136 - The Leaky Bucket: Finding Where Patient Retention Breaks Down with Dr. Chris Grier

[00:00:00] We need to manage by metrics, not by emotions. We can't just go, it feels like everybody sticks around, or it feels like everybody's quitting. You know, like those feelings are inaccurate almost all of the time. We have to have the numbers so we can just have an unemotional conversation about where is the leak in the bucket.

[00:00:28] Hello and welcome to Build Your Remarkable Practice for Chiropractors. This podcast is dedicated to chiropractors who are in the seasons of launching and building their practice. Join myself, Dr. Lona, and my co-host, Dr. Bobby, as we have conversations each week as it relates to building the practice of your dreams. And remember, you can have a remarkable practice as part of a remarkable life, not instead of one. We are here to lead you on the way.

[00:01:00] All right, welcome back to the Build Your Remarkable Practice podcast and I am back with one of our frequent guests, Dr. Chris Grier. Welcome back, Dr. Chris. Good to see you. Thank you, Dr. Lona. Always a pleasure for you to have me on. Thank you. Yes, yes. And we were just chatting offline about like, all right, what's the conversation going to be today?

[00:01:18] And I said, Chris, I think we should go left-brained here and talk about some of the metrics that a doc, especially a doc building a practice, may not know that they should be looking at, may not even know how to get. But if we were trying to improve our practice, certainly being able to look at the numbers is really an important way to be more effective at knowing where you even need some training and some help. Right. Absolutely. Yeah, absolutely. And yeah, I think this could be a great discussion.

[00:01:48] You know, there. Yes, we need to be fired up about chiropractic and what we can do, the practice side of things. You know, what is our practice doing? It's delivering results for people. And how does it do that? Well, chiropractic philosophy will tell you all that. And when it comes down to running a business, we have to know our numbers, people.

[00:02:08] Like we have to know our numbers. And as I was saying to you, Dr. Lona, man, I just find it time and time again that people do pretty well with their attraction numbers. And yes, we need to make sure that we're dividing those up into internal, external and digital. That's as simple as it could be. Right. Then the conversion numbers, they do pretty well, too. Who converted or who didn't? Now, what they're converting them to that sometimes is a question. But did they start? Did they not start? People are usually pretty good with that.

[00:02:38] But it's the retention numbers that usually I get a blank stare when I'm talking about any other retention numbers to people. I think it's absolutely worth our next 10 or 15 minutes to have people get a pen and paper out, make some notes, identify what that looks like in your practice. And then, of course, take action on it. So good. And you are lovingly called the professor.

[00:03:03] And so, professor, take us to town on some of the retention things that we should be looking for in our numbers and how we'd even go about getting them. Great. So the first question I'm going to ask the listener is, how many active practice members do you have? And I'm just going to put a period on that and then I'm just going to sit back and wait. Because all the time I get like this deep breath from people. They're like, but I think probably around 200.

[00:03:33] Maybe is it 100? They don't know. They don't know how many human beings they're taking care of. So in I consider total active patients, or we call it TAP, that is your retention baseline. You have to know how many people you're taking care of. And so I just want to take a minute with that before we get into the other metrics that we will talk about. But people say, well, how do I know?

[00:04:00] Do I just run a report out of my software? That's how many unique visits I've had in the last three months? And the answer is no, you don't do that. Because that would include new patients who didn't start in there. It would include people who stopped in for a visit or two, but were never active patients. For total active patients, these need to have a designation. These people need to be people who are following a care plan that you've recommended,

[00:04:28] ideally based on their goals and your findings. They have their care set up, their care schedule set up. And you know how they're going to pay you. The ideal for that, of course, is auto debits. Some people, if it's, oh, everybody prepays. Okay, that's fine. That counts as a way they're going to pay you. Auto debits, monthly auto debits are my preference. Yep, that's a way that they're going to pay you. Or hey, we have an agreement. They're going to bring me a check once a month.

[00:04:55] Whatever the agreement is, that's the agreement. But I don't encourage you to count an active patient as somebody who just schedules and pays every visit. That is not an active patient. So to review, they are following a care plan that you've recommended. They are on the schedule ahead of time. They've scheduled out their visits. And they have a payment method set up with you. And I think, importantly, whatever way you're going to define this, right?

[00:05:23] If you define it exactly the way Chris just laid it out, or you're going to define it some other way, that you define it and that you use that definition on a recurrent basis when you're measuring. Yes. And that is the case for total active patients. And really, it's the case for everything. But for your total active patients, there is like a, we just have to know whether they're active or whether they're not. And your office needs to come up with your guidelines on that definition for that.

[00:05:52] And that also brings to the point, well, how do we know if a person remains active? Well, they're doing the things that you define. And what's the option if they aren't doing the things that you define? They are inactive. And this, we all have such a hard time with inactivating. They're going to show back up. Oh, they just have this thing going on. And they'll be in next month. I'm sure of it. Even though they haven't returned our calls or our text messages for the past two weeks. Yeah.

[00:06:19] We need to get better at having a binary switch, right? It's they're active when they're doing those things that you define them as active, or they're inactive when they're not. And that's okay. Because when they do show up next month, just like you thought, great. You just reactivate them as long as they're getting back into whatever fits your definition. So active, inactive is huge because the baseline number for retention is total active patients. Right.

[00:06:45] And it potentially could, like some of the softwares I know have an ability to look at things like who's been in in the last 30 days into certain parameters, and then who hasn't been in in the last 30 days to something parameters. And that can be very helpful as long as you can remeasure it the same way every month to have a number that is going to be objective. Yep. And I actually recommend a quarterly manual process where you do just that. You print this page off.

[00:07:15] Like literally, I have my front desk. She prints it off. And then we go through everybody who has been in in the last, we do three months, who's been in in the last three months. And we highlight people who are inactive. Because in our practice, I mean, we have 96% retention rate after R6. We'll get into what I really mean by that. But long-term patients, they stick around with us. It's really, really high.

[00:07:42] So we highlight the people who have gone inactive. And sometimes then that creates meaningful action items. Oh, shoot. I do need to reach out to that person. Or I'm going to send them a postcard or whatever it might be. But that manual process, I think, is still about the best way. I haven't found a software that really totally nails total active patients yet for various reasons that are constraints of software.

[00:08:09] Yeah, we have several different ways that we can run reports so that we can go person by person and review for, yeah, if there's action steps that need to be done. And so people aren't falling through the cracks without an important conversation that needs to happen if need be. Yep, for sure. And the bigger the clinic, the more, you know, this process is going to take. But, you know, lots of clinics are in that 100 to 600 active patient range.

[00:08:39] It's not that long of a process to drink through that. Okay, so that's total active patients. Well, now we got to say, all right, well, how do I know how my retention is doing otherwise? And for the purposes of this conversation, I think it's best to say at the remarkable practice, we recommend a three-phase care process with people. So initial intensive care, then corrective care, then ongoing maintenance or wellness care with an annual review.

[00:09:08] And so we know, you know, it's well known that we have this nomenclature that we use that's R4, R5, and R6. Just for the sake of this conversation, here's one of those things to write down. What is R4? It's the report that you give a person at the end of their initial care with you. What is R5? It's the report that you give people at the end of their next care plan with you. And what is R6?

[00:09:35] It's the annual review that you do with your retention patients every year that they are in care with you. So in the metrics, R4 and R5, so your initial intensive care and your corrective care have a set of metrics. And there aren't, it's not unlimited. It's a very finite amount. But you need to know this number, which is called R4 and R5 stick rate. This one's really, really, really important.

[00:10:05] So you can look at where people are falling off, if they're falling off. And that can help you identify the hole to fill in your bucket, so to speak. So what's the stick rate? It's real simple. However many people say yes to your initial care plan. Let's say this month you have 10 people say yes to your initial care plan. And your care plan is four months. So four months from now, you do your report visits with them.

[00:10:35] And you do report visits with seven people. 70% of the people who started made it to that report. That's your R4 stick rate. That number is, again, very, very important because clearly we want that high. And there are things that we can do. There are mechanisms we can put in with our continuing education and with making our flow better and with making all various things. We have the big seven reasons people drop out.

[00:11:04] We can, you know, that's a whole different podcast. We can get really good at making a great experience where people get good results. And that drives that number up. Then the only other thing you need to know is how many of those people say yes to the next phase. And that's your R4 conversion percentage. So of those seven people, let's say four of them say yes to your next phase. Well, you're a little bit better than 50% conversion percentage. That's a retention metric.

[00:11:34] And that one would be well below the standard that we're looking for. And I'll talk about standards in a minute. But that again would be like, okay, now we need to work on what is it? What do we need to work on for our conversion from initial care to the next phase of care? And that one I find to be the area that people have the most ability to grow with. Because I think there's a lot in our profession, there's a whole lot of like, yeah, they said yes to a care plan. Awesome. That's great.

[00:12:04] And then we just kind of aren't that great at educating and keeping people engaged in their care and so on and so forth. And then we have basically spiked the football with them like, ah, they're lifers. They said yes to our initial thing. And then if they get to when they get to that end of that initial intensive care, and we say, hey, let's keep going. And they're like, oh, I thought I was done. Like, I thought this was it. And all of a sudden, we're having to backpedal with them.

[00:12:30] That's a moment that metric, which is our four conversion percentage can really illuminate right there. Yeah. I agree with you that I think that first phase has a lot of opportunity, whether it wasn't strong starts, or it wasn't delivering what we said we were going to deliver, or people got to the end of it. And we're like, yeah, thanks. And that's that. Yeah. They get the results they thought they were coming from, which is different than usually what we think they're there for.

[00:13:00] We always say that if you're going to do anything perfectly, do the first care plan perfectly. Like, make sure you've got your stuff down for that. Because that's where people go from believing that you're the place that can help them to understanding how chiropractic fits into their healthy lifestyle. That conversion, that transformation for a person is what allows them to be a great retention patient. What do you think are some of the biggest, when you said like, you know, we get real excited about them starting.

[00:13:30] Yeah. What do you think are some of the biggest, yeah, where we need to slip and check ourselves in that first phase of care? What do you see? I really see two primary areas for this. One is table talk, and the other is progress exams and progress reports. Probably when I just said table talk, the listeners were like, yeah, I could probably do better with that. And then when I said progress exams, progress reports, we probably had half of the group go like, oh, yeah, I don't do that.

[00:13:59] I see a lot of offices just don't do them. They don't. I know. Yeah. And it's unfortunate because it's a great opportunity clinically for us to know exactly what's happening there. And it's a great opportunity for the patient to be reengaged in what they're doing. This is a great time to review goals. It's a great time to review the life effect that they had talked about early in care. Yeah.

[00:14:25] And there's just these couple of moments in those initial four months where it's like the flywheel effect. It's like, OK, that just kicks them into the next phase. Oh, yeah. Kicks them into the next phase and it builds their understanding. Yeah. That's the progress exam, progress report with the table talk. Again, could be a whole other podcast. But what we teach is that there's two reasons why doctors don't do good table talk. And it's because they feel like it's awkward and they don't know what to talk about.

[00:14:52] And we completely train on that because it's very, very simple. It doesn't have to be awkward if you tell people you're going to do it. You have to tell people you're going to do it. And there's a set of things that people need to know to be healthy. We call it the dirty dozen. Yeah. And the three legged stool of results, which is talking about how they are managing their care, that there's infinite amount of things to talk about. So I think it's a great question, Dr. Lona. What is it that we could do to do better?

[00:15:20] Man, I think if everybody did great table talk and had an excellent progress exam, progress report protocol. Yeah. Solve most of our retention problems, early retention problems. It's really good. I love that. Thank you. You bet. So then now we talk about these people. OK, they just made it through, right? We are increasing the percent of people who start care with us that make it to the end of their initial care. We're increasing the percentage of people who understand why.

[00:15:48] Yes, of course, I want to keep going with this next phase of care. Now we go into what in our office we call the next 12 phase because I plan a four month care plan initially. Then I plan a 12 month plan after that. So we call it the next 12. But whatever that second phase is, we have the same metrics we just talked about in our four. What percent of people start that next phase that get to the end of it? And what percent of people who get to the end go to the next? Yeah.

[00:16:18] So it's our five stick rate. That's that percent that make it to the end. And it's our five conversion percentage. What percent of people at that report visit make it to the they say yes and go forward. And this is the moment. Lots of times we have a big retention issue a couple of months after in a next 12 format, a month or two after that conversion into that second care plan. That's where we start finding that people drift.

[00:16:48] You know, they typically they feel well at this point. You know, their life is doing much better. And nobody's life gets less busy, though. And we're asking their resources. Right. So we have to be even better. We have to train our teams to be even better at engaging with people, staying on their goals, helping be their guide, because that's what people want. People want guidance from us. Yeah. They want to be directed as to how to be healthy human beings when they're at that point in care.

[00:17:17] And when we start talking about the football game and, you know, just like shooting the crap with them instead of actually being their health guide. That's where they're like, I don't really have time for that. I can do that elsewhere and not spend my time, energy, focus and money doing it. Yeah, I think, you know, in TRP, it's like the three things that we have to keep in the forefront is like they're going to get checked. They're going to get a great adjustment and they're going to be taught something. And that doesn't really ever stop. Yes, absolutely.

[00:17:46] And we as the people delivering care and the people supporting the care, like our CA groups, we all have to keep that in mind. It's not our job just to only to have a nice place to be. Yeah, we have to have a nice place to be. And we need to remain their guide. They are there for a reason. And that's our purpose. So good. Yeah. That's great. So then the last thing would be our six.

[00:18:14] And this one always confuses people because our six doesn't ever get to our seven, eight, nine, ten. It's just our six. And that's the annual review for people who are in maintenance or wellness care. Again, define what maintenance or wellness care is for you. My office weekly care is wellness care. Every other weekly care is maintenance care. I don't really do anything else. There's a handful of people that are on a different cadence than that. And each year they have an annual re-exam.

[00:18:43] By the way, I do a progress exam, progress report in the middle of that year also. And then they have this re-exam, re-report where that's where they get to say, yep, let's do this for another year. I just had Lori earlier this week. Yeah, earlier this week. And she started her 19th year of care with me. Those are easier reports than others. And I can't just spike the football on Lori or Deb or like all these people that have been in my practice for nearly 20 years.

[00:19:14] I can't spike the football with them. I'm still having to make sure that I'm talking about the right things with them. Yep. If I visit. Yeah, that's great. I think that's an important piece is like retention is earned visit by visit by doing the right things and staying present time consciousness and realizing our job is service and direction.

[00:19:35] Like you said, like we were having this conversation, I think, with Andrew on one of the last episodes about there's no shortage of places that people can get advice from right now. But the accountability piece and accountability with someone that they've developed a relationship and a trust with because you keep their health and their goals at the focus of what you're doing. That's really valuable. And the fact that you're teaching them a new paradigm is another part that's very valuable, too. Absolutely. Yeah.

[00:20:02] And maybe that's a good thing to point out to guys leverage your technology for this like, it's like, how do I remember what people's goals are? What did we talk about last time or whatever? Hopefully your software even just has a box like somewhere. And pre-shift, post-shift. Yeah, pre-shift, post-shift for sure, especially for those patients in need of care, patients in need of gifting, like make sure pre-shift, post-shift, you're talking about that. And I love having it where I pull up a person's note and I look down and I see their goals.

[00:20:32] I see their current goals. And then I can simply, hey, Lona, it's great to see you today. And then as I'm getting them adjusted, hey, how's that going with getting back into your running routine? You know, a person's going to be like, oh, wow, they remembered that I'm on a running routine. Like, okay, good. Those are the things that drive these metrics that we're talking about. That drives up your stick rates. It drives up your conversion, your reconversion rates as well.

[00:20:58] So I know we only have a minute or so left, but just as a recap, again, there aren't that many numbers to get, but you have to get them. So whatever action you need to take from this to get your, first off, new patient conversion percentage, because that gets you how many people started. Make sure that you have a process for marking people inactive. And therefore, you're going to have an accurate total active patient. Okay?

[00:21:23] Then for all those people who start, you need a percent that may get to the end of the care plan you've recommended. That's an R4 stick rate. Then you have a percent of those people that move on to the next phase. That's your R4 conversion percentage. Those people that make it all the way to the end of that next phase with you, that's your R5 stick rate, the percent of people who make it all the way to the end.

[00:21:48] And then again, you've got that conversion percentage from R5 into the next phase. That's your R5 conversion percentage. And then you have R6 conversion percentage that just rolls. So that's it. In one minute, those are your retention numbers. And I have found consistently that clinics just drop the ball after attraction and conversion.

[00:22:12] They don't really keep retention numbers when everybody tells me, oh, I would just love to have better PVA. Which is, I haven't even mentioned that in retention metrics. I know. Because it's not honestly my favorite. It's a wellness metric, but it's one that gives us an idea. And if your patient visit average wasn't going to go there, but here we go. Your patient visit average is your total patient visits for a time period divided by your new patient starts, your new patient conversions for that same time period.

[00:22:42] That should grow year over year in your practice. And if you, there's the different numbers that are thrown around that once you have a wellness practice, your PVA is going to be over X. I've heard 60. I've heard 30. Both of those numbers. I don't know. I would love to see that number in our profession be like 100. You know, you have a wellness practice and people see you 100 times. Yep. We could talk more. I think that that's a really good point is like most of us, that's the retention number we've learned.

[00:23:11] And then for me, that was where TRP really helped me much better understand that like, sure, we of course want to see that number grow. But that number is an average and not really telling us where the leaky bucket actually is. And so we're really doing this to improve our care, to really improve our ability to communicate and to look at why the leak is there in the first place.

[00:23:35] You know, what Chris just went through for all of us is where the juice is worth the squeeze in learning better about where do I actually need to spend more time improving our process and our ability to communicate and deliver care. Right. Absolutely. Because we want to, we need to manage by metrics, not by emotions. We can't just go, it feels like everybody sticks around. Right. Or it's good. And it feels like everybody's quitting.

[00:24:00] You know, like those feelings are inaccurate almost all of the time. We have to have the numbers so we can just have an unemotional conversation about where is the leak in the bucket. Thank you for enlightening all of us to have probably some homework from this call. That's right. But it is a really good thing to get in order now because your future version of your practice is very grateful for this work. Yes, absolutely. And people, of course, can reach out to us.

[00:24:28] You know, I'm sure in the show notes we've got our information. People can reach out to us. And if there are any questions about it, just focus. We'll help. We're here to help more people, help more people. Thanks, Chris. You're the best. You bet. All right. Love it. Thank you very much, Dr. Lona. We'll see you next time. That sounds great. See you then. All right. Bye-bye. Thanks for listening to this episode of Build Your Remarkable Practice podcast. Remember, what the world needs now is chiropractic.

[00:24:55] And what chiropractic needs now is more successful chiropractors. If you like the podcast, please subscribe. Share with your friends and leave us a review. And if you'd like to connect with us personally, please click the links in the show notes to schedule a call.