquent. This data shows part of the financial health of an orthodontic practice. Another important, but often ignored, area of concern is the effectiveness of the clinical area.

Let’s compare the treatments of two hypothetical patients, Nancy and Mark. Nancy has her second molars and is ready for orthodontic treatment. She is told to expect approximately 24 months of treatment. Mark has a nearly identical malocclusion and is quoted the same fee and treatment time as Nancy. Nancy finishes her treatment in 10 visits and 20 months, but Mark’s treatment takes 22 visits and finishes in 28 months. Why the disparity in the number of appointments and treatment times?

We can all think of the possible reasons: Mark didn’t keep his appointments, didn’t wear his elastics, or held his toothbrush too far away from his teeth. But wait! That is not strictly the case here. Mark was scheduled for more orthodontic appointments and more planned archwire changes. His treatment slowed because his brackets were not fully engaged into the archwire (unlike Nancy’s) and his second molars were banded late in treatment. Granted, just as no two patients are alike, no two orthodontists are alike. Treatment modalities vary; clinical staff talents differ. There is not just one right way to treat an orthodontic patient. However, we can analyze overall practice numbers and find benchmarks—the best of the best. Comparing those standards to the numbers for an individual practice offers us an opportunity to evaluate techniques and protocols and determine where there might be room for improvement. Let’s look at some examples.

Accurate Estimated Treatment Time
Commonly, orthodontic treatment is estimated at 24 months for the vast majority of cases. Some orthodontists estimate treatment times within a 4-month window. Whenever possible, giving a 2-month leeway sets a more specific goal for the orthodontist and the clinical team.

Here are some questions to discuss with the clinical team along with the best orthodontists in your study club or other contact group: What is the average treatment time for the various types of cases? How many visits are required? What age is the best time to begin the treatment of each type of case in order to finish in the fastest time possible with the best result? Making such estimates with the input of several peers will provide the benefit of greater total experience, and will contribute to the accuracy of your case-management decisions.

Production Per Appointment
Nancy’s case was much more profitable than Mark’s. How much production is generated by each visit? This is an easy number to calculate. Just divide the full treatment fee by the total number of visits (including emergencies) from the initial exam through the delivery of retainers. Frequently, orthodontists find that Phase I treatments have a very low production per visit, whereas full-treatment cases have a higher production rate. You may want to consider the following: What can be done to reduce the number of visits needed for treatment? Is the fee charged appropriate to the number of visits required? Do you have too many visits between Phase I and Phase II? Are those visits considered when quoting a Phase I treatment fee?

Time Per Appointment
Nancy’s initial banding took 75 minutes, including excellent home care instructions given to Nancy and her parent. Mark needed two 1-hour appointments to get his appliances on. Mark’s routine visits were twice as long as Nancy’s. Mark also waited a long time in the chair for the orthodontist.

Some thoughts to consider: Can appointments be combined to save time for the patient as well as the practice? Are patients waiting more than a few minutes to see an assistant or an orthodontist? How well is your current schedule serving you and your patients?

Appointment-Failure Rate
Mark missed three appointments during treatment; Nancy missed one. How much lost production did Mark’s orthodontist incur because of the three appointments he was not able to fill? Was Mark aware of the consequences of the missed appointments? Though a single missed appointment is not considered horrendous, what did the lost production represent for Nancy’s orthodontist?

What percentage of your patients miss their appointments? Missed appointments most likely extend the patient’s treatment time, and another appointment time needs to be reserved in the schedule to accommodate these patients. It is easy to end up working extra time every month making up for failed appointments. The failure to show up of more than 6% of patients scheduled is cause for alarm. As fellow consultant Debbie Best and I tell our clients, at that rate you could be working up to an additional full day per month just to make up for missed appointments.

What can be done to encourage patients to keep their appointments? Are patient reminders and reward systems in place? Are patients and parents educated from the outset about the crucial importance of doing their part in the team effort of orthodontics? Are patients and parents made aware of the potential drawbacks of missed appointments and failure to follow care instructions?

Scheduled Emergencies
Patients with loose brackets, deformed or poking wires, and broken appliances are the Achilles heel of orthodontic practices. Mark had four emergency appointments during his treatment, two of which were for the same poking wire. The other two were for loose brackets. One of the brackets was loosened because Mark ate something he shouldn’t have, and the other was loosened by occlusion on a lower bracket. In addition to the frustration with the schedule, Mark’s mom had a difficult time getting Mark to the office for repairs.

When more than 3% of patients are scheduled for extra visits in an average month, it is time to evaluate prevention. What can be done clinically to minimize these problems? How can patient and parent education be modified to encourage a higher level of cooperation?

Cases Exceeding the Estimated Completion Date
As you recall, Mark’s treatment extended 4 months beyond the estimated completion date (ECD). Treatments lasting beyond their ECD can sneak up and bite you. When more than 4% of a practice’s active cases exceed their ECD, it’s a cause for alarm. Cases that run long decrease profitability, and patients and parents are disappointed with the extra treatment time. What can be done to keep patients on time and on target with their treatment? What protocols are in place to track treatment progress? How is the clinical team helping keep patients on schedule with their treatment?

The Number of Retention Visits
There is also a major difference in the retention protocol for Mark and Nancy. Mark was scheduled for seven additional appointments over the next 3 years, which included taking impressions for retainers, placing retainers, checking retainers 1 week later, then monthly for several months, before going to a 6-month recall. He missed several of these appointments after the first few months. After reviewing his appointment schedule, Mark’s orthodontist learned that almost 10% of his daily schedule consisted of patients in retention, with several patients each day missing appointments.

Nancy’s orthodontist devoted an average of only 3% of his daily schedule to retention patients. Oh yes, Nancy did have a problem: Her dog ate her retainer, and she needed a replacement. She was scheduled for a total of three post-active-treatment appointments, but due to the breakage, she had four. Since Nancy called immediately after her retainer was lost, her orthodontist was able to quickly make another from the model. How many retainer visits are really necessary? Realistically, most patients would prefer not visiting the orthodontic office more than a couple of times once the braces are off.

The Final Word
These are just a few of several numbers that can be tracked. Many practice-management systems include reports to help assess the efficiency and profitability of the clinical area of the practice.

Tracking clinical efficiency and effectiveness is a critical part of assessing the profitability of an orthodontic practice. Mark’s orthodontist and team learned a lot from analyzing his treatment. They decided to combine certain appointments, enhance patient and parent education, analyze treatment progress each visit to stay on track with the ECD of treatments, schedule training time for the clinical team (particularly in the area of emergency prevention), and reduce the number of required retainer checks.

Increasing efficiency, effectiveness, and patient satisfaction is a journey requiring vision, patience, tenacity, and commitment. What actions will you take for the continual improvement of your valuable orthodontic practice?

Lori Garland Parker is a clinical consultant and co-owner of Consulting Network. She works with orthodontic teams to maximize their talents to achieve clinical efficiency and effectiveness, develop systems for continuity of care, and enhance communication skills with patients and parents. Her clinical coordinator courses and customizable clinical training and procedures manual prepares participants for the important job of managing the clinic. She can be contacted at (805) 552-9512 or via the Web site