Starting from scratch

Dec. 1, 2009
Dear Dianne, I have been a hygienistg for more than five years now and have always worked in established offices.

by Dianne Glasscoe Watterson, RDH, BS, MBA
[email protected]

Dear Dianne,

I have been a hygienist for more than five years now and have always worked in established offices. I have recently accepted a job with a brand new practice and will be the first hygienist ever hired there. They want me to launch a successful hygiene department, and I do not want to fail. My question is this: Do you have any suggestions or tips that may help me launch a successful program? I have worked with recall systems, but this practice does not have anything implemented because the practice is brand new. Please help!
Kasey, RDH

Dear Kasey,

How exciting it is to be able to build the hygiene program from the ground up! To build anything, you need the right tools. You also need a plan.

Consultants talk about office "systems" within the practice, such as financial protocol, scheduling, public relations/marketing, communication skills, overhead control, etc. The hygiene department protocol is one of those "systems." In my opinion, it is one of the most important systems in the practice, because hygiene typically drives the rest of the practice. A busy hygiene department equals a busy doctor.

One early decision the doctor has to make is if he or she is going to see new patients at the first visit, or if new patients will come through hygiene first. My preference is for all new adult patients to see the doctor first for a comprehensive examination, which includes a thorough restorative and periodontal assessment. The doctor would decide, based on the findings, if the patient will need definitive periodontal care or a regular prophylaxis. Next, when the patient arrives in the hygiene department, you will already have the necessary radiographs, initial periodontal charting, and diagnosis. You can hit the ground running.

However, many doctors with very busy schedules prefer to have new patients seen by the hygienist first. They know hygienists are excellent at gathering data, doing assessments, and educating patients related to periodontal needs. If you see new adult patients first, you will need to perform all the initial assessments and chartings, take any necessary radiographs, and then summon the doctor to confirm your findings. If the patient has periodontal disease, you need to have the doctor deliver the news to the patient and lead him or her toward definitive care appropriate to the patient's needs.

Now, let's address the patients who do not have signs and symptoms of disease. These are your "bread–and–butter" patients who come in at the appropriate interval for routine care. The time needed to treat them should be based on their individual needs. While many hygienists like the traditional "one hour per patient" routine, the fact of the matter is that patient needs vary. Some will need an hour; some need less than an hour. For you (just like the doctor), time is money. I urge you to be realistic and proactive with scheduling. For example, if your patient got a full–mouth periodontal charting and bitewing X–rays today, she will not need those services at the next visit. Therefore, the next visit time can be adjusted as needed.

One of the most important systems in hygiene is recall. I urge you to schedule your patient's next visit at the appropriate interval before the patient leaves the office. This is especially important for new practices when the patient base is being built from the ground up. Some patients will prefer not to preschedule because of the nature of their work or because they are on a one–year cycle. An alert should be entered into your computer system to contact them to schedule at a future date. There are many good ways to communicate with patients, including regular mail, e–mail, telephone, and text messaging. Find out which method of communication works best for your patient.

The business assistant should be providing patients with courtesy reminders of their upcoming appointments. These reminders are not confirmations. The whole concept of confirming an appointment that the patient scheduled sends the message that there is uncertainty on the part of the practice as to whether or not the patient is actually coming. Our thinking should be that when the patient's name goes in the schedule, that appointment is confirmed. There is the expectation that the patient is coming, and there should be no necessity to "confirm" or make sure that patient is coming.

It is important for you and the doctor to be calibrated regarding protocol for the periodontal patient. A written protocol stipulates the course of treatment based on severity. Here is an example of a written protocol:

Type II — Early Periodontitis. Slight bone loss is detected with some pockets in the 4 mm to 6 mm range. Some areas may need anesthesia to scale thoroughly. However, the disease has not progressed to the point of furcal involvement or mobility. Early periodontitis patients will have three or fewer teeth in the quadrant that are periodontally involved. They will require site–specific periodontal treatment. The remainder of the dentition is appropriately treated with a prophylaxis — D1110.

1st visit — prophylaxis for nonperiodontally involved teeth — Code 1110

2nd visit — UR/LR periodontal scaling — Code 4342 (specify teeth)

3rd visit — UL/LL periodontal scaling — Code 4342 (specify teeth)

Type III — Moderate Periodontitis. Bone loss is in the 6 mm to 7 mm range. There is moderately heavy calculus, both supra– and subgingival. There can be furcation involvement and Class I mobility. Depending on the severity and number of teeth present, this type may need anesthesia throughout.

4 visits of quadrant scaling or 2 extended length visits — Code 4341 X 4

Type IV — Advanced Periodontitis. Heavy bleeding, suppuration, and pockets in the 7 mm or greater range. Mobility and very tenacious calculus. Will need anesthesia throughout the entire process. Heavy emphasis on ultrasonics and revisiting each previous quadrant scaled on subsequent visits.

4 visits of quadrant scaling with anesthesia — Code 4341 X 4

Since scheduling is primarily a business office function, keeping the hygiene schedule full typically falls on the business assistant. The task can be daunting if you do not have quick access to unscheduled patients or people available for short notice appointments. I urge you to work with the business assistant to establish a "priority" call list of people who can come in on short notice. It is a poor use of hygienists' time to be on the telephone. Good communication between you and the business assistant is vital in keeping the hygiene schedule full.

Finally, I want to stress to you that your value to the practice is increased when you do these things:

  • Help your coworkers when you have periods of downtime.
  • Be a problem–solver, not a problem–maker.
  • Promote the doctor's restorative services by educating patients with restorative needs.
  • Be serious about the importance of a productive hygiene department to the overall financial health of the business.

I hope these simple guidelines will help you set up your hygiene department and get you off to a good start. The very fact that you wrote and asked for help is a positive sign indicating your commitment to excellence. I believe you will be a great asset to this practice!

Best wishes,