Helping Healthcare Scale

Dr. AJ Acierno: Navigating Post-Pandemic Challenges in Dentistry through Provider-Centric Strategies and Operational Excellence at Smile Brands

• Austin Hair - Real Estate Developer

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Discover the transformative shifts in the dental industry with our special guest, Dr. AJ Acierno, President of Clinical Operations at Smile Brands. As the dental field grapples with post-pandemic challenges like workforce shortages and financial pressures, Dr. Acierno shares his insights on maintaining access to care and achieving financial stability for dental practices. Listen in to learn how a provider-centric approach, emphasizing clinical and operational excellence, can help navigate these turbulent times. We explore the strategies Smile Brands employs to integrate new team members and improve patient flow, ensuring that clinical staff aren't overwhelmed.

Understanding the patient journey has never been more crucial, especially within Dental Support Organizations. Our conversation with Dr. Acierno reveals how clear expectations and Standard Operating Procedures can enhance the patient experience and uphold high clinical standards. We also delve into the comparative advantages of group practices over private practices and offer practical advice on safeguarding professional standards through contracts. Lastly, we spotlight the importance of networking and open communication in the dental community, providing resources and connections through Smile Brands to support practice growth and collaboration.

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Speaker 1:

I am sometimes honestly embarrassed as a dentist that this is actually happening in the dental field.

Speaker 2:

It's embarrassing, just clinically, how they handle their patients.

Speaker 3:

The goal of this show is to help healthcare organizations scale by leveraging real estate strategies and interviewing high-level healthcare executives in order to pull out lessons learned along the way. If you'd like a free site selection analysis from our team, visit us at wwwreuniversityorg and drop us a line.

Speaker 2:

Hello everybody, welcome back to Helping Healthcare Scale. I'm Austin Hare, and our guest today is a second time guest. It's Dr AJ Asciano. He is the founder of D1, which he grew to 40 locations before merging with Smile Brands and now he's the president of clinical operations for Smile Brands. So thanks for coming back on the show. Absolutely, I'm happy to be here. Let's just dive right into it. You guys are undergoing some massive transformations right now and give us a peek under the hood.

Speaker 1:

Yeah, I think everybody has Austin.

Speaker 1:

to be honest with you, it's a totally different world of dentistry. Post-pandemic. You have 18,000 hygienists leave the industry, dentists retire, hard to find dental assistants, the workforce down in general, doctors and every provider really working less, which is really like the nail in the coffin. That happened for a lot of people. Like all of a sudden you're like, okay, I can handle all these pressures that are occurring, but now, once the providers started working less, you're like, oh man, what's going on? And as a dentist, access to care for our patients, making sure that our team members get a paycheck, making sure that our providers are still increasing their paychecks what we call the win we take our team members' paychecks as seriously as we take the P&L, literally. We knew that we had to do some things differently in the whole entire world of dentistry.

Speaker 2:

Yeah, I think I don't know that statistic about the 18,000 people leaving, but it's one of the challenges in healthcare specifically is just reimbursement rates, because as your interest rates and your expenses come up like you mentioned inflation a second ago inflation is causing everything to go up. Producers, the providers, are working less but you cannot charge the patients more because you're capped insurance like and medicare and medicaid especially. It's insane. I don't know if you guys take those or not, but my wife's a provider for PA dermatology and you get the highest inflation on record in our lifetimes and they lowered reimbursement rates.

Speaker 1:

That's crazy. Yeah, austin, it's a crazy world. We're not a burger shop. We just can't increase the price of burgers. The reality is that we work with insurance companies that give us a fee and they're not at our size. It's a benefit to our doctors and everybody that we can negotiate, but not a fact that you can negotiate to a realm that beats inflation. That's impossible. If you just look at where we were five years ago before the pandemic, we were light years away from where we needed to be in the pandemic or in reimbursement fees Post-pandemic man. Now we're worlds and worlds away of where we need to be. So it's tough, but that doesn't mean that it's not possible.

Speaker 1:

I think one of the things that we're doing differently is which is it's ironic, right? I think one of the things that we're doing differently is which is it's ironic right? Like you, if you could just think of a house, a dental office, and then a bunch of bubbles around it, right? That house is really team member and patient satisfaction. That is the dental office.

Speaker 1:

There's a lot of things that go in to making sure that team members and patients are taken care of. Those are what we call systems or daily operations that help each dental office. But what's really important that's important and you also what's really important is having clinical excellence, clinical standard of care that is second to none. That is important in every one of our practices. So you take those two things and sometimes it runs in its silos. We don't want it to run in their silos, we want it all together, like if somebody needs a night guard, if somebody needs fluoride, cancer screening, x-rays, perio, all the clinical standard of care, we know that you have to have operational excellence in that office, great systems in order to make that happen for a patient. And so we know those two things go hand in hand. As president now of clinical operations, I want to bring both those things together. A little bit of a provider-centric mentality, and a lot of people say what do you mean provider-centric Meaning? We want to know what our customer, our offices, really want.

Speaker 4:

We want to listen to them, so we went on a listening tour.

Speaker 1:

We did a number of surveys and really heard from our teams what they felt was missing from them being able to do operational excellence and clinical excellence in their offices.

Speaker 2:

Okay, I think it would be interesting, like then and now, then versus now. So like how have you guys evolved your thinking, like what were some of the things that you were doing operationally and clinically before this transformation, and how specifically are you changing that, moving forward?

Speaker 1:

I would say that we relied a lot on tribal knowledge in the past. Okay, so a lot of our team members were longstanding team members and we still have a lot of longstanding team members. As you bring in new team members into the organization, we we want to make sure that everybody in the dental office understands both clinical and operational excellence and how they work together. That's the big difference of today.

Speaker 2:

Okay, so I guess, like maybe is there any example of a problem that this was creating for you guys beforehand.

Speaker 1:

Yeah, I'd say financial presentation and treatment presentation, the fact of we want more patient flow in the practice, and how do you gain more patient flow without overwhelming the clinical team.

Speaker 1:

And those are areas that deal with both operational and clinical excellence, right, and sometimes we just feel that there's just two different worlds going around. It's crazy, like you'll have somebody going, we want to see new patients in the office, but a doctor will only allow us to see two a day, right, and you're sitting there going and that's weird. I was just talking to the doctor and the doctor wants as many new patients as possible, but there's some gap in communication there and when you sit down and you really discuss it, they were both on the same page. It was just doctor had a vision of how they want the patients to flow into the practice and operations had a different vision of how they wanted the patients in the practice. So that we want to really garner the support of the providers and get to understand what they want for that individual practice, understanding that we want to continue to grow. If you're not growing, you're dying. We want to continue moving that practice forward.

Speaker 2:

Yeah, it's so interesting. I think it leads to a higher overarching theme. I think like I was listening to Alex Hermosi podcast and he was like saying the problem, like the answer to resolving your stress, is on the other side of a difficult conversation, meaning so many times we don't have good communications, we might not have a good communication cycle or system, like you were talking about earlier, or we're just scared to say what's on our mind and it's crazy how much internal, not only conflict but just friction that can cause in dealing all these things. Like essentially in this situation, they both wanted the same thing but because of whatever communication cycle was in place, they thought it was something totally different. So is this something like where you have more like when it comes to actual systems that you've implemented? Brass tacks is this I'm just going to spit ball, but do you? Is it about creating feedback loops in an environment where you can share? I don't know. Direct feedback without being the answer is yes and yes.

Speaker 1:

So I love what you're saying on the opposite side of a difficult conversation. I believe that great leaders and great communication is established with good expectations. Okay, so, literally, as the DSO we are, our customer is the office and the office's customer, of course, is the patient. Okay, In order to really understand a dental office and make a dental office work well, you have to understand the journey of your customer. Just like any business, you want to understand the journey and the touch points of your customer. Just like any business, you want to understand the journey and the touch points of your customer. We have mapped out the touch points and the journey of our patient walking through any of our dental practices. We have created an SOP manual and best practices for each of those touch points in order to help somebody along in their journey to yes and when I say yes meaning getting treatment and getting help we as a support team need to look at that journey and say how can we support that better for our team members?

Speaker 1:

Okay, so now the expectation from a business support side is very clear we are there to help our customer on the patient journey. From the office side, it is very clear. Our expectation is this patient journey and the touch points, and here's where my job actually rolls into that and can help a patient through that part. You have to have measurements in each one of those areas in order to continue to measure and see how you're doing in those certain steps of the patient journey. That is what we see can help avoid difficult conversations. To be honest with you, no one likes difficult conversations, so the answer is create great expectations so you actually don't have to have a difficult conversation, because if somebody isn't doing their part not answering the phone properly, not checking them out properly, not greeting somebody properly into the office it's no longer difficult because it's. Remember we talked about this, Remember we taught this, Remember we have an SOP manual on this. Therefore, how do we get you to do this more? And so that's an area that we really put a lot of emphasis on.

Speaker 2:

Okay, yeah, I like that. So what advice would you have to doctors and associates Like, what should they be looking out for, or what should they look for in both in terms of protecting themselves, maybe in the contracts they signed, or and then also in terms of working for a DSO? Because, let's be honest, I think with a lot of private practice, dsos still have a bad name, right. So what would be your advice to them?

Speaker 1:

So the first thing that I always move to is my dental hat. I still practice dentistry. The clinical standard of care, as I said before, is immensely important for me. Austin, that is number one when I walk into a dental practice okay, in a private practice you have four walls, you're doing dentistry on somebody okay, people, patients and you only have your team around you.

Speaker 1:

It is very difficult in a private practice to judge yourself and measure yourself on success okay, especially clinical standard of care. So I believe in a group practice we can elevate the standard of care in dentistry to a level that is very difficult in private practice not impossible, but very difficult, because we are being able as a clinician me as a clinician and we have a board of PC presidents that are fantastic doctors around the country that help our doctors through some difficult periods. And we were. We will always think, man, if we weren't there to help them and support them, what would they have done if they were in private practice? They would probably have not known that they were doing something wrong until somebody sued them or somebody got really upset, or it was two years later and they're like man, all my team members quit and my patients don't like me and heck what am I doing wrong? So it's, I think that is a massive benefit in the group practice world.

Speaker 1:

Right, I would tell doctors, what you learn in school is not just oh, it's in school. So therefore it's all pie in the sky. But when we get into private practice it's different. No, it's different. Yes, the flow of patients and how you do a treatment presentation and financial presentation. Yes, not the clinical standard of care. And that sometimes gets a little wonky because I over a thousand practices Austin I have looked at, I have bought over a hundred dental practices. When I'm going in and doing due diligence on practices, I am sometimes honestly embarrassed as a dentist that this is actually happening in the dental field.

Speaker 2:

It's embarrassing, just clinically, how they handle their patients.

Speaker 1:

X-ray protocol, perio protocol, cancer screening protocol, fluoride protocols just not being followed. Okay, Dentistry that is not meant to be a lifetime care type of option, but a dentistry that is done just to hopefully get somebody by for a couple of months of option, but a dentistry that is done just to hopefully get somebody by for a couple of months. The lack of notes and clarity that are in somebody's chart, just you can go on and on, but it is literally. Hygienists and dentists go to schooling. They learn the same thing and somehow, when we get out into the real world, we change that and we have to be different, we have to be better. Like that is my. That's what burns inside of me my passion of just making sure that we can provide this clinical excellence and continue moving it up and setting the bar higher so patients get better.

Speaker 2:

Yeah, yeah that's. I think that's definitely super important. So what would you? How would you coach a doctor to if they're looking to be an associate or they're looking to I don't know? Just get better. They own their practice problems. What do you, what can they do to fix?

Speaker 1:

them measurements in place for your standard of care, because you're not in the room usually when x-rays are going on. You're not in the room when perio like a bloody prophy, and then you walk in and there's a new bib on there and it looks great, right? And you're sitting there going oh okay, this patient must be okay. I really want to get our providers to measure how that's happening, right? Is your x-ray protocol in the proper place? Is your perio protocol and et cetera. I believe that is the number one thing that us in private practice and in group practice should be looking at in order to elevate that standard of care.

Speaker 2:

And then, where do you see the future going, like in terms of there's a couple of things you can mention perio, so a lot of times it was these specialties were totally separate. I feel like I'm seeing more and this is just anecdotal but I'm seeing more become multi-specialty. So Ortho and sometimes Perio and whatever like in-house. In addition to that, we talked about all the inflationary problems that just create long-term effects. So do you see more consolidation? Not on a corporate level, but just like hey, we're going to use more automation, we're going to bring more things in house, we're going to try and get more efficient. What I don't know. What are you seeing firsthand?

Speaker 1:

I would say the first thing that we need to correct is the lack of hygiene in dentistry period. There's just not enough hygienists. We have to get more hygienists. And is that graduating more hygienists? We have to get more hygienists. And is that graduating more hygienists or is that different technology to and I hate to say this not replace hygienists but to help hygienists continue to see the volume of patients that we need to see.

Speaker 1:

There are less patients going to the dentist because of that. You just there's offices all over the place where you just can't get in for a cleaning. So therefore, what do you do? You just don't go, and so we really need to make sure that we're providing a service, that we're giving access to care. I think the secondary part is from a provider standpoint, an office standpoint. I would agree having specialists come into your office. I would advise a general dentist to be really good at the simple specialty right the clear aligner. Cases of minor malocclusion get that done. Posterior implants make sure that's happening. Bone grafting, for sure. Extractions, for sure. Endo, for sure.

Speaker 1:

These are things, as a general dentist, need to start improving in our skill set. That will help some of the inflationary things that are improving in our skill set. That will help some of the inflationary things that are occurring in our practices. Why? Because I don't think any general dentist likes to hear which medicine did. Instead of seeing 14 patients a day, can you see 21? And then, oh, of course, doctor, if you see 21, you're going to make more money. It's not as easy as said. Nobody wants to just run around like crazy and have the standard of how you practice reduced because you're seeing too many people. The answer is what can you do on a patient that maybe is better reimbursement? Make the patient better without having to see a bunch more people.

Speaker 2:

Yeah, as you're talking about from the patient's perspective or from the doctor's perspective, to not doctor's perspective and for the doctor's perspective it's a.

Speaker 1:

You don't have to see more, you can do just better and bigger procedures. On the patient perspective, they love it, man, they don't want to go. When you're going to a general dentist and you create a relationship, they want you to do the work. They really don't like that. You have to refer them out somewhere and I love my specialists. I refer a lot out but I try to keep. I've tried to hone my skills to being really good at the simple specialty is what I call it.

Speaker 2:

Yeah, it's like healthcare in general is so siloed 42 different branches of medicine that you have to choose from when you go to proper medical school.

Speaker 4:

I just found out today that it's like.

Speaker 2:

Patients don't like that. How is that helping the patient experience? I think that the more things you can have taken care of from the same place, just the more convenient it is. I know we're about out of our time. Is there anything left that you want to talk about that we didn't address so far?

Speaker 1:

No, I think hey, listen, it's a tough industry. It's always been a tough industry, austin. Literally even in the best times of dentistry, you always had something that was tough to do. In these times in dentistry it's really tough, but that's okay. That's the way it is. We're going to keep taking care of people. I think you need to reinvent yourself and really look at some of the things that you can do differently to attract your customer. That means for us, our offices, and for our offices, our patients.

Speaker 2:

Okay, I love that. If people want to learn more about what you guys have going on and reach out, what's a good resource for that?

Speaker 1:

Smilebrands. Go right to our website there. We're all on there so you can email us directly. Love to hear from you. I'd love to help out anybody in the industry.

Speaker 2:

Awesome.

Speaker 4:

Yeah, you've always been really easy to talk to and very generous with your time with me. We appreciate that. Thanks, austin. Appreciate it, man. Thank you. If you need help finding the perfect location for your practice or you're ready to invest in commercial real estate, email us podcast at leadersreecom R-E as in realestatecom, or go to leadersreecom and fill out our form. See you next time.