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21st century scheduling

Oct. 1, 2010

Creating a higher standard of care for your patients

by Karen Donaldson, CDA, RDH, BS

Do you still see your hygiene patients in a standardized, pigeon-holed appointment time where everyone gets 45 minutes or one hour? Are you trying to squeeze localized periodontal therapy into a "healthy mouth" appointment? Does your new-patient appointment consist of full-mouth radiographs, blood pressure data, full-mouth periodontal probing, complete dental charting, and a cursory prophylaxis crammed into a one-hour appointment? If you answered yes to any or all of these questions, you need to move your hygiene department into the 21st century!

Many hygienists who have worked in the same office for several years have a good insight into what each patient's needs are for the hygiene appointment. Changing the schedule to reflect these needs could give you more time for the ones who need it and increase your patient load in a more manageable manner. One positive way to make those schedule changes is to utilize new guidelines that the ADA has issued as the recommended standard of care for all dental patients.

The new ADA guidelines for the standard of care includes a focus not only on optimum oral dental care but evaluation of all oral tissues and identifying the correlation of patients' oral and systemic health. If your office has not developed a plan to include this standard of care in the hygiene visit, you need to present one to the doctor to ensure a higher quality of care for your patients and to reduce the stress you are probably experiencing by redundantly seeing your patients in the same allotment of time.

When the hygiene department was first introduced to the dental office as recommended care for patients, the standard of care was very different than it is today. Doctors needed their patients to return before a serious dental problem arose and needed to get patients' maintenance off the doctor's schedule. The usual hygiene appointment consisted of necessary bitewing radiographs, checking for caries, evaluating and scaling supragingival calculus on the lower anterior teeth, and polishing. Thus a standardized time of 45 minutes to an hour was created, and appointments were recommended every six months.

In the past 20 years, research has developed overwhelming information about the cause and effect of periodontal disease and its correlation to systemic health. If we do not approach this evidence-based care when we see our patients, we could be liable for neglecting the level of care mandated by the ADA and ADHA. How can you make this major change in your office? The first step is to develop an action plan. Here are some tips to help you get started.

  • Gather data stating the ADA's standard of care and what is mandated for a new-patient visit and a patient-of-record visit. Current research correlating oral inflammation, periodontal disease, and systemic disease validates the need to recommend and initially treat periodontal disease, and mandates the need for ongoing soft-tissue evaluation and treatment. Take advantage of information that is available on the ADA and ADHA Web sites to present your argument.
  • Evaluate your current schedule to determine how you would have to change it to allow time to complete the more thorough exam and care. Because of today's stressed economy, you may already have holes in your existing schedule that are creating stress for you and your doctor. You can relieve some of that stress with your new plan by lengthening some appointments to implement more thorough care. If you are lucky enough to have a packed schedule, you may need to develop a plan of action to reschedule some appointments, thereby opening up some extended times. Some aspects of your plan may need to be implemented six months from now. If you schedule your own patients in your room, place template blocks in your schedule to hold the necessary appointment lengths for future scheduling.
  • Make a template for each procedure you perform in your room, scheduling the amount of time you need to achieve the standard of care level for that task. Provide a list of all the procedures that need to be included in each type of appointment. Include time to chart data if you do not have an assistant to help with this task. Don't forget to include intraoral photographs to document existing conditions in new patients or to have a photograph to accompany insurance pretreatment authorization forms for procedures such as periodontal therapy, crown and bridge, and cosmetic dentistry due to systemic or traumatic causes. Remember to allow 10 minutes for turning the room, disinfecting, and setup. If you sterilize your own instruments, remember to include that time as well.
    Make sure you emphasize how much periodontal care you are currently giving away in your prophylaxis appointments. Try to provide a dollar amount to emphasize this data.
  • Develop a plan for products already sold or products you would like to sell. In the evidence-based dentistry now being promoted by the ADA, many products are recommended for home-care use. Your office could increase production by offering these products for sale as part of the changes you recommend as you develop a new approach to the hygiene appointment. Use this opportunity to include this concept in your plan, especially if your doctor already offers some products in the office.
  • Create a practice philosophy, shared by both the doctor and hygienist, that works as a partnership for care. When making a major change in the way the office provides care for patients, develop a statement that reflects both a standard of care and a partnership between the doctor and hygiene staff. This will reassure the patient that everyone is focused on his or her optimum health.
  • Provide your doctor with evidence that the new approach can increase the hygiene department production even though fewer patients will be seen. A dental office is a service-based business. This means the business needs to make a profit. Many offices think packing the schedule with more patients can achieve this, but they are wrong. The hygiene schedule can actually produce more when patients are scheduled according to their individual needs.
    When a higher standard of care and evidence-based dentistry is used to diagnose and treat your patients, production will automatically increase. Evaluate how many patients-of-record you see each day who really have isolated periodontal disease that you are treating as part of a standard prophylaxis. If these patients were seen for periodontal therapy that allowed you to thoroughly treat the area, perhaps they would return with a reduced pocket, instead of your doing a quick subgingival scaling while performing a full-mouth prophylaxis and hoping for the best.
  • Evaluate the need for assistance while gathering more detailed data to elevate the standard of care you offer. If you currently document the probe measurements and complete oral evaluation data, you also need to approach your doctor with the idea of having an assistant help with this task. Using an assistant eliminates the risk of cross-contamination while documenting data into a computerized patient chart or even on hard copy paper charts.
  • Present a time frame to implement the new appointment schedule and decide what type of meetings you would need to inform staff members and discuss the plan. Anytime a major change is implemented in the office, it is imperative to have a full staff meeting to introduce the plan, present staff members with their responsibilities, and offer a target date for completely activating the plan. Additional meetings are also needed to follow up, when necessary, to make sure the program continues on the projected path.
    It is highly recommended that the hygiene staff and doctor meet first to determine who should present the plan to the other staff. In some cases, it might be more effective if the appointment book managers also meet with the doctor and hygiene staff to include them in the plan before its introduced to the rest of the office staff. This will ensure a higher level of acceptance to this new idea from the front desk staff.
  • Maintain a goal to continually advance your plan as research and standard of care recommendations change. By making sure you stay up-to-date with treatment modes, products used, and evidence-based knowledge, your plan will always be current and timely for your patients' optimum care. You can also benefit from this approach by including quality continuing education as part of the initial plan to advance your hygiene department toward these new ideas.

Today's economy is forcing us to reevaluate our focus for dental hygiene. Patients are cutting corners financially to make ends meet in these tight financial times. We need to place a higher value on dental care so that patients will see the importance of not cutting this care out of the budget. When we provide an evidence-based standard of care approach and offer individualized care, everyone wins. We reduce our stress level and increase the hygiene department's production while not compromising what we can offer each patient.

This is a positive choice for negotiating appointment lengths and a sure way to guarantee that you always provide a high standard of care while performing the task for which you have committed yourself. This idea can open new doors in a practice you thought had become monotonous, giving you a newfound love for dental hygiene. Moving your hygiene department into the 21st century can provide a win-win solution to getting the appointment lengths you need to work in a low stress environment.

Karen Donaldson, CDA, RDH, BS, has worked as a dental hygienist since 1989 when she graduated from the University of Southern Indiana as a nontraditional student. She graduated magna cum laude in 1990 with a bachelor's degree in health sciences with a geriatrics and social services emphasis. She also holds certification from DANB as a certified dental assistant and has had expanded functions training.