Mutual benefits

Sept. 1, 1997
A noted dental author examines some plausible scenarios for retaining hygienists as `happy, productive members of the health-care community.`

A noted dental author examines some plausible scenarios for retaining hygienists as `happy, productive members of the health-care community.`

John A. Wilde, DDS

Everyone in the dental community shares a concern over the shortened career of many hygienists. The reasons for this are complex and, to some degree, unique for each individual. However, one general factor accounting for reduced years in the profession is burnout. This occurs when rewards received are not commensurate with effort expended.

Hygienists are limited in their response to such imbalances. Reducing job-related performance is not a viable alternative for skilled, caring, ethics-based professionals. Thus, the only possible solution to restore equilibrium (and joy) is to increase rewards. If the compensation can`t be enhanced, many hygienists continue to be dissatisfied or abandon their careers entirely.

The challenge: to retain hygienists as happy, productive members of the health-care community. To do this, dentists must increase the rewards inherent from their labor, yet do so in a manner that doesn`t diminish the care their patients receive or reduce office revenue. How can this difficult, but essential, result be achieved?

There exists no magic bullet - i.e., a single, simple remedy - to solve this complex dilemma. However, I would like to suggest a series of logical steps you can take which, when implemented, will result in significant benefits to the hygienist, the dental practice and the patient.

Compensation by commission

Remuneration based on commission creates a heftier paycheck plus a healthy sense of control. In our office, this change resulted in an immediate 25 percent increase in hygiene productivity (and thus salary). That percentage has never declined during the 12 years and through the four hygienists that have enjoyed this system.

Changing this one factor has created a strong, personal motivation for our hygienist to work more effectively by establishing a mechanism that fairly rewards her for her efforts. The quality-of-care standard never wavered, but open time was filled, schedules were tightened and extra procedures (one or two sealants are common examples) were occasionally blended into the day.

During my 22 years in the profession, I`ve chosen to work hard when I`m in the office. I rarely have 10 minutes open in my day because I`m there to produce and maximize my income. I`ve seen thousands of emergency patients, worked in unscheduled procedures (often found in hygiene) for the convenience of a patient and stayed late to do a crown prep for a patient who fractured a tooth.

I view this behavior as part of my job - my professional responsibility. My patients appreciate this extra effort on their behalf and it frequently leads to kind words and referrals; but I`m also very aware that each and every one of these efforts enhances my income. Shouldn`t hygienists be granted the same opportunity?

Large bureaucracies (the military and school systems are two with which I`ve had intimate contact) fail to reward effort. The military dentist who places four fillings during an hour-long appointment receives the same compensation as the doctor who performs one. (I`ll allow the reader to guess the average restorations placed per hour - it shouldn`t be too difficult!) The teacher who hides in the lounge is paid the same as the educator who spends her free time helping students. To me, these are examples of fatally flawed systems - illogical, unproductive, unAmerican and out of contact with human reality - in a word, stupid!

What about an office where the hygienist is compensated the same for a difficult deep scaling as for sipping coffee during a failed appointment? Is it realistic (or even sane) to expect maximum effort if no rewards are forthcoming? Yet, this idiocy describes the compensation system of most dental offices today. We could discuss why salary is the standard method of paying hygienists, but the bottom line is concise: it isn`t effective!

I suggest the creation of a system in which compensation always will precisely reflect effort and value. This system should be consistent with our nation`s value heritage, often forgotten in this modern world of those who don`t work or don`t eat.

To create such a system for our office, we took our hygienist`s W-2 tax form for the preceding year and divided it by her total production for the previous 12-month period to establish a percentage of compensation. For example, assume your hygienist`s total compensation for 1996 was $20,000 and hygiene production was $100,000. The future percentage of hygiene compensation would be 20 percent of production ($20,000 is 20 percent of $100,000). From the moment we activated this policy, the harder our hygienist chose to work, the greater her rewards.

Because W-2 totals include all paid benefits, every benefit (sick leave, paid vacations, continuing education compensation, etc.) automatically would be included with this percentage (none are lost). Separate payment or recordkeeping would no longer be required.

Some hygienists may prefer to keep their benefits separate. No problem! Merely remove the benefits from the W-2 total and recalculate to get an accurate ratio of last year`s compensation, leaving benefits to be paid exactly as they had been paid in the past. With this type of system, figured with or without benefits, rewards and efforts achieve critical balance.

Creation of a hygiene profit center

This added production creates a hygiene profit center for the office. The 25 percent increase our office and hygienist enjoy is accompanied by only slightly higher practice overhead, thus insuring the dentist of increased profits and resulting in enthusiastic support and enhanced commitment to the hygienist and his or her department.

Let`s be candid. The core of most hygiene-dentist disputes is the small or nonexistent profitability of far too many hygiene departments. Asking for a salary increase, without increasing hygiene production, is asking dentists to take money from their own paycheck to fund the hygienist`s raise. Refusal of a salary increase can leave the hygienist feeling frustrated and powerless. If the request is granted, the dentist may be plagued by lingering resentment.

The dragon of low hygiene profitability must be slayed if both the dentist and the hygienist are to be satisfied. The added 25 percent production from hygiene based on commission is achieved with a minimal increase in overhead. Most expenses - equipment, rent, insurance, utilities and other staff salaries - remain unchanged. Only the hygienist`s salary and a few pennies for supplies are taken from this extra production to reduce profits.

The ironclad reality that any business must prosper for the employees to do well needs to be understood by all dental staff members. In these competitive times, dentists must comprehend the basic business truth that increased incentive yields increased effort resulting in higher profits. Each member of the team, down to the office cleaning person, must see how his or her economic fate and personal happiness is intertwined with the office`s success. Mutual profitability enhances pay and improves the work environment for all team members.

Creating an office leader

This growth springboards the hygienist into a position of a respected office leader - a person who has demonstrated the ability and earned the right to control his or her destiny. Future goals might include implementing or strengthening a soft-tissue management system; establishing a hygiene-controlled, tooth-whitening program; in-office dispensing of needed electric brushes and fluoride supplements; developing a halitosis center; and designing other practice-enhancing, profit-building strategies that match the interests and personality of the office and staff. Each of these projects will enhance further patient service, while increasing hygiene compensation and office profitability.

Awareness of the now clear relationship between office production and staff remuneration also can result in increased periodontal treatment recommendations from hygiene possibly enhanced by an intraoral imaging system now affordable due to greater hygiene revenue. This type of growth creates a sense of control and personal power, a vital component of personal health and happiness.

Expanded hygiene

Expanded hygiene, featuring two dedicated rooms and a full-time hygiene assistant, is the next logically progressive step and will lead to explosive hygiene and practice growth.

This isn`t the right forum for a detailed discussion of expanded-duty hygiene (a reference at the conclusion of this article will direct you to more definitive information), but let`s consider the benefits such a system provides.

Using two rooms, have an assistant:

- Perform the room set-up.

- Take all needed X-rays.

- Review medical histories.

- Polish, floss and administer fluoride (if the law allows this in your state).

- Review oral hygiene (including any aids suggested by the dentist or hygienist).

- Sterilize instruments.

- Schedule recalls.

- Seat and dismiss patients

In short, have the hygiene assistant do all the fatiguing, nonproductive tasks hygienists usually perform. This will allow your hygienist to treat 12 patients daily instead of the current standard of eight.

With expanded hygiene, each patient receives 80 minutes of staff attention, where before only 60 minutes were available. (Two staff members, working eight hours each, create16 total hours for 12 patients or 80 minutes per patient.) During this valuable added time, information can be provided, questions answered and relationships strengthened.

The practice income benefits in two ways. First, seeing 12 patients daily, rather than eight, creates an additional 50 percent increase in hygiene production beyond the anticipated 25 percent occurring from the switch to a commission form of payment. Secondly, the added care diagnosed from the 20 extra examinations each week (four per day for five days) or 1,000 per year (20 per week for 50 weeks) further enhances office revenue.

The hygienist is freed from many tedious tasks and allowed to perform the special skills her training and license uniquely permit. She is less fatigued at day`s end and her income, based on the percentage of her production, increases an additional 50 percent!

Let me review the numbers from our practice, which is located in a rural section of Iowa where fees are low by almost any measure. This will illustrate the possibilities we are discussing here. Our hygienist and her assistant produce, on average, $120 per hour. That`s $960 per day or $230,400 per year, based on 240 days of hygiene.

The portion of production that becomes the hygienist`s salary depends on the percentage of compensation established previously, using past salary and total hygiene production figures as a basis. While these numbers will vary greatly by geographic location, fee level and office productivity, a realistic range of salaries would be from 20 percent ($24 per hour at $120 production level) to 40 percent ($48 per hour at the $120 production level).

Increased productivity must occur before other positive changes (raises, for example) are forthcoming. To ask for rewards before achievement is akin to telling a fire to give you heat, then you`ll give it fuel. Allow this article to serve as a road map, guiding you and your office to higher levels of service and thus greater rewards of every kind.

Implementation of the above changes results in hygienists, dentists and patients all being better served and rewarded. If the needs of all the parties aren`t met, none will achieve lasting happiness or fulfillment. Working together, we all become more!

Dr. Wilde will be happy to answer your questions and can be reached at home evenings or weekends by calling (217) 847-2816. His first book, Bringing Your Practice into Focus, examines expanded hygiene in detail. It may be ordered by calling (319) 524-8811 or faxing (319) 524-9785.