The Hygiene Goldmine: Insights from Janet Hagerman, RDH

Joseph: Marketing Matters with WEO Media is a podcast designed first and foremost to share best practice pearls and meaningful growth opportunities for our clients. But in this episode, given our experience in serving DSOs as well, the demand for exploring their needs is something we fail to address on several levels. Much of what we'll explore together will still include pearls that apply to a single location office, and I'm sure you'll see, we'll be interviewing executives and thought leaders that have a unique appreciation for the challenges facing our industry, as we further expand into the DSO world as many others that we know.

So welcome to Marketing Matters with WEO Media. As your host for this episode, I am joined by my good friend Janet Hagerman, RDH, who is the fractional CHO as in Chief Hygiene Officer. She is an international speaker and consultant. She' written numerous articles, been on several podcasts and webinars, and she' the author of three books: Selling Dentistry, Meetings Make Money, and Bloom. She' a graduate of the Medical College of Georgia with 30 years of clinical and coaching experience with both solo and group practices, having managed over 100 practice locations in a single DSO as Director of Dental Hygiene. Janet, thank you for taking the time to be with us.

Janet: My pleasure, Joseph.

Joseph: In the years that I had the privilege of coaching and consulting in the dental industry, I learned very quickly that hygiene was truly the heart of the practice. And often as I began working with the practice, the heart wasn't healthy and needed to be pumping more energy and lifeblood into that practice. And so that' where we'd often start, that was where much of our initial success was focused. And because of the impact that hygiene would have on the practice, it was a really good place to start. I'm sure that' probably the same with DSOs. Tell us about that. What are the complexities around a DSO hygiene department in a DSO organization?

Janet: Well, first of all, you're absolutely correct in your observations that the hygiene department is one of the foundational legs of the practice. So from a solo standpoint, it' really not any different in terms of what the hygienist should be doing in the treatment area. And, you know, we've gone from that cleaning lady model of only doing prophylaxis to much more, and I'll get into that. But when you compare that to the DSO, I mean, first of all, you have to think about the fact that you want consistency. So you want consistency from practice to practice for many reasons, not only for the patient experience, should they go to a different office, but also from the clinician experience if the clinicians are going from office to office, and just consistency in standard of care are receiving the same standard of care in all our offices, from a recruiting perspective, from an onboarding perspective. And from a training perspective, that consistency needs to be in place for a DSO.

To elaborate on that a little bit, a lack of consistency, whether it' the communication systems that we have for our people, how do we present treatment? How do we talk about treatment case acceptance? How do we talk about fees? How do we talk to our patients? How do we listen to our patients? All that needs to be consistent because everything we say and do in the practice either pushes patients away or pulls them toward us. One person who is not mindful about the language that they use to speak to patients can sabotage the whole communication from the rest of the practice. So it' important for consistency, and more and more we're seeing now ROI of soft skills from the practitioners.

Joseph: If there' no consistency, when something happens that you need to change, there' really no way to change that, right? Or when you do something right, how do you leverage that? If there' no consistency in the actual system, and it' a much bigger problem or issue when you have multiple locations, the need for systems is even probably more important.

Janet: The problem with DSOs that they sometimes face is they grow location-wise too fast before they had the systems in place. It could be any system, not just hygiene. But hygiene needs to be the foundation of the practice. And it benefits the practice in so many ways, from patient loyalty to generating revenue, and everything in between. So it is really crucial for a DSO to get their same-store growth solid as far as hygiene is concerned or any of their systems really, before they start to expand in terms of adding locations. It certainly makes onboarding new locations much easier and smoother if you already had systems in place. Otherwise, you just have hygiene chaos.

There's the hygiene gold mine in every practice and every DSO. And it' patient-centered. But if those systems aren't in place, you don't get to tap into that hygiene gold mine. You haven't found it yet. It' there, you just haven't mined it, and you have hygiene chaos. So you have the systems that whatever the hygiene of the day, the hygiene du jour, if you will, brings to the practice which may or may not be congruent with your standard of care and values as a DSO as a solo practice.

Joseph: You're already hinting at a few pain points there. I can imagine there are multiple pain points that you see commonly. Would you like to address some of those?

Janet: Well, right now what we're seeing a lot of is, you know, just finding hygienists. Hygiene turnover. Finding good hygienists and then keeping good hygienists. Good hygienists want a good culture, they want to feel that they are part of the system, that they're part of the decision-making process. So I think the pain points would be hygiene turnover, patient turnover, low case acceptance, those are all indications that have a need for an opportunity for growth. Low perio percentage, all those would be pain points that are opportunities for growth to increase periodontal procedures, because we know three-quarters of the population has some level of periodontal disease. So we go into a practice or practices and you look at the metrics and you say, only 30% of perio is being done or less, there' a big discrepancy there, that practice is not taking care of their perio needs of their patients. So that would be a pain point.

Joseph: And clearly, the way a small to medium DSO grows and scales, they often begin growing before they have all of the systems in place to accommodate those additional locations. Ideally, they have the systems in place that then they can replicate for healthy growth. That must be something of where you would come in, because in a DSO, you're generally going to have a hygiene director, will you not sometimes?

Janet: Yes, sometimes. No, it just depends. I mean, you know, there' that saying, if you've seen one DSO, you've seen one DSO. There is no consistent business model. They just kind of grow organically. When I was hired, there was no hygiene director, I pretty much created everything from scratch, which was daunting at first till I figured out what a great team I had to work with. And then it became great because you had this blank palette from which to build. So you know, some DSOs may have one person that' hygiene leader, they may have a couple of hygiene leaders, they may have a couple of hygiene mentors, it pretty much is all across the board. And it depends on how many locations they have. But a lot of times what happens is, hygienists are promoted from being a top-producing hygienist to a leadership position when the skill sets are really totally different. Now, you know, there may be hygienists that have great leadership potential that are also good producers. But there should be different types of criteria for a hygienist that you take out of a clinical position or at least graduate them gradually to a leadership position. Leadership skills are becoming more and more important and communication soft skills are becoming more and more important on a corporate business level, which is really what a DSO is. It' more of a corporate structure than what we're really used to in a sole proprietor, single office.

Joseph: If a DSO already has a well-structured hygiene department with a hygiene director, where does a fractional CHO fit into that model?

Janet: Well, they may not need a fractional CHO. But they may. I mean, I recently talked to several DSOs, one that had a group of leaders, hygiene leaders, another one that had a director of hygiene, but that was newly appointed. And she had only been in position a couple of months, but she was frustrated and overwhelmed and didn't really know where to start. She was a great hygienist, had great leadership skills, loved learning, wanted to learn, wanting to be coached, and just felt like, you know, I have these issues, and I am not sure how to solve them.

So one of the challenges is coming from clinical to management is the heartbreaking realization that you cannot be in every office. It' just not physically possible. When I came to my position with this company, they had over 100 practices. I think they had 130-140 practices. And I came in and naively said before the year is over, I am going to visit every one of our practices. And it just didn't happen and it doesn't need to happen, especially now with Zoom. There are so many ways that we can really stay in touch and figure out how to manage good productive meetings as well. So that when you are together, you make good use of that time, figuring out how to manage, figure out how to roll out the procedures or the systems that you want for your DSO that touches everybody, but in a way that makes them feel like they still have a connection with you, that you're not sitting in some remote location, even though you may be, but that they still feel like they're cared for, that their opinion counts. And that you're all part of a team, whether it' the team within your practice, or the bigger team within the entire DSO, and that comes down to the culture and the core values of the company.

Joseph: You really do take a personal people approach to the type of coaching and consulting you do even though it' hygiene, it' all about people and that' the training I can see that you provide.

Janet: And you know, Joseph, now more than ever, is what the whole industry needs. Because our patients are savvier than ever and they have the ability to walk out the door and go someplace else for reasons we never know. And it could be something subtle. So we need to learn to be more and more aware of how we use our soft skills and not just come in and think of the clinical work that we need to do. But we need to think about how we appear to our patients and the conversations to have more focused conversations.

So here' the thing, when patients have decisions to make about their dentistry, we have a left and right brain. And scientists tell us now that they're quite specific. The right side of the brain is the creative side, and it is the emotional side. The left side of the brain is the logical side. So in dentistry, where do you think we live? We live in the logical side of millimeters. And when our patients are in the chair, and we're talking to them, we talk very logically. Our patients don't care about that. And quite frankly, they don't know if your dentistry is any good or not.

Our patients, surveys tell us, want to be a part of the decision-making process. They want this thing called shared decision-making. Surveys tell us that most buying decisions are made with emotion. And then they are rationalized with logic. I mean, all you have to do is look at 99.9% of commercials that are out there for anything to see that they appeal to people' emotions. So how do we do that in dentistry? How do we appeal to people' emotions and meet our patients where they are emotionally and learn what their values are, rather than expecting them to know? You know, we used to talk about this thing called dental IQ. We need to raise the patient' dental IQ. No, we don't. We need to meet them where they are emotionally and learn what their values are.

I talk a lot about asking good open-ended questions and listening to our patients rather than telling, telling, telling. And this is not just hygiene, this is all across the board. As our society globally, and granularly in the dental industry becomes more and more technically oriented, I mean, you know as well as I do, the technology in our industry alone is breathtaking. It happens so fast. And a lot of it is really cool stuff. And as we become more technically proficient, we need to balance that with deeply human skills, which is empathy, understanding. These are the skills that are required by businesses and Fortune 500 companies even. So it' imperative that we spend, we invest in our people and train them in these human skills, which we are hardwired to relate to. We are not hardwired to relate to millimeters of bone loss of periodontal disease and crown margins.

You know that saying, people will not remember what you say, but they will never forget how you make them feel. So that' the type of training that we need for our people. And that just gets exemplified in a DSO. DSOs are here to stay, they're growing. And so they need to be, and in many ways, they are at the forefront of new technologies. So we're quick to jump on the new technology bandwagon. But what about the technologies that serve our employees' soft skills, which are going to serve our patients?

Joseph: I've always been amazed at how technically intensive dentistry essentially is. And we spend so much time on the technical side. And yet, it's the soft side, the people skill side that will determine how much of those technical skills you will ever get to use.

Janet: Yeah, there was a study that was done. They did this project at the Cleveland Clinic, which is renowned for being very exceptional in their clinical skills, but they were getting low readings on patient satisfaction. And so they did a project where they trained their, you know, there' low like brain surgeons, you know, really highly technical clinicians, doctors, and they did a project where they put them all through training in empathy, and how to talk to patients and their patient satisfaction skyrocketed after that. It was a very interesting, very successful project, which they now embrace full time.

And I think we're gonna see more and more of that. I was on a podcast yesterday, earlier this week, and we were talking about the patient experience, these shared patient experiences. And there are some schools now that are starting to teach that. It' very new. But I think we're going to see a huge trend in this type of human investment work, because people demand it. I mean, people do not have to come to your practice or your DSO, they have choices. And they're not going to become loyal patients because you do the most beautiful crowns on the block. What they care about is how do they make me feel? Did I feel like they just told me, here' an $8,000 treatment plan? I just came in for my free cleaning. And now I've got an $8,000 treatment plan. Or, wow, you know, that was a really thorough exam. And I felt like they really cared.

Joseph: Janet, I would really love to have you back so that we can explore that, especially the book you've written on selling dentistry. What' the full title of that book?

Janet: I'm glad you asked that because, you know, I've had doctors say, when you come to our practice for our training, can you teach my team how to sell dentistry? Because I know dentistry is walking out the door. But whatever you do, don't call it selling dentistry. We and I've even had dentists say you really should change the title. And I said, well, but when I speak about it, the rooms are always packed. They say, Oh, no, we want to learn how to sell dentistry. We just don't want to call it that. I want to call it that. So I think book Selling Dentistry, because we have to get over that reluctance to give selling a bad name. So the tagline is "Selling Dentistry: Ethically, Elegantly and Effectively."

So ethically means we're not selling somebody a bill of goods that they don't need, selling them the treatment that they do need. And effectively just means did we succeed, you know, patient education, patient education all day long. But if the patient doesn't say yes, you haven't been effective. Yes, I want it. Yes, I'm scheduling the appointment. Yes, I showed up, I got the treatment done, and paid for it. And then elegantly is about, I don't ever want anybody to feel salesy or sleazy or pushy. That' not what good selling is about. And so we want to feel elegant about this and like it' comfortable. And we want our patients to feel good about the way they receive information as well.

Joseph: Taking us back to the DSO world, then what I mean, this is an investment. Hygiene, as a department is a huge investment for that practice. What' a realistic ROI? What' the best return on investment that they should be looking for there?

Janet: You know, the best way to answer that, because it' going to be unique to every practice. I mean, with my case acceptance courses, I can get them to double and triple their case acceptance. In a practice that has a low perio percentage, that could double, triple or even more, increase their perio procedures with information and training. So it depends on where they are. Anything from 50 to 80%, just depending on where their numbers are. So it' looking at where are you now? And where do you want to go? You may have some really high benchmarks that you're doing great at, and you may have some others that are flailing. So those are the ones that you would need to improve.

Joseph: Those benchmarks have over time become extremely standardized. You just know by looking at the numbers, whether they're achieving what they should be, or if there' just no opportunity. There are some industry standards. I'll give you a few. So for example, perio procedures should be more than prophylaxis procedures, 50% or over for periodontal procedures. Also, hygienists can make a huge difference in referring restorative work to the doctor. So in other words, I'm the hygienist. I'm assessing the patient, I spend more time with the patient than the doctor does. So I'm in a position to identify and assess some areas that might need treatment and say, "I see some areas here that certainly appear to be decay and they're going to need to be treated. When Dr. Smith comes in, I'd like for him to take a look at that. But in the meantime, while you and I are here, what questions do you have for me about that?"

By the time Dr. Smith comes in, I've already prepared the patient, we've had a conversation, I know their values. So hygienists can be huge in that. And as a result of that, what we see in successful practices is that 30% of the restorative revenue should come from the hygiene department, referring to the doctor. So there' another benchmark to look at. If that' not happening, there' a huge opportunity for growth. A lot of hygienists either haven't been sufficiently trained, or it hasn't been reinforced that this is part of what we do. We look at not just perio, the gum surrounding tissue, but the actual hard tissue, the teeth, the teeth that the doctor restores. And so in a great situation, the doctor and the hygienist, it' symbiotic, they help each other. It' like a great marriage. So they partner together to be advocates for the patient. In my "Meetings Make Money" manual, I talk about the doctor-hygiene meetings monthly, and how that can help reinforce that partnership.

Joseph: You mentioned the other day when we spoke that you knew of two revenue generators that they could implement immediately, for a greater return. Do you remember what those were?

Janet: Yeah, there is a code out now for periodontal patients who are in the early stages and don't have permanent bone loss. And in the past, we never had a code for that. It was very frustrating for hygienists. They didn't know where to put these patients because there wasn't a code for it. If you want to get paid by your insurance companies, everything has to have a code. So we didn't have a code for this gingivitis, where there' bleeding, but there' no permanent bone loss. So we now have a code for that. So that would be the first thing that I would say.

The second thing is, I would say look in your reports and pull a report for untreated treatment plans. These are the patients who have been diagnosed, this is the treatment that I'm recommending, here' the treatment plan, but it hasn't been implemented, hasn't been accepted. You can look in any practice management software, there will be a report of who are the patients who have outstanding treatment that hasn't been done. And just start getting in touch with those patients. That is a gold mine waiting to be tapped. They've already been diagnosed, they already have a relationship with you. Send emails, start with emails, follow up with some calls, send little thank you notes, little cards in the mail if you have to, but just continuing that relationship with the patient. So those would be the two.

Joseph: Excellent. Janet, you've been a wealth of information. I thank you for joining us. How will people be able to reach out to you if they have questions?

Janet: My website is simply JanetHagerman.com, H-A-G-E-R-M-A-N, and they can email me at info@JanetHagerman.com.

Joseph: Wonderful. Thank you, Janet. I can't wait to have you back so we can fully explore specifically your book "Selling Dentistry." That will be fun. I look forward to that. Thank you again.

Janet: Thank you for having me, Joseph. It' been great.