Practice Needs Assessment

checklistWelcome to the Practice Needs Assessment. By completing the sections below, you are beginning the process of assessing the needs and potential of your practice. The information you provide here and during our on-site visit will enable us to develop a tailor-made plan for achieving your goals and maximizing the potential of your practice.


Each section of the assessment is a PDF file that can be downloaded and filled out using Adobe Acrobat. Here is a quick reference on how to fill out the forms using Adobe Acrobat’s typewriter tool. Please note, the directions may vary for different versions of Adobe Acrobat Professional or Adobe Acrobat Reader. Once you’ve filled out the form in Acrobat, you can save the PDF file on your computer. Most sections can be returned to us via email at this address: The only exception is the Team Questionnaire, which should be printed and mailed to our office to maintain confidentiality.


There are also downloadable Excel worksheets after some of the sections. These can be downloaded and edited using Microsoft Excel. Please return the completed worksheets to us at


If you have more than one doctor in your practice, they will each need to complete some sections and worksheets individually. We’ve noted this when applicable for each section. However, if you find other sections that you feel each doctor should complete separately, please do so.

The symbol indicates items you will need to send to us, with the different sections of this workbook, before our visit.

The symbol  indicates items to have ready at the time of our visit.

At the end of this page, you’ll find two checklists to help ensure that you’ve gathered the information needed for an effective practice assessment.

Option 1: Print entire workbook, complete by hand and mail to us.

Here is a copy of the PNA workbook as one file if you would rather print it to fill it out and mail it back to our offices. Our mailing addresses are included in the Team Questionnaire section of the workbook. If you decide to fill out the workbook manually, you will need to also complete the Performance Tracking Worksheet, the Doctor worksheet (one for each doctor in the practice) and the Hygienist worksheet (one for each hygienist in the practice).  Here is the definition list to use when completing the worksheets.

If you select this option, you can disregard the remaining sections of this page. All of the information you need can be found by visiting the links in the paragraph above.

Option 2: Download each section below, complete in Adobe Acrobat and email them back to us.

Make sure to include the following information each time you email us a different section or worksheet: contact name, number and email address; practice name; practice location. If you have any questions as you are completing the information, please contact us: Mosaic Management Group | 1.800.966.7242 |


 You are ready to begin. Enjoy learning more about your practice as you complete this survey!

Section 1: Introduction

This section contains the same information as above along with a description of each of the sections in a downloadable or printable format.

Getting Started

Section 2A: Assessment Forms

Personal and Practice Profile

To help us to know you better and to learn about your vision for the future, please give yourself time to carefully consider your responses. This information will help us to develop a plan that is consistent with your vision and philosophy. Each doctor in the practice should complete these sections.

Marketing Assessment

The information in this section helps us to assess and review your marketing methods and identify opportunities for improvements. Please complete this survey based on what is occurring now. The Assessment Visit Checklist at the end of this page includes marketing related items to have on hand during our visit. The first part in this section should be completed individually for each doctor in the practice ( Part one contains: In-Office Marketing and Community Involvement). The second part in this section should only be completed once for the whole practice (Part two contains: Advertising and Facility Upkeep).

Doctor Assessment of Systems

This section is to be completed by the doctor(s). This provides us with information about the current scheduling, financial and computer systems used in the practice. Please answer these questions as comprehensively as possible. Each doctor in the practice should complete this section individually.
Dr. Assessment of Systems

Team Assessment of Systems

This section captures the team input. Complete this section together during a staff meeting before our visit. This insight will help us identify areas to explore for improvement.
Team Assessment of Systems

Business Performance Tracking

Our analysis of your practice performance will be based on data from the previous 12 months and the previous calendar year. You will need the following information on hand as you complete this section:

  • Production
  • Collections
  • Number of New Patients
  • Number of Days Worked
  • Number of Hours Worked
  • Accounts receivable reports

If you do not have standard reports for some of this information, you can gather it from past appointment pages, day sheets, new patient lists or monitors, and referral lists. Many practices do not know the exact number of hours worked in a given month. Please estimate based on your usual patient care hours.
Business Performance Tracking

Performance Tracking Definitions

Performance Tracking Worksheet: Doctor Please submit a separate worksheet for each doctor in the practice.

Performance Tracking Worksheet: Hygiene Please submit a separate worksheet for each Hygienist in the practice.

Performance Tracking Worksheet: Total


Section 2B: Assessment Forms Cont.

Expense Tracking and Cash Flow Management

To complete this section, use information from the previous 12 months’ records and the previous calendar year’s profit and loss statements. You may need to ask your accountant to determine how expense items have been allocated.

You may also need to ask your insurance agent what coverage is included in which policy. Please include the following when you email this completed section to us before our visit:

The profit and loss statement you used to complete this assessment or any ledger used for expenses (we will return the P&L statement to you)
A summary of your practice loans, including interest, principle and the total amount paid per month

Expense Tracking and Cash Flow Mgmt

Team Management

This section helps us understand policies and procedures that are in place for to encourage the office team to strengthen performance.
Team Performance Management

Section 3: Team Questionnaire

Team Questionnaire

Ask each member of your team to complete the Team Questionnaire, which we will hold as confidential. Their responses help us to assess team satisfaction, levels of motivation, leadership, and the team’s perception of areas to improve in the practice.

Provide each team member with a copy of the questionnaire and the cover letter that goes with it. Ask each team member to mail the completed questionnaire in a separate envelope to your consultant at Mosaic Management Group. The address is provided in the cover letter. Team members may sign the survey, if they wish.

Confidential Team Questionnaires, mailed separately by each member of the team.

Team Questionnaire


At the end of this document you’ll find two checklists to help ensure that you’ve gathered the information needed for an effective practice assessment:

  • A Mailing Checklist of all the items to send to us before our visit
  • An Assessment Visit Checklist of items to have on hand the day of our visit