Fine Relationship-based Restorative Practices

Build your relationships first….then your dentistry. ~ Bob Barkley

Fine Relationship-based Restorative Practices

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Fine Relationship-based Restorative Practices –

A Closer Look at 23 Common Characteristics

Paul Henny, DDS

(This article was originally published in the Pankeygram in 2004)

The success of The Pankey Institute is highly correlated to its unwavering commitment to helping dentists learn about Dr. Pankey’s patient-centered practice philosophy. Many of us have applied this philosophy and have found it to be both a successful and healthy one for our practices, care teams, and patients. I have also personally found Dr. Pankey’s philosophy to be most effective when applied within the context of what is known today as the Tier IV practice model.

The concept of Tier IV dates back to the work of Avrom E. King in the 1970s and later Christian B. Sager of The Pankey Institute in the early 1980s. Chris Sager describes it today as the fourth and highest level of practice development, and characterizes it as being comprehensive, personalized, low-volume, health-centered, quality-oriented, and highly service oriented. As everyone is aware, the expanding interests of the insurance industry are having a dramatic influence on the practice of dentistry today. This trend, in direct conflict with the ever-advancing capabilities of today’s dentistry, has created a gap between what employers and the insurance industry are willing to offer “the insured” and what they truly need and desire. It has also created a mindset within the general public that care beyond the boundaries established by the insurance industry cannot be afforded, is of limited value, or should not be pursued.

In spite of this, a growing number of dental health care consumers are rejecting the limitations put on them and are demanding more choices, more involvement in decision-making, and ultimately a much higher standard of care than the insurance industry and the dental practices heavily influenced by it are willing to provide.

It has been my experience, that the highly personalized Tier IV practice model, empowered by Dr. Pankey’s philosophy, is uniquely designed to address current market trends. I believe students and alumni of The Pankey Institute, who have a clear understanding of how the Tier IV practice model works, are in an ideal position to successfully engage the growing market segment of dental health care consumers who desire much more than they have received in the past…individuals who are therefore likely to request your best and finest services.

23 Characteristics

As I have worked with my care team on our practice, and with others, who are in the process of transitioning to Tier IV, I have identified 23 characteristics common to the model. Let’s take a closer look at them.

1) Tier IV practices are visionary. The creation of a practice vision by a Tier IV dentist represents an act of optimism. At the core of this optimism is faith—faith in the dentist’s ability to adapt and create a practice of choice. This vision is a natural outgrowth of the dentist’s clarified core values, principles, and desires. It is used by the dentist to select and develop a care team, and to attract patients who identify strongly with the dentist’s principles and value system.

2) Tier IV practices are committed to a mission. A mission can be thought of as the means by which the practice vision is implemented on a day-by-day basis. The mission acts as a reference point around which important practice decisions are made. Much like a practice vision, missions are unique and values/principles centered. A Tier IV mission is collaboratively developed, nurtured, and implemented by the entire team.

3. Tier IV practices understand and utilize the power of synergy. Tier IV dentists understand that the power of team synergy can catapult a practice to new heights. Conversely, a team that lacks the power of synergy can substantially undermine a practice’s performance. Therefore, Tier IV dentists view team building as a top priority as it fosters growth, collaborative interaction, and optimal outcomes for the practice and patients alike.

4) Tier IV practices are committed to maintaining advanced clinical skills. The Tier IV dentist and care team take their professional obligation to provide patients with access to optimal care very seriously. They view constant refinement of their own clinical skills and learning about the capabilities of collaborating specialists, within their community, as essential.

5) Tier IV practices are committed to mastering interpersonal skills. The dentist and care team recognize that clinical mastery alone is insufficient to achieve consistent long-term clinical success. Viewing dentistry as both technical and behavioral, Tier IV dentists are masters of behavioral dentistry. They recognize that an essential behavioral role of the care team is to facilitate patient values clarification, problem identification, ownership, appropriate choice making, and ultimately the creation of a collaborative effort to achieve a shared goal.

6) Tier IV practices are committed to “organizational wellness”. Successful Tier IV practices recognize that sustained, meaningful service to others requires that the emotional and financial needs of those who work within the practice also be met. Consequently, Tier IV practices are at their core, emotionally and financially secure businesses. This has been called “organizational wellness” and is critical to a Tier IV practice’s success. It allows a Tier IV practice to keep the needs of patients foremost in mind at all times. Organizational wellness allows the practice to have emotional and financial strength, which it uses to strategically avoid situations where the financial needs of the practice could interfere with how, when, and why patients are treated.

7) Tier IV practices have successfully integrated laboratory functions. Tier IV practices recognize the dental laboratory staff is an integral part of the total care team. They understood that it is the dentist’s responsibility to have a working knowledge of laboratory processes so that he or she can assume a well-informed leadership role with the dental laboratory technicians. The Tier IV dentist willingly assumes full accountability to the patient for the quality of all dental work provided. This commitment to quality is widely known and frequently cited as a reason why many patients chose to enter the practice.

8) Tier IV practices provide care within an appropriately designed facility. Virtually all Tier IV practices have a facility that demonstrates planned excellence. By design, Tier IV facilities support personal and professional growth as they make it easier to render the finest care and service to patients. Tier IV facilities are also unique as they represent a physical expression of the care team’s commitment to quality. These facilities foster smooth “flow” of both technical tasks and interpersonal relationships. As a result, Tier IV facilities tend to support privacy, respect, comfort, sincere caring, and personalized attention.

9) Tier IV practices have mastered health-centered relationship marketing skills. Tier IV teams recognize fine dental care is not designed for the “income elite” but rather for those who value dental health highly and see it as an essential part of their total wellness. Avrom King called this group the “values elite.” A Tier IV practice understands who the “values elite” are, what they want, and how to create and maintain long-term, positive, mutually respectful, and collaborative working relationships with them.

10) Tier IV practices have developed supportive practice systems. Well-designed practice management systems exist to ensure that the practice mission is smoothly executed on a day-to-day basis. Many of the dysfunctional “medical model” systems, which are reactive and “unit-oriented” (and which overtly or subliminally imply to patients the primary objective of the practice is to make money), have been replaced by “wellness model” systems, which nurture health and patient self-responsibility. The care team’s mission helps define the practice systems. The care team monitors and runs the systems, which in turn predictably drive the practice forward toward realization of the vision.

11) Tier IV practices are committed to developing leadership skills. The Tier IV dentist is committed to constant development of personal leadership skills. The dentist understands that when he or she leads the care team to share ownership of the practice vision and mission, he or she is successfully empowering the organization. It is understood by the Tier IV dentist that real leadership power is gained by a person who is able to freely empower others. A dentist exhibiting a high level of leadership skill can be viewed as one who has been given the gift of reciprocal empowerment by the care team through their faith and trust in the dentist’s ability to lead.

Similarly, this dentist will more easily lead patients to optimal health choices through effective communication and education. For many Tier IV dentists, leadership extends more broadly out into the profession through their involvement with study clubs, dental societies, faculty positions, and in the development of CE programs. Many Tier IV dentists demonstrate leadership by formally mentoring students and newly graduated dental professionals.

12) Tier IV practices demonstrate emotional intelligence. Tier IV dentists exhibit a high level of emotional maturity which can be measured by Goleman’s Model of Emotional Intelligence. Behavioral traits include high levels of self-awareness, self-regulation, motivation, empathy, and social skills. The dentist additionally selects for and nurtures emotional maturity within the care team. High levels of emotional intelligence support self-confidence and a willingness to take risks for the benefit of positive change. Self-confidence and willingness to take risks are core components of creativity, an essential ever-present force in a successful service-oriented practice.

13) Tier IV practices favor a multi-disciplinary approach to care. The Tier IV dentist has nurtured and developed strong collaborative relationships with dental and medical specialists in their practice locality. It is noted that these specialists have a high level of trust and faith in the care, skill, and judgment of the Tier IV dentist and vice-versa. As a result, they regularly collaborate on complex cases to create optimal outcomes.

14) Tier IV practices have mastered clinical photography. Tier IV practitioners consistently exhibit high levels of clinical photographic skills. These skills are used almost daily for patient education, case documentation, group consultations, and presentations. It is understood that the power of photography with patients lies in building awareness and what Bob Barkley called “future focusing,” where individuals become motivated to change when they see themselves in a future timeframe, looking, feeling, and perhaps behaving in a new and better way.

15) Tier IV practices have health-centered hygiene departments. Tier IV practices have successfully transitioned away from the traditional “hygiene-driven” practice model. Success of the hygiene department is less measured by productivity (although they are highly productive) than by the health and movement toward health of the patients within it. This is achieved through exceptional clinical skills and exceptional collaborative health-relationship-building skills within the hygiene care team.

16) Tier IV practices understand communication styles and how people learn. Tier IV practices are consistently able to facilitate patients’ awareness of their current dental health status through the use of co-discovery learning systems. Tier IV practices have an enhanced level of understanding of how people learn and are able to individualize the learning process for each patient to achieve optimal effectiveness. The practice is able to assist patients in learning about possible and probable outcomes with and without intervention by the care team.

The care team is able to help the patient clarify his or her value for dental health, and the team ultimately assists the patient in making choices based on the patient’s desired long-term outcome. It is noteworthy that the vast majority of patients within a Tier IV practice are actively in pursuit of these collaboratively developed health goals or have already attained them as a result of facilitation skills practiced by the care team.

17) Tier IV practices walk the talk. The Tier IV practice has a high level of congruence between what is believed and known to be appropriate and what is done consistently on a day-to-day basis. This is what is called “practice authenticity” or “walking the talk.” Practice authenticity is an outcome of shared commitment to the vision and mission of the practice by the team. As stated earlier, the practice vision and mission are based on shared principles and values. Practice systems are designed to support the mission and ensure achievement of the vision.

18) Tier IV practices demonstrate an unwavering commitment to professionalism. The practice exhibits true professionalism, which in action is similar to the meaning of the Greek word for love, agapé, which is defined as a willingness to selflessly put the best interests of others ahead on one’s own interests.

19) Tier IV practices are balanced. The structure and systems of a Tier IV practice allow for an uncommon balance among Work, Play, Love and Worship. Tier IV dentists consistently exhibit healthy interpersonal relationships with their family, team, patients, friends, colleagues, and community.

20) Tier IV practices are spiritual and sharing. Tier IV dentists understand that “Of those to whom much is given…much is expected.” They also understand the value of two important gifts that we are all given: creativity and sense of humor. These gifts help us achieve our highest aspirations, while they simultaneously help us cope with our humanness along the way. Tier IV dentists understand the value of reflecting and drawing upon the strength of a “higher” purpose. Many are men and women of great faith and are thankful for their abilities and gifts. They willingly and freely give of themselves to benefit others who are less advantaged.

21) Tier IV practices masterfully manage patient expectations. Tier IV practices are very adept at clear, concise, communication with their patients. They have well-planned and designed patient education materials, as well as policy guidelines that function seamlessly with planned discussions with patients regarding practice philosophy, financial obligations, scheduling policies, and home care responsibilities. Therefore, these practices experience very few misunderstandings regarding money, compliance, insurance company actions, and scheduling. Additionally, these practices are very adept at communicating clinically with patients via use of diagnostic wax-ups, approved provisional restorations, and photography of similar cases—again strategically avoiding misunderstandings and disappointments with patients.

22) Tier IV practices prefer a low-volume, high-profitability practice model. Tier IV practices recognize that the best-managed small practice is often more consistently successful at providing optimal patient care than the best-managed large practice. This is due to the synergistic effect of relationships best nurtured in a small, personalized environment. Tier IV dentists also acknowledge that successful, fine dentistry is as much a creative act as it is a highly technical one, and that consistently high levels of creativity are possible only when sufficient time is routinely allowed for it to occur.

Tier IV practices abandon the conventional wisdom of trying to be everything to everyone. It is believed that such a philosophy dilutes the limited resources of time and energy, ultimately diminishing the quality of treatment over time. Instead, Tier IV practices focus on excellence through personalized care strategies for values-elite patients. These personalized services are properly priced by the practice and accurately reflect the care, skill, and judgment of the clinically astute Tier IV practitioner and care team. Additionally, the Tier IV practice maintains a well-managed, appropriate level of overhead expense. This, in combination with proper fee structures, allows for generally high practice profitability in a low volume setting.

23) Tier IV practices function independently of insurance industry needs. Tier IV practices have successfully transitioned away from financial dependency on insurance reimbursement patterns. They have achieved this by building patient value for broader-view, comprehensive approaches to care.


from insurance industry influence is achieved over time through combining co-discovery systems with controlling overhead expenses, termination of all providership contracts and agreements with insurance carriers, and in the vast majority of cases, requesting insurance carriers to pay subscribers directly.


The benefits of independence from negative insurance industry influence are seen as multi-fold:

·  It helps reinforce the practice’s mission to provide primarily comprehensive, health-centered restorative services.

·  It removes the insurance industry’s agenda from the treatment planning process and properly focuses the patient’s attention on their preferred long-term outcome and how to best achieve it.

·  It fosters financial self-responsibility on the part of the patient.

·  It unburdens the practice from real or perceived accountability to insurance carriers.

·  It returns ownership of the actions of insurance companies to the employers and patients.

·  It allows the practice to accurately set fees reflective of the true value of the services provided.

·  It allows the practice to focus on appropriate care instead of being enslaved to a least expensive alternative care orientation.

·  It helps protect the financial future of a practice by eliminating the ability of the insurance industry to manipulate fees, profit margins, patient flow, or withhold a significant amount of rightfully earned income. This ultimately enhances profitability.

·  It allows for more time to develop true helping relationships with patients and avoid the hollow, task-oriented encounters frequently seen as an outgrowth of fast-paced, insurance-dependent practice.

The Tier IV Challenge

As you can see, the Tier IV practice model entails many elements, skills, and attributes. Although this list is long, all aspects can be learned, developed, and acquired over time by those who have the desire and commitment to do so. I have personally found Tier IV to be challenging and life enhancing. I would like thank the The Pankey Institute for the essential role it has played in my personal and professional development. I also would like to encourage those of you, who have a strong interest in the Tier IV model, to use the Institute as a resource and to continue to work toward it. I can promise you that the rewards for your efforts will be numerous and long lasting. Please feel free to let me know if I can assist you in your journey.

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