Th 172304

Hygiene heaven

March 1, 2005
Dear Dianne, During the past few months, it has become increasingly difficult to keep our hygiene schedule full.

Dear Dianne,
During the past few months, it has become increasingly difficult to keep our hygiene schedule full. There is another full-time hygienist besides me, and we’ve both had days with gaping holes in the schedule. I feel bad that my doctor pays me such good wages, yet I have so much downtime in my schedule. I don’t mind confirming appointments and calling patients when I have downtime, but I also do not feel it is my job to keep the schedule full.

Recently, the doctor asked me what I thought about “accelerated hygiene” and working with an assistant. I think he is considering reducing hygiene days for the other hygienist and having me work with an assistant using two rooms. The very thought of that scenario scares the heck out of me! I told my doctor that I would like to give it some thought. It seems to me that I would be working a lot harder and probably not getting any more pay for those efforts, which does not appeal to me in the least! Right now, I am accustomed to seeing eight patients per day (one per hour). Both the other hygienist and I are averaging two to three openings per day, but some days have been much worse. Recently, I had a day where only two people out of eight actually showed up.

If I started using two rooms and seeing more patients, I feel the quality of care will go down. What are your thoughts on “accelerated” hygiene?
Anxious in Atlanta

Dear Anxious,
There seems to be some “busyness” problems in your practice. Believe me, it is not just in your practice. Doctors who used to be scheduled out six to eight weeks solid now find their schedule filled only a week to a few days out.

Several of my clients have noticed a downturn in demand over the past year, which seems to be related to the mass exodus of jobs to foreign markets, especially in manufacturing. My home state, North Carolina, has been especially hard hit by losing thousands of jobs in furniture and textiles to foreign markets. Some companies moved operations to areas with abundant cheap labor. Others simply shut down; others downsized. In all three scenarios, people lost their company-sponsored dental benefits.

A discourse on the pros and cons of third-party dental benefits will not help your current problem, but it does help to clarify what is happening in many areas of the country. Over the past 25 years, company-sponsored dental benefits have become a double-edged sword. On one hand, dental benefits have allowed people to receive much needed dentistry. On the other hand, these same benefits have caused people to abdicate their financial responsibility in paying for their dentistry. They came to feel that, if they lose their dental benefits through job loss or downsizing, they simply cannot afford anything beyond emergency dental care. Sad, but true.

Let’s get back to your problem. The logical thing to do when demand is low is to reduce supply. Your doctor is looking at ways to increase productivity and decrease costs. This is a wise business move. At least for the present, it would appear there are too many available appointments for the number of people seeking preventive care.

Let’s look at the financial realities of your present situation. You stated that both of you are averaging two to three openings per day, with some days literally falling apart. For our example, let’s compromise and say each hygienist has 10 openings per week (that’s two days with three openings and two days with two openings). In a four-day workweek, that would be 20 openings. If the average cost of a hygiene visit is $100 (I’m averaging periodontal and prophy procedures), and you multiply that times 20, that’s $2,000 of lost revenue ... for one week. Then, multiply this number times 50 weeks, and the figure mushrooms to $100,000! That amount is significant for any doctor, no matter what the size of the practice.

I assume you are being paid a salary of some daily or hourly rate. So the doctor is obligated to pay you, even if your production that day is less than your pay. By your letter, I can safely surmise that there have been days when you didn’t even produce enough to cover your salary. No business can survive when costs exceed production over an extended period of time.

The industry standard is that hygienists’ pay should be about one-third of hygiene production. I don’t know where this came from, and I didn’t set this standard. I know hygienists who earn more than this and some who earn less than one-third of their production. You didn’t state your current pay, but said your doctor pays “good” wages. So, I assume you’ve been happy with your pay.

One factor we have not touched on is front-desk efficiency. Maintaining the hygiene schedule has to be someone’s job. I assume that there is someone whose job description includes filling openings in the schedule. There are situations where keeping the hygiene schedule full is not a priority, but it should be. In all fairness, I know of no way to eliminate cancelled appointments in the schedule completely, but the amount of unfilled openings in your schedule is inordinate and requires action.

If the scheduling coordinator simply cannot keep the schedule full because of low demand, then the number of available appointments needs to be reduced, which requires reducing someone’s work schedule. If there is sufficient demand, but the scheduling coordinator does not focus on the task of keeping warm bodies in chairs, maybe the scheduling coordinator needs to be replaced. In other words, the problem has to be clarified and the appropriate strategy implemented to solve it. I feel it is an unwise, unproductive use of hygienists’ time to be calling patients. Hygienists’ time needs to be spent at chairside. (As a footnote, I also feel it is unwise and unproductive for hygienists to be relaxing in the staff lounge with a magazine when there are unfilled openings in his or her schedule!)

So far, we’ve looked at the “busyness” problem and the two possible reasons for having an inordinate amount of unfilled time in the schedule, such as low demand for services or inefficiency at the front desk. Now, let’s talk about solutions.

First of all, I’d like to throw out the term “accelerated” hygiene, which conjures up unpleasant images of a frenetic pace with the hygienist running from room to room like her lab coat is on fire. The very word “accelerated” means everything is suddenly thrust into high gear and moving faster. When we speed up in order to cram more patients in the schedule, quality of care issues are sure to surface.

However, a different model of practicing dental hygiene emerges with “assisted” hygiene. There is a vast difference between assisted hygiene and accelerated hygiene. The primary difference is that many of the tasks that occur during the appointment are performed by a qualified assistant. Here is a list of procedures that commonly occur during a typical hygiene appointment:

• Set up operatory
Review patient record
• Seat patient and greet patient
• Take blood pressure
• Review medical history
Oral cancer screening and head-and-neck exam
• Expose any necessary radiographs
Inquire about dental concerns
• Plaque control and oral hygiene instructions
Discuss dental needs
Periodontal charting
• Signal and wait for doctor
• Dispense oral hygiene aids
Record areas of caries or other pathology
• Relate concerns to doctor
• Make patient’s next appointment
• Document in patient chart (computer) all observations, patient comments, and future treatment recommended
• Perform aseptic techniques in operatory, prepare instruments for sterilization
• Set up operatory for next patient

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If we look carefully at these 21 tasks, it is easy to identify certain tasks that could be delegated to a qualified assistant. Of all the above tasks listed, only ones identified with the larger, golden bullets require a dental hygienist. Yet, hygienists spend vast amounts of valuable time performing tasks that could be delegated.

A true assisted model in hygiene works like most doctors work. The doctor’s time, which is the most valuable thing he or she has, is spent doing things that cannot be delegated. Think of how productive a doctor would be if he or she had to process all the contaminated instruments, do all the operatory setup or teardown, etc. If the doctor performed all those tasks, productivity would be greatly reduced. The same is true for hygienists.

If we could design the perfect hygiene environment, it would be like this:

You never have to wait on the doctor to check your patient.

You never have to clean up or set up your operatory.

Someone takes the necessary radiographs for your patients.

Someone is always available to help with periodontal chartings, suctioning, and assisting with sealant procedures.

You never have to schedule continuing care appointments or dismiss your patient, because someone else does that.

Does this sound a little like “hygiene heaven?” Practicing assisted hygiene is like “hygiene heaven” to me. It is a much more pleasurable way of practicing. I could see 12 to 13 patients in an eight-hour day and be less tired at day’s end than when I saw nine in a solo model. Give me assisted hygiene any day over solo hygiene!

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However, there are some prerequisites for assisted hygiene to work. First, there must be two operatories that are equipped alike. Second, the assistant must be dedicated to work with the hygienist only on those assisted days. She cannot be shared, except if downtime occurs. Nothing will sabotage assisted hygiene faster than when the doctor hires an additional assistant and expects that person to help doctor and hygienist simultaneously. Third, the assistant must be organized and have a thorough understanding of what her job is. Fourth, the hygienist must see the assistant as her strong right arm and not her “flunky.” No egos are allowed! Finally, the schedule must be controlled and not overbooked.

As for production, I’ve seen productivity increase anywhere from 33 to 50 percent with an assisted model. It is easy to move from seeing eight patients per day to 12 patients per day with an assisted model. Most reasonable doctors are willing to share the increase in profit with increased pay, often with a bonus incentive over a set production goal. Even if my doctor didn’t pay any higher wages, I’d still rather practice dental hygiene with an assistant than without, given the choice.

As you can see from our example in the sidebar, there is the potential for greater profit with the assisted model. Profit aside, my advice for you is this: If you get the opportunity to do assisted hygiene, go for it! You’ll never know if you like it or not until you try it. If all the prerequisites are in place, you will probably find that you enjoy your work more than when you worked solo!

Dianne D. Glasscoe, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe for speaking or consulting, call (301) 874-5240 or email [email protected]. Visit her Web site at