A written standard of care: Your dental office must-have

Several years ago, after practicing clinical dental hygiene for more than 25 years, I attended a CE course that really changed things for me. Often, we find ourselves taking CE courses that merely “check the box” for requirements without really getting much out of it except for the credit. Or maybe we attend a course where we leave with a new sense of purpose and a burning passion to immediately institute what we learned into practice the very next week.

During this course, I found myself making a list of the things I wanted to discuss with my dentist, as well as outlining the steps or solutions that it would require to accomplish the change. The course that did exactly this for me was a hygiene boot-camp style course that instantly had my brain kicked into high gear.

Fortunately, my office fully invested in the knowledge and expertise of the hygienists and encouraged us to make necessary changes to benefit the office and patients. When one of us on the hygiene team had an idea or suggestion in terms of systems, protocols, or processes, we had to provide the “why” behind the suggestion as well as the “how” it would be best implemented. We would problem-solve and make a list of the pros and cons for everyone involved if we made the change. And then, collectively as a team, if we decided to pursue, we would decide the steps necessary to get the ball rolling.

Also, fortunately, many of the recommendations that were covered in this course were already in place in our office but just needed some minor tweaking. However, although we had most of the systems, protocols, and processes in place, we didn’t have them in writing. We had been having regular hygiene meetings and making changes as needed but they were only covered via oral communication; we hadn’t actually developed a written document defining it all. This was to become our standard of operations manual or as it’s more commonly called, the Standard of Care document for our hygiene department.

Standardizing the standard of care

As hygienists, we have the knowledge, skills, and expertise to care for patients. In many cases, we have our own way of making decisions based on our education and experience. We know about the hygiene diagnosis process, the importance of recording and interpreting vital statistics, taking and then interpreting a thorough medical history, and about standards for radiographic exposure. These are a few of the topics that we are expected to make decisions on every day that we practice.

But about your hygiene team members. Do you all practice the same about such issues or is everyone just doing their “own thing”? How does that reflect on your patient care? Could a patient be seen by any of your team members and receive the same standard of care? Would their care be a series of continuous, unconflicted events or would the patient have doubts about why or how a particular service was offered, discussed, or completed?

What happens in your office when you have a guest hygienist for the day or when you hire a new team member? Who reviews the office standards for care? This is why you need a written document, and why it’s shown to be so valuable in practices that embrace it.

Once our team put together our written standard of care document for the hygiene department, my boss found it so useful that a similar document was created for the restorative team as well as for our administrative team. We developed the documents, trained the teams on the content, and regularly met to make necessary changes. It was a fluid, ever-changing set of documents that we were revising as needed based on the collective input from the teams. My boss would meet every two to three months with each team to see how the documents’ utilization was going and if any changes needed to be made.

Of course, if something new popped up that was important, we would meet as needed. A great example of this need to make an immediate change was when, in 2017, the American Heart Association and the American College of Cardiology made changes to the guidelines about hypertension. These were the first changes that had been made since 2003, and they were long overdue. The revised guidelines determined that a blood pressure reading of 130/80 was considered high and not borderline.¹ This led the American Dental Association to release recommendations on how dental pros should manage our patients with hypertension, including when they should be denied treatment and referred to a medical facility immediately.²

Our standard of care document

If you’ve never considered creating a standard of care document for your office, I encourage you to have a discussion with your dentist(s) and team to decide if it would benefit your office. Here's what we use, and it's easily adaptable.

1. General appointment standards: Time allowance in schedule for new patients, child and adult recare or perio maintenance appointments, full mouth debridements, gingivitis therapy, periodontal therapy, and sealants
2. No show/late to appointment policy
3. Outline of frequency of different types of radiographs based on the risk of the patient for periodontal disease and caries
4. Outline of duties assigned to our hygiene assistants
5. Example of ideal appointment flow since we were an assisted hygiene department. We used the 20/20/20 model for recare patients, which is a common model that many practice consultants/coaches use to teach teams.
6. Complete description of each hygiene procedure code that we used and how the hygiene diagnosis would fit. Remember that ADA procedure codes are exactly that: procedures and not insurance codes as many think. We gather our information, develop the proper diagnosis, and then match the most appropriate procedure code to that diagnosis. An example of this would be D4346 which, according to the 2022 ADA procedure code, is “Scaling in presence of generalized moderate or severe gingival inflammation, full mouth, after oral evaluation" and is defined as “The removal of plaque, calculus, and stains from supra- and sub-gingival tooth surfaces when there is generalized moderate or severe gingival inflammation in the absence of periodontitis. It is indicated for patients who have swollen, inflamed gingiva, generalized suprabony pockets, and moderate to severe bleeding on probing. Should not be reported in conjunction with prophylaxis, scaling and root planing, or debridement procedures.” ³ We would use this procedure code instead of doing a “bloody prophy” that so many hygienists report a good percentage of their day. We would follow up in four to six weeks and then continue to use this procedure code until the gingivitis had resolved or was more localized. We didn’t base their diagnosis or disease level on their insurance coverage.
7. We used the blood pressure table provided by the new AHA/ACC changes referenced above and outlined how our boss wanted us to treat each patient who presented with less than ideal blood pressure. For example, we would take their blood pressure in the correct patient position and arm using the correct monitoring system. We also outlined how many times we would repeat the procedure.
8. Description of high-risk medical conditions that would need follow-up if our hygiene assistant or another team member identified high risk for a patient to include medications, need for premedication (see below), etc. Our hygiene assistants were trained on medical histories and wouldn’t hesitate to ask us if they felt uncomfortable making any decision on a patient based on their presented risks for care.
9. Outline of patients who would possibly need premedication based on the newest guidelines published by the ADA⁴
10. Outline of daily, weekly, monthly, and yearly procedures to be completed by each team member to include such things as daily cleaning protocols for the office, weekly procedures for cleaning of suction traps, monthly use of suction shocking, and yearly need for updates such as OSHA, etc.

There are many other processes that could be in your standard of care document, but this is a starting point based on what we did. The beauty of this document is that you can tailor it for your office to help eliminate confusion for your team. Perhaps you need to add other treatment modalities such as irrigation, laser therapy, guided biofilm therapy, chairside HbA1c testing, or salivary testing, to name a few.

References

1. American Heart Association. What is High Blood Pressure? 2017. Accessed October 7, 2022
2. Hypertension/ADA. 2020. Accessed October 7, 2022
3. ICD and CDT Coding Examples/ADA. 2021. Accessed October 7, 2022
4. Antibiotic Prophylaxis Prior to Dental Procedures/ADA. 2022. Accessed October 7, 2022