By Nancy Miller, RDH, BA
Much has been written about the utilization of the accelerated hygiene model to increase hygiene production numbers. The ability to see more patients in one day certainly increases production numbers in the short run. If quality patient relationships are sacrificed in the pursuit of a few more dollars, however, the bigger objective of case/treatment acceptance gets overlooked.
Accelerated hygiene models that propel the hygienist from room to room as a scaling maniac while the assistant does the polishing and room turning are a career killer for the team-not the most efficient model. I prefer to think of using an assistant as a practice productivity booster. The hygiene assistant is another patient contact person and an integral part in building patient relationships and trust.
Today's four-handed, reclined-patient dentistry model evolved from the two-handed, stand-up dentistry model prevalent prior to the 1960s. It is much more efficient and ergonomically correct for doctors to sit in one position and have assistants suction and hand them instruments rather than having to look up and reach for things themselves. Being able to leave during treatment to do hygiene evaluations or go to another treatment room while the assistant stays with the patient is another positive feature. Delegating all that is legal to the assistant frees up the doctor to also start treatment in another room.
Having two assistants and two treatment rooms allows the doctor's schedule to be dovetailed throughout the day for the most efficient use of the doctor's time and abilities. Competent assistants in both rooms keep the patients occupied and the doctor moving.
Similarly, a hygienist with one assistant and two treatment rooms can maximize the time spent with the patient for education and value-added services. This allows for better data collection, better dissemination of information to the doctor and patient, and better business handoffs and documentation.
In today's forward-thinking practices, the hygienist's role is critical. Hygienists have the most repeat contact time with the patients, the most one-on-one time with the patients, and the best ability to build goodwill and loyalty to the practice. Giving patients a reason to come back keeps them healthy, the practice healthy, and the doctor's chair filled. It is estimated that 60% of the production in the doctor's chair comes from the hygienist's chair. Personalized attention to the patient and value-added services such as blood pressure or oral cancer screenings create patient appreciation and loyalty and "buzz" in the community.
The traditional hour for a hygiene appointment when all of the evaluations and procedures (see sidebar) are done solo is barely enough in most cases. If no doctor exam is needed, it might just barely fit in an hour. However, it's common knowledge that the time wasted waiting for an exam routinely sabotages schedules and makes us tardy all day long.
One way to alleviate this is to have the doctor come in at his/her convenience no matter where we are in the appointment. Gathering all of the diagnostic data in the first 15 minutes leaves the doctor with a broader range of time in which to do the exam. Occasionally, you will have to "punt" handing off information if the doctor arrives prior to all the data being gathered. As experienced professionals, we are co-diagnosing, and this should not be a problem.
More time to co-diagnose
The time spent should be totally focused on the patient in the chair. Unfortunately, this is often impossible due to many factors having to do with the procedures themselves. Solo data collection is time consuming and not as accurate, nor as valuable to the patient when they don't hear it for themselves. Time spent turning a room is better spent accurately completing documentation to have better continuity between team members, better communication of the patients' needs, and to protect the practice from any liability issues.
Once the findings have been explained and shown to patients, being able to determine patients' "hot buttons" and levels of understanding is imperative to getting to the next level of acceptance. The hygienist can also explore other treatment options by asking the question, "Is there anything you would change about your smile if you could?" This often leads to more cosmetic treatment questions and more elective types of treatment.
When the critical doctor evaluation is smooth, with a complete handoff of information, that enables the hygienist and doctor to co-diagnose, and the patient should feel as though the doctor spent 15 minutes with him/her when he/she actually got only five minutes. Of course, if the doctor goes off on a tangent about golf, fishing, or kids, that can become a time waster. Some personal conversation is needed by the doctor to foster a relationship with the patient, but good teams will have a signal between themselves to zip it up and get moving!
After the doctor leaves the treatment room, the hygienist should explain recommendations and treatment so the patient fully understands what is being proposed. Patients cannot accept and commit to treatment they do not fully understand.
Escorting the patient to the business area and completing the handoff to the business team eliminates the last minute "dodge" (where the patient may schedule the appointment without fully understanding what the next step is only to cancel closer to the appointment time, or where they don't schedule at all as they have no perceived need or sense of urgency). Finishing all documentation of things said, procedures done, and recommendations made while still fresh in everyone's mind is essential.
How the assistant assists
In an eight-hour day, with two treatment rooms and a dedicated assistant, I am able to see two to four more patients, depending on their history. This adds up to more than enough revenue in fees to cover the hygiene assistant's salary and benefits. But the real value comes from being able to spend more time with the patient without rushing, and not having to do the more time-consuming, nonprofit procedures such as turning a room and resetting it, which, when rushed, isn't done effectively anyhow. The extra time spent with the patient in education leads to better case acceptance. The ability to not have to keep the next patient waiting, as the assistant will have him or her seated and started, is a total stress reliever.
Before the hygienist enters the treatment room, the dental hygiene assistant can:
• Seat and greet the patient
• Review the medical history
• Deliver an antimicrobial preprocedural rinse
• Take blood pressure readings
• Take necessary digital images
• Polish the patient's teeth, if legal in your state
The hygiene assistant can support the hygienist by talking with the patient if the previous patient is taking more time or the hygienist is delayed for some other reason. They then stay in the treatment room with the hygienist and help with data collection, which has a better educational benefit when collected out loud and together.
This attention to detail and the patient is a value-added service and critical in developing patient trust and loyalty. Having the time to explain the data and why it is collected builds value and can increase patient involvement in their own treatment.
If needed, the dental hygiene assistant can also assist with evacuation if it is a more involved treatment or a patient with accessibility issues. Otherwise, the assistant is free to leave, and, once he/she has the other treatment room decontaminated and set up, he/she can assist in sterilization, with maintenance or inventory issues, or with whatever else can help the entire team stay on schedule.
This effectively turns the dental hygiene assistant into a productivity booster who helps relieve the hygienist of more routine procedures so she/he can concentrate on the delivery of care and acceptance of needed treatment.
Too often, a dental hygiene assistant is chosen from a field of "lesser" candidates as a sort of fill-in kind of employee. Someone who can't relate well to others or knows little about dentistry and health is not a good choice for this important role. A mature and seasoned team member or a bright and personable young person are better choices for this position.
Just as the move from standing solo dentistry to four-handed seated dentistry was a paradigm shift for dentists, the time has come for a hygiene paradigm shift through utilization of an effective dental hygiene assistant model and two treatment rooms. With expanding knowledge of the oral-systemic link, increased education time with the patient should lead to increased treatment acceptance. This, in turn, should lead to healthier patients and higher productivity. This paradigm shift will benefit all involved, especially the patient's overall health and secondarily the practice's bottom line. RDH
A list of tasks
Here is a list of most of the things that doctors usually desire for the hygienist to accomplish in a typical recare appointment:
- Seat and greet/social graces/connect/reconnect
- Medical history update/review/education/medication review/documentation in chart
- Premedication review/educate
- Blood pressure screening/document/educate/refer
- Query about most recent restorative treatment performed; problems or positive comments documented
- Patient concerns/chief complaint/peeling the "onion" to get to the real concerns/documentation
- Antimicrobial prerinse/educate
- Necessary radiographs/digital images/educate to reasons why taken and what they show
- Cosmetic concerns/whitening/current unattractive restorations
- Oral cancer screening/soft-tissue evaluation with or without a device/education and interpretation
- TMJ/ortho relationships/bruxism/sleep apnea needs/education about potential long-term problems
- Hard-tissue evaluation with or without device/new caries, recurring caries/broken restorations, new restorations
- CAMBRA risk assessment/education on caries
- Perio evaluation/charting/education on oral-systemic connections/treatment if necessary
- Intraoral photos/extraoral photos
- Alert for doctor exam
- Air or rubber cup polishing
- Scale teeth/use hand and/or power instruments
- Floss teeth/evaluate oral hygiene/introduce and demonstrate new aids such as SoftPicks/document
- Prepare/educate for next services to be delivered
- Alert for doctor exam again!
- Do hygiene/doctor exam handoff
- Place diagnosed treatment plan in computer
- Document reasons for recommended treatment in patient record/patient reaction or comments
- Fluoride treatment if indicated/educate as to why needed and explain fee
- Schedule next recare/schedule any delinquent family recare appointments
- Walk out to business team
- Hand off to business team, informing them what was done today and what needs to be done next/reinforce importance of keeping next appointment
- Tear down room/disposables/instruments to sterilization
- Decontaminate room/set up room for next patient
- Document treatment done
- Document treatment needed
- Document any and all recommendations of the hygienist and doctor
- Document any comments made by the patient for future reference and add personal notes
Nancy Miller, RDH, BA, has, since 1992, presented lectures and hands-on courses through her company, Ultraconcepts, on topics such as ultrasonic instrumentation and air-flow therapy for biofilm removal, ergonomics, assisted hygiene, and periodontal and caries disease treatment. She practices two days weekly in a general practice in Green Bay, Wisconsin. She also has been a dental practice management advisor with Jameson Management since 1998, specializing in clinical department coordination with the business team. Nancy is also a product evaluator for several manufacturers including Crown Seating, Hu-Friedy, Perioptix, and Florida Probe.