Interview with Jerry Durham, PT

Interview with Jerry Durham PT

Ray Berardinelli: We're talking about the front desk drop offs and how the first call relates to that. We're going to dive into this and the metrics of it. I think that the metrics are inadequate, and I've discussed this a number of times on the metrics and but we'll dive into that here. 

First, the role of the front desk and drop off. The front desk is where your drop off starts. Your cancellation, no-show rate, and where all of our KPIs, they all start in that initial phone call. That's our first contact on as we've discussed before, and even goes further than that.

It goes in your messaging. You got to be targeting the right people. Maybe you want to talk about the front desk’s role in that, and how that first phone call impacts that number.

Jerry Durham: What I have found, and again, I think everybody knows this, but I think this is important context, too. I answered the incoming new patient phone calls in my practice for about a year. Without going too deep into that story, what you need to understand is at the same time, I was running a business. 

I was involved in one step within the ecosystem of my business, while at the same time trying to change metrics. At the same time that I was answering phone calls, I was trying to solve other problems. Slowly over time, if you go back and listen to my podcast series one and two, you'll hear all the things that were changed over time by the first phone call. 

Where it started was understanding that we put all this emphasis on our providers to do everything, get people better sell plans of care, keep no show cancer rate down, make sure the NPS scores are high. 

There's research to show how our providers can do that. The shipping velocity, point to DERA, a lot of research into that.

RB: So I need to talk to you about that because I want to start looking at the NPS data in relation to those outcomes. What are the patient's thoughts in relation to your outcomes?

If we look at Net Promoter Score, that basic score of zero to 10 on how likely they would refer to  family or a friend - if we look at that in relation to your outcomes, how does the patient's perception of how much they like you impact the outcome?

JD: Here's a dirty little secret for everybody watching. It plays in as hugely we all would consider it does, and it's research proven. I took all that research, expectations, Alliance research, and one day, I looked at it and just went, “Why don't we move this upstream?” 

We're working so hard with this person, and we're giving the person one hour, roughly, to be successful because all of this is it's make or break in the one hour, first impressions.

So I said, “Let's move on this upstream.” I slowly but surely started doing more and more of what we were doing with the therapeutic alliance. I started moving conversations around expectations into the incoming phone call. 

What I saw then which changes in the downstream metrics, and no-show cancel rate - not first visit arrival rate, that's different - 99.9% of the practices out there holding their providers accountable for that. And that is an incomplete metric. 

No-show cancel rate will be changed by the conversation at the front desk, because what you're starting to do is building trust and alliance. You're starting to decrease fear, doubt, and uncertainty with that provider they're going to sit across from. 

What I say, I'm doing on this first phone call to change the metrics downstream. This is that business as an ecosystem. What I'm doing is setting up that therapeutic alliance. Trust is already being built so that when the provider walks in the room, and it has one hour. 

I liken it to this is my favorite baseball analogy. In the old model, we put our provider in the room, and it's bottom of the ninth team down by one. You're facing the best closer to outs, and we're asking you to hit a home run. 

In my scenario, when we set it up this way, I put you first inning man on third, no outs. All you have to do is put the ball into play to be successful. That's that's where this all comes together. 

That's the gist of all this and looking at your metrics - understanding your business as an ecosystem change one thing at a time and look for the results.

RB: I love that analogy, because if you think about it, you don't have the right person up the bat. If you're calling about a drop off after the third or fourth visit, and you're having the front office call, not only do you set them up for failure, you have the wrong person at the plate.

They're not as likely to be successful in that situation. As the therapist, you know we're taking it one step further.

JD: I looked at the response when I said we set our providers up for failure, and then we yell at them when they fail. Currently, most practices will look at no-show cancel. 

We'll go to a provider and say how can we change this? What will they do when the person cancels and asks the front desk to call him back? Why did you ask the provider how to change this and make them responsible for it then tell the front desk to do the accountability?

There's two things that play here. I read this first and reading a book about Napoleon. Responsibility and accountability don't always go together. It was when I was reading this book that he talked about accountability being the ultimate, it's not enough to make people responsible. 

So if I yell at a PT and say “You're responsible for this,” where's the accountability? What are we going to do next to do what that is? That's what's really important. Accountability has to come with responsibility. Don't tell someone you have to do something then not follow through.  

RB: It's so important, the idea that keeping the right person in the right place at the right time. We look at the drop offs and we look at our KPIs, your cancellation, no-show rate, your vacancy rate. And when you're looking at symptoms, this is my argument. 

You have a patient, and you’re like, “Hey, you have a fever. Why do you have a fever?” You need other measures about what is actually going on. What does the patient think about your front desk? What does the patient think about your overall practice? What does the patient think about the therapist that they have? 

Not only do you view those KPIs, you really have to dive in and see where the hole is in your bucket in order to fix it. You can't fix it if you're just looking and say, “Oh, we have a bad drop off.” 

People start talking about the phases of recovery, make people sign off on the plan of care - it's not going to work, because that might not be the problem at all, and they might not trust you.

You can sign it all you want, and they'll sign just because you asked them. They'll sign it, but they're still going to drop off. You show them the phases of rehabilitation. They don't trust you, because you haven't set the expectation. 

JD: It says cause and effect, that sticky note sits in front of me all day long. Because as Ray said, the effect is the number. So what caused it?

This is what happened in my practice a lot. I'm asking the provider back to my original scenario, I'm asking the provider to maximize trust. Most people say established, but I'd say maximize trust in one hour. 

Whereas if I back it up to the front desk building for us, I now have two weeks, a week, or five days to build trust, because that front desk person is going to build an alliance. She's really the one that really kicked this forward. 

We've been in contact because there is correlation and research to prove that an alliance is built with your non licensed or non providers team and alliances, and I like to default to trust. That's not always what the research says but alliances about listening, connections, conversations and the surrounding relationship. 

The sooner we do it in their journey in your practice’s lifecycle, the more successful your providers will be. I'm not saying they will get everybody better, or treat everybody better, or get everybody’s completed plan of care.

I would say a good course of care is someone who's out of the system sooner who shouldn't be in the system. Whether they get them to complete a plan of care, but the trust or the relationship is there. We do what we need to do. 

It's all about moving stuff further upstream, and understanding back to the metrics part. What is the metric of success for this step?

My front desk, when they answer the phone - may probably have two or three different metrics that they are accountable for. I've made them responsible to do these 12 things. They're accountable through three metrics.

RB: And what are the metrics?

JD: NPS score of the front desk is one of them. If you follow me on Instagram, the only post from practices I share, or will respond to, is a testimonial. They post something like, “The whole team was awesome,” or “The front desk was great.” 

If it just mentioned your provider was an awesome PT, I don't comment or share it. That is everywhere. You're just you're under the bell curve. You're under the belt. Everybody has reviews that says the providers are great. They’ll just find the practice with the cheapest price that has great providers. That's easy. 

When it says, “The team listened to me,” or “Everybody was engaged, I felt taken care of,” - that's the stuff that wins. 

So NPS score, conversion rate, first phone call to arrived patient. The no-show cancel rate is a is a team metric. I even did a Facebook Live -on what the three metrics are. Conversion rate, NPS, complete a plan of care.

That's a team metric, those are the big ones, because that's what they're there for. They're there for taking care and starting a relationship. If we're not getting the right people to support, conversion rate goes down and maybe we're not doing good marketing back to your point.

They’re still answering the phone. They're responsible for getting people onto the schedule, I'm responsible to get the right phone calls. That's still a team effort, but they're accountable to that. And then there’s the NPS score. Those are the big ones. 

RB: Would you mind talking about how important you think of using something like a script or practicing your objections in improving all these numbers?

JD: Consistency, persistence, and patience. You have to do it the same way over and over again, and trust the process. We can call it a script or you can call it what you want, yet it's still going to present itself as an outline template script. 

In order to be consistent and make sure that what you're measuring is the right thing, you must have a consistent formula process. That is a script. You must train it, you must work on objections.

Everybody always says the primary objections are time, distance and money. I disagree. The primary objection is either you don't give them a reason to invest their time, you don't give them a reason to invest their money, or you don't give them a reason to go the distance. It's actually one step deeper when we come to the objections.

If we're just teaching people how to deal with time, money and distance, we’re setting them up for failure and will yell at them. Part of that script is getting their story building. 

And if I want you to go deeper and to be able to use this script to be successful, I'm going to tell you is not to get people scheduled this with my Facebook Live this week.  I'm going to tell you, your role is to start a relationship with this potential patient that will last through their entire life cycle with the practice. 

That sounds a little different than schedule people. And it also takes the responsibility out of us checking boxes and putting people on a schedule.

I don't care when someone gets scheduled, they could call the day and schedule a month later, you still get credit for the conversion. 

If I tell you it's about starting a relationship, then you're more likely to follow up with people. You're more likely to not do, “We can't help you.” As the front desk person, you're more likely to call someone two weeks later who didn't schedule with you to say, “How are you doing?”

So building the system around that second thing, rather than the first thing actually facilitates the person you're holding responsible to be more successful through their metrics and their accountability. 

RB: I like what you’ve said that all of the objections come down to trust.

JD: In health care for sure, because the opposite of trust is fear, doubt and uncertainty. Your doctor told you to go to physical therapy, and we could go down a million things. “I don't know what physical therapy is, is it going to hurt?” We could go down, “How's it going to help me?”

We could double that back to uncertainty. If we don't deal with that uncertainty, which is build some trust before they arrive, then we've set the provider up for failure. You guys will notice this stuff is looping back and back and back. This always does. 

RB: I got a funny trust story regarding uncertainty and trust. I'm giving away my free Net Promoter Score app. First off, I run all my NPS stuff. I have an internal server, like I duplicated Google's reviews closely. 

We're trying to see what's converting, what’s getting people to click on it. I can measure that more on my server than I can on Google's because they're not going to give me access to all their stuff.

I've been running this internal for eight, nine months, testing stuff out. Ariel checked up on me and she’s like,  “You have six Google reviews. It sounds like what you're saying is going to work, but you have six Google reviews.”

So even within us, there isn't trust. I was explaining to her and she's like, “Well, now that makes sense.” But I was checking up, and she didn't trust me - and she should.

JD: That's a great example. This is the thing, you asked about learning scripts and handling objections. That's all sales training. Let's talk about your sales cycle.

Everybody’s cell cycle is so short, there is no industry that expects someone to call and convert and turn into $1,000 paying customer on a two-minute phone call. Yet we do that. 

Back to what we were talking about before. If I empower my front desk - which is one of my favorite words, a lot of people don't like that - that means they know their responsibilities. I train them to know their accountabilities. 

Then I reward them for their success. That can be financially rewards or an acknowledgement, it can be all those things.

That's step number one, because what I do during this training. If you believe the process is over, when you hang the phone up, you're done. 

We follow up with every single person who doesn't schedule. Now you're going to say, “Oh, you're just trying to upsell them.” I'll give you the script number one callback. 

Someone didn't schedule. Five days later, you call them. Let's say I took the phone call because I used to do this. “Hi! This is Jerry from ABC physical therapy. We spoke last week.” There's usually some response there.

And I say, “Yeah, I'm just calling because I know you didn't schedule with us for your low back pain, and I really want to make sure you are getting taken care of.” And that's all we say.

So you call back and say, “I'm just following up to see how you're doing.” Let me tell you what I did the step before.

The step before, which we didn't talk about, was when they didn't, when they chose not to schedule. Okay, that's cool. I'm okay with it. They made a choice. They had all the information they needed, they made a choice.

Now I have a choice. What do I do? Well, my responsibility as a healthcare provider is to make sure that they get to the right place. 

And I say, “Ray, I get it. I hear you, man. Let me do this for you. Based on what you've expressed to me, I've got two phone numbers here for you. Let me give you these two phone numbers. You call them because they will be able to accommodate you. If they don't accommodate you, or they can't get you in quickly, call me back, and I will call them for you.”

Now I did that for about seven months. Everybody's freaking out, “My front desk is too busy.” Your friend desk is too busy doing stuff that they shouldn't be doing. That's why they're too busy, and they're not doing the stuff that they should be doing. That's your fault, not their fault. 

We need to step back when that happens. You know how many people took me up on that? Less than 5%. The act of doing that and being genuine about it, the 5% who took me up on it, I called the clinic, “Hey, you’ve got to help me out here. I got someone who needs physical therapy, get them in.”

I would. I would owe them that, and I follow through. If you're going to give someone the phone number, then when you call them - when's the last time one of their healthcare providers called them when they didn't schedule? 

They're going to remember that last thing, and it's going to be they did not schedule out your practice, and it's going to be a positive experience. We can get into the story of referrals I've had from those examples. People have never stepped foot in my clinic who referred me customers, patients, and clients.

RB: I want to start talking about about the metrics. You said that your favorite metric is, other than the NPS, is the completed plan of care.

JD: It's the ultimate metric. We could call it practice metric because a completed plan of care will mean the patient got to where they needed to, and therefore the business is winning. Is it okay to say that it's okay to make a profit when we help people because we're helping people?

RB: Yeah. We can't pay our bills on goodwill. None of us can say, “Hey, I helped a lot of people this month, don't shut my lights out.”

JD: Let's go one further. I ask everybody, whether you own or you work in a practice, do you want to get paid? Do you want a paycheck every two weeks? Then it's a simple conversation. The company needs to make money. 

Let me help you understand how the company can make more money. That's by helping more people, because what's good for the patient is good for business.

RB: That's where I was going with the metrics that I'm tracking. I'm tracking that NPS number, leveraging that for the Google reviews, and also hopefully, to identify drop offs. 

If I can identify if somebody's not happy, I can fix it. If I don't know that they're not happy, and I'm going along assuming they're happy, I can't fix it. I don't even realize that that that it's there. Then the other thing is, if they're not happy, number one, are they improving? They're here to get better. 

If I take my car to the mechanic, and he’s a super nice guy, the place is great, and I trust him, but he gives it back to me, my car doesn't work. How long am I going to keep returning? I might give them one or two times and then I'm out. 

That's also another very important metric, the therapist, you know, and we need context for these measurements. We need to be able to say, “Okay, 85% of my patients say they're getting better.” 

What does that mean? Where do I relate in relation to everybody else? Are they happy with your, your front desk? Are they happy with their therapist? 

We can start looking at these. We can start graphing. We can start comparing people to one another, then we really have something. That's the big problem with metrics. That's why I like the NPS so much, because previously in my practice, I had done some questioning but honestly, it really wasn't worth anything.

I got satisfaction scores, but I didn't know what they meant. I had no basis for comparison. It  was just a number, and I wanted to improve the number in relation to itself. 

Am I good? Am I bad? How do I know if I have a huge problem in my practice? If I'm looking at a number, and I only can compare it to me, that creates an enormous problem. I did it for years. 

If you're bigger then you can get some semblance of of a number, but even at that, how do you know that your practice that your systems are dialed in, if you're only measuring it against your other practices? All the variables are the same.

When we start doing this, we start getting big numbers. Now, you can start to split tests, and you can start looking at different things. How is this working compared to somebody else is doing it differently?

That's part of my hope with a free NPS number. With the free NPS app, we get their NPS number or that net promoter score, “How likely are for a family or friend dear to 10?” Then we asked if the person is improving. 

My hope from this is we get it out to enough people, and we started getting some data here. Now I can start giving you feedback. If your numbers are low, I can reach out to you via email and say, “Hey, look, your NPS score is slightly lower than average. Is there a way we can do a deeper dive? How can I help you?”

That's why I say I think the metrics are incomplete. I didn't like Web PT, we've talked about this before. I did a talk at one of the things about the WebPT, their State of Rehab survey, and their drop off numbers.

It just blew my head apart when I read that best case scenario is that 75% of your people aren't completing their plan of care - that just flipped me out. This is the actual numbers that we have on 10,000 or 11,000 clinics. You can see how big the problem is.

I had no idea how big of a problem or how widespread this thing was until I really got to look at some of the numbers, and data that gave it context. I knew what my number was, but I didn't know what anybody else's number was.

JD: Let me jump in there really quick because you just identified a huge issue. Early on, when I started working on this patient lifecycle, client lifecycle and getting into the patient experience, I thought, “Well, the in-network clinics, they got this figured out,” So my customers really out of networking, cash paid PT. 

What I learned early on within six to eight months that the in-network clinics, because of their no-show cancel rates and their drop offs, had far more to gain from this work. Do not fool yourself that because you're majoring this, you know how to manage it. It is with the in-network clinics. 

This is a pitch of understanding your patients lifecycle. I just spent 40 minutes on the phone with someone telling her how to do this yesterday, and I'm happy to do that with anybody. Because if you haven't, you're going to help yourself and your employees a lot. 

I've gone into a couple out of in-network clinics and the return on investment to the bottom line - because all they did was pay for me, they didn't buy anything else. The return of investment on their bottom line was enormous because of this bringing in the understanding of the customer lifecycle and really where they really got dialed in with little change. 

I'm going to tell you a little cheat here is you got to change the front end, or what I call phase two of your patients lifecycle from first phone call to customer arrival. The last place I went to put a zero on the end of their monthly revenue just by managing the front desk. 

Everything I said would go down went down. No-show cancel rates went down and complete a plans of care went up. I didn't make this claim, going in revenue per visit went up, and that is why the people who were calling the clinic previously who weren't scheduling because of out of network or or my deductible were now scheduling. 

So revenue per visit went up in in-network clinic where that's what you say that shouldn't happen. This isn't a pump. This is a pump for understand your customers lifecycle. 

Your front desk is the entry point into your business. No matter how you manage it, whether you believe they're the most important thing is the first step in the process. It should be all we do. We all deal with the providers that are like four steps down five steps down. 

RB: I know you like to tackle, but they're kind of like a center. They're the one who snaps the ball, the play doesn't start without them.

JD: They're calling the blocking strategies and the leader of the offensive line. 

This stuff, with what Ray's talking about with these drop offs and the NPS and managing all this goes back to the beginning of this conversation - that you must understand your business as an ecosystem, and what you do in one place is not just an effect on that one step, but will affect other steps. 

When you have that life cycle mapped out, you can take a step back anytime you have a problem and go, “Hmm, let me dig a little deeper before I go yell at people.” Let me look at where this can actually be solved in the shortest amount of time with the least amount of energy and therefore the least amount of money. 

RB: You were saying the bigger providers that that same Web PT study showed, that if you have 21 or more providers in your business, your completed plan of care rate is less than 7%. The bigger you are, the more you have to gain because the bigger the problem is. The small providers are closing three times as many plans a care as these huge national therapies.

JD: Here's my statement on that. My question, is it the provider who I'm not knocking? Because what I'm going to say is the provider is doing a good job in every setting. I'm going to go out on a limb and say the providers do what they need to do.

Or is it the fact that in the smaller clinics, the entry point is controlled? There's only one or two people answering the phone. In the larger clinics, like a 26-clinic practice, you got 26 times two. You have two different entry points into the business. 

I would take a step back and argue that it's the controlled entry point more than the providers themselves, because we're all trained to deliver. So what product and what type of person are we delivering to this provider? 

I'm having some talks with some very large clinics, and the first question I asked him is, “How many front desk people at how many locations?” And then I immediately follow up with, “How are you controlling the quality of that first phone call systems?”

RB: That's part of the problem is as the system gets bigger, it becomes harder to control. That's why I love automation.

JD: That's where I thought you were gonna go with that. As soon as you get that big, not only all the systems get harder to control, but the entry points into your business. 

Because if you think about it, some of the best stuff I've read, like these other huge online companies, what they understand best is where their customer’s entry point was. So when someone comes in and makes contact with someone in that company, they know how they entered, so they know their experience. 

RB: That's why Disney nails it. They sell you magic. They don't sell you an amusement park. They sell you magic.

JD: The key is to start building those systems now. If you’re a 1-person or 2-person clinic, I’m going to tell you to build the systems right now. Get your lifecycle mapped out, because you and that other person will going to build it out. The system that you will need to maintain when you have 30, 40, to 50 employees is established today.

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