How Patients Judge

Early in my dental career, I was exposed to Malcolm Gladwell’s best selling book The Tipping Point. Gladwell tells a story of how Mayor Rudi Giuliani having been exposed to “the broken window theory” made the strategic decision to try and reduce the crime rate in New York City by creating an environment of order out of the daily chaos of graffiti; vandalism and gross littering that plagued the city. The broken window theory was first described in an article in 1982 by two social scientists: James Q. Wilson and George L. Kelling. The essence of the theory that influenced Mayor Giuliani was that people make assessments about a societal setting by surveying the landscape. To simplify the story, Mayor Giuliani ordered city workers to tirelessly remove graffiti, repair vandalism and pick up litter, in what at first seemed like a never-ending repetition of effort. Eventually, the fruits of the tremendous effort paid off, and vandalism and crime were reduced to historic lows, which helped revitalize the city.

I have no idea if the science that the broken window theory is based upon is valid, but it does seem intuitive, and since that day I have been obsessed with the cleanliness and order of the dental offices in which I have worked. Combining this story with the early advice that I received from the senior endodontist in my community that patients cannot easily judge the quality of our care, and thus revert to evaluating the things that they can appreciate such as cleanliness of the facility and the friendliness of the staff, I was on a mission. That mission was to fix all the “broken glass” in my office if a patient or staff could see it; I wanted it to be clean and orderly.

“Perception is Real, Even When it is NOT Reality.” Edward DeBono

Over time and multiple practice settings, I have tried with vigor to instill this philosophy of cleanliness and order into the DNA of the office culture. In my first office, I had a staff of ten, and I gravitated to hire employees who lived their life in a clean and orderly way. Of course, I missed the mark a few times both to the chagrin of my hyper-anal teammates and myself. As I have moved around and opened multiple offices and hired dozens of more staff members, I have discovered many things. I found that although sometimes it is possible to find employees who care as deeply about cleanliness as I do, that it is not always essential to have a team full of this type of person. If the culture of “smooth, spotless glass” is lived on a daily basis even the less inclined team members, tend to keep things in tip-top shape—essentially one of the tenants of the original broken window theory. I have also found that entropy is real.

Entropy is the scientific theory that states that all things tend toward a gradual decline into disorder. How I wish this were not true, but it takes a diligent leader to keep stoking the fire. In one of my current offices, I significantly reduced my daily presence a few years ago to open another office. In so doing, the gradual declination of order and cleanliness began to take hold. Recently, I have returned to a greater day-in day-out presence in my large office that employs greater than thirty employees, and it has again started to take on the cleanliness and organization, which I desire. I can’t say with certainty that this focus generates bottom line results, but I am certain it feels better to me, and our overall patient survey results are ticking upward.

Every day I encounter something that is a deviation from the vision of perfection that I hold tightly in my mind and that I have tried to articulate frequently to the team. I am still amazed at how many times I have an internal debate as for whether or not to point out the “broken window” that I see. More often than I should I hold in my comments because I do not want to berate the staff and have them think of me as a relentless taskmaster. After further reflection, I have decided that every time I hold in my observation, I lose an opportunity to end the cycle of entropy and I embrace mediocrity. I offer this article to the dental community to encourage others (your team) to hold firm (in a loving and accepting way) to the ideals that you have for your practice and to strive daily to eliminate any and all deviation from the standards you have set.



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