In Lean Times, Remember the Rule of 33
Recently, I received a phone call from a dentist who was considering cutting one of her hygienist’s hours and instituting an assisted hygiene program. Between her two hygienists, the practice was averaging six cancellations and/or no-shows per day. Understandably, this doctor was extremely concerned. There were a variety of factors contributing to this office’s situation, but “word on the street” is that more than a few practices have seen hygiene holes skyrocket, which makes this a good time to revisit a few of the fundamentals of successful hygiene departments.
In 95% of the practices that McKenzie Management works with, hygiene alone is losing $35,000-$150,000 annually – and that number has likely gone up over the past 12 months. This says nothing of the thousands of dollars in additional dentistry that also disappears, all because patients aren’t in the chair.
To maximize the effectiveness of your hygiene department, follow the Rule of 33. This means that the hygiene department is expected to produce 33% of the total office production, not including doctor's exams. Each hygienist provides 33% of their production in periodontal procedures such as 4910, 4342, and 4381. And the hygienist’s compensation should be no more than 33% of his/her production. If the hygienist receives a guaranteed salary, the expectation must be that she/he produces three times his/her wages. If the hygienist is paid $40 an hour and the cost of the prophy, not including the doctor’s exam, is $80, the hygienist is making 50 cents on the dollar, well above the 33% benchmark. In some cases, fees are too low.
To determine where you stand on the Rule of 33, retrieve the production analysis reports from the practice's management software prior to your monthly meeting and report the results to the team. Next, take a good hard look at recall. Oftentimes when hygiene salaries outpace production, it’s because no one is paying attention to recall. Doctor and staff are lulled into complacency by the appearance of full schedules rather than the reality of last minute cancellations and no shows.
I know that many of you are all too familiar with this scenario: It’s 9 a.m. on Monday morning, and Jane the hygienist is having coffee and perusing the supply catalog because nothing else was on her schedule at this hour. On Wednesday afternoon, she’s organizing magazines in the reception area. Obviously, Jane is not as busy as she should be. And sitting around waiting for patients is every bit as agonizing and stressful for most hygienists as it is for most dentists. It’s time to face the reality of recall. The recall duty is the “red-headed step child” of practice management systems. It is commonly tossed aside, disregarded as a nuisance, and all but forgotten, but it is critical to the financial health of the practice and the financial health of the hygienist.
Part of the problem is that dental offices will blindly rely on six-month scheduling, sending the recall system into autopilot. The lack of accountability typically results in high cancellations and appointment failures. Practices using this technique squeeze out only about 76% patient retention and, if that weren’t bad enough, they have a nearly 50% higher loss of patients than similar-sized practices that do not pre-appoint. The patient base goes down; the overhead goes up.
Integrate a new system. At the next appointment, the hygienist should clearly explain the need for follow-up prophies and exams to the patient. Ask the patient to address the envelope in which their recall notice will be sent. The hygienist writes a personal message to the patient on the professionally written recall letter, noting something specific relating to that patient’s dental needs. Also included in the mailing is an educational brochure relating to the patient’s condition.
If you pre-schedule patients for their six month appointment, the office absolutely must confirm all appointments using not only the telephone but also email confirmation and/or text messaging. Most patients today would much rather receive an email or text message than a phone call. Moreover, they are far more likely to respond promptly if communicated with using these common everyday technologies.
A successful recall system helps patients to secure the dental care they need in a timely fashion – one of the primary responsibilities of your practice. Next week, who’s dropping the ball on recall?
Some Reasons Why Hygiene Departments Don’t Produce
So many hygiene departments are not producing enough income. As a result, doctors are looking for help in trying to find out why their hygiene is not profitable and how can it be fixed. First, let’s look at some of the reasons why hygiene departments are under producing.
The number one reason is that recall is not continuously worked in a systematic way that will keep the hygiene schedule full. If you just count how many hygiene appointments were not filled, last minute cancellations, or no shows in the last month and multiply that by what the average hygiene appointment produces, this will give you one portion of the puzzle. However, the other piece of the puzzle usually has to do with the periodontal side of the production being low. This may be because of the way things were done in the past, i.e., misuse of codes, or periodontal therapy not being treatment planned correctly or on a routine basis.
There was a time when the hygienist would do root planing and then the patient would return in 3 months and be billed as a prophylaxis. Then the patient would continue to return at a 3-month interval, and continue to be billed out as a prophylaxis. Eventually the patient may be referred to a periodontist and the patient may refuse to go. So the hygienist keeps cleaning them as a prophylaxis every 3 months. This is still true in many offices today.
The other thing that has happened in practices is that they learned that the patient should be billed as a periodontal maintenance once they had root planing. The next time the patient came in for what they thought was going to be the cost of a prophylaxis, they were now billed out as a periodontal maintenance and it cost more money out of the patient’s pocket. Now the patient is on the phone complaining and mad at the front office, hygienist, and the doctor because they did not perceive anything different was done and they were billed more for the same procedure, it was just called a different name. This caused a lot of patients to seek treatment elsewhere because they lost trust in the dental office.
Then there are the offices that are probing the new patients and continuing to follow the old way of thinking that only 5 mm or above need to be root planed. So they use the code for full mouth debridement and having the patient return for a prophylaxis in 2 weeks and then come back in 3 months for their continuing care. The problem with this is that the patients that are being billed out as full mouth debridement probably need to be treatment planed for root planning, whether it is one to four quadrants, 1-3 teeth or 4 or more teeth. They are not entering the correct insurance code with the treatment needed.
The code for a full mouth debridement is very specific in its use and I may have seen two patients in an entire year that require this code. Misusing the full mouth debridement code is not doing a favor to your patients, hygienist, or practice production. Using this code is usually under-treating a periodontally involved patient, and makes the hygienist work twice as hard at half the cost that it should be done. It usually costs the patient more out of pocket money also. Many insurance companies will not even cover the full mouth debridement code. Even if they do, it may only be covered once in the patient’s lifetime or it may only cover a portion of the amount.
There is always the concern of the periodontal maintenance being put in the computer correctly and linked to the correct code and months in the future. In many software, if the patient is anything other than a 6 month prophylaxis, you have to actually go in and change the months and put it in as perio. When this is not done correctly, you have patient recall that should be at 3 months set for 6 months. As a result, the patient will receive two less appointments than what they need, and this is two less possibilities in a year that an appointment could have been filled with a patient that needed it. This will add up quickly if not caught, and when they do return, it will be in the computer as a prophylaxis and not a periodontal maintenance. The result - your office will bill it out as a prophylaxis and not a periodontal maintenance, causing the production per hour to be less.
All of the above and more are causes of why many offices are under productive when it comes to looking at the periodontal production compared to overall production of the hygiene department. Thirty three percent of your hygiene production should be periodontal therapy treatment.
Interested in knowing more about how to improve your hygiene department? Email firstname.lastname@example.org.
No Excuses Feedback
What would it be worth if you were able to improve the productivity and effectiveness of every member of your staff? To reduce employee conflicts? To prevent communication breakdowns? To increase practice revenues? To expand the quality of work-life satisfaction in your office?
It would be priceless!
You have two choices: you can tolerate mediocre performance or you can insist on a team that follows your standards and executes on your goals. If you choose the latter, you must start holding your employees accountable.
In coaching dental leaders, I have found that too many do not hold their people accountable. But it’s a leader’s job to provide effective feedback for his/her employees. Constructive suggestions can help them succeed. On the other hand, resisting your feedback may cause them to miss an opportunity to grow and develop within your practice. The key to creating a successful performance conversation is to emphasize what the employee needs to do to succeed, rather than focusing on what has caused them to miss the mark in the past. Here are some examples to illustrate how to improve your communication and overcome resistance and denial.
Jenny is your Front Desk employee. She has a challenging job that entails scheduling, billing, and general reception duties. You have a busy practice that requires her to juggle customer service with detailed tasks. Over the past three weeks, several patients have complained about how Jenny has talked to them. You are concerned about this and schedule a private meeting with her. She makes excuses as follows:
Jenny: “I don’t know what you’re talking about. I’m friendly with the patients”
No one likes to listen to what they're doing wrong, and the words are not that easy to say either. It’s natural that people will react differently to information about their behavior and performance. Remember, feedback with employees can be uncomfortable, but it’s rarely as bad as you imagine. Getting to agreement should take no longer than 20 minutes. Additional time should be scheduled to discuss solutions to the agreement. If you’re still struggling to get an employee to acknowledge the issue at this point, it is time to stop the conversation.
Last but not least, hope for the best but be prepared for the worst. Create messages that avoid inflammatory wording. Anticipate how the employee is likely to react to feedback and prepare for how you will respond. Demonstrate leadership courage. Continue to give effective feedback and watch your people improve - both themselves and your practice!
To assist you in building skills in feedback, read the “Communication Series” Ideas into Action Guidebooks offered through McKenzie Management.
Dr. Haller provides training for leadership effectiveness, interpersonal communication, conflict management, and team building. If you would like to learn more contact her at email@example.com
Interested in having Dr. Haller speak to your dental society or study club? Click here.
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