A long fuse would be nice

Oct. 1, 1997
Your day is planned, your patients are confirmed and you leave at night knowing that you have filled the appointment book. Unfortunately, your full day turns out to be lots of activity, many emergencies, but no production. You and your staff end the day frustrated and stressed out. What happened?

Just about everyone agrees that explosions and tantrums are unwanted. So what causes the stress?

Laurel J. Grantham

Your day is planned, your patients are confirmed and you leave at night knowing that you have filled the appointment book. Unfortunately, your full day turns out to be lots of activity, many emergencies, but no production. You and your staff end the day frustrated and stressed out. What happened?

Your office has been hit with one or more "stress bombs." These are the result of poor planning and confused scheduling. By making yourself aware of certain problem areas, you can develop an action plan that will keep the appointment book stable and the office productive. What follows are the most common stress bombs and what to do to prevent them from happening. They should be reviewed periodically at staff meetings and corrective action taken if necessary.

Stress Bomb No. 1

Not scheduling efficiently and effectively.

If the reception room is crowded and you always are running late, you may need to take a closer look at your scheduling process. Running through lunch and leaving late each evening are major stress bombs for the entire dental team. This is one of the top reasons for dental burnout and staff turnover. By using precision scheduling, the appointment coordinator can allow for emergencies and keep the day on schedule. Use the following procedures for nonverbal communication and clarity when scheduling appointments.

Schedule the next procedure indicated on the appointment worksheet in the chart. It should be indicated by a yellow highlighted line. When the procedure is completed, the doctor or assistant then will draw a pink line over the yellow line, which turns the line for the completed treatment orange. All procedures that have an orange line through them have been completed and charged out.

This is a highly efficient procedure for speeding up the checkout process at the front desk. The dental assistant does not need to verbally communicate the next visit to the appointment coordinator. The procedure and time needed should be highlighted in bright yellow on the sheet. (This also is a fast method to determine unscheduled dental work in the files at chart audit time!)

Indicate doctor and assistant time by using a dot (*) for the assistant and a slash (/) for the doctor. Each 10-minute unit should have one of these marks to indicate where the doctor is at all times. The procedure times and sequences should be available from the appointment worksheet in each patient`s chart. By following these scheduling times, you will keep the office productive and efficient. Be sure not to schedule two doctor units adjacent to each other!

Identify appointment-book columns by the treatment room it represents to create a visual plan. Make sure your appointment coordinator is scheduling "actual time," not what you optimistically write down for the next visit. By timing your procedures for several weeks, you should have a better idea of the actual time needed for each individual treatment.

Chain appointments onto each other by overlapping the assistant time in different columns. Begin at the top or bottom of the schedule rather than the middle of the morning or the afternoon.

Learn communication skills that will help you and your appointment coordinator guide the patient into the correct time slot. Remember, you control the book!

Stress Bomb No. 2

Not preblocking the schedule.

Work smarter, not harder. If you do not preblock ahead in your appointment book, you are asking for a roller coaster day with lots of activity, but very little production.

Preblock your schedule first with primary-care procedures (crowns, bridges, root canals, etc.). These services account for 60 to 70 percent of the production and are the building blocks of your schedule.

Plan flex time for you to examine patients. Do not allow the appointment coordinator to create a solid row of doctor time down the column without time for hygiene exams.

Preblock staff meetings, holidays, conventions and meetings, doctor vacation days, etc., one year in advance. Since hygiene appointments usually are scheduled six months in advance, it is crucial to have all days marked out ahead.Mark off one day per month in the hygiene schedule (which should be scheduled six months in advance) to save for unexpected time out of the office.

Ask for feedback from the clinical staff regarding the schedule. They can be a valuable source of help in guiding the appointment coordinator.

Mark off one day per month in the hygiene schedule (which should be scheduled six months in advance) to save for unexpected time out of the office.

Ask for feedback from the clinical staff regarding the schedule. They can be a valuable source of help in guiding the appointment coordinator.

Stress Bomb No. 3

Ask the patient, "When would you like to come in?"

By asking this question, you have just relinquished your control of the appointment book! The schedule has to be controlled or it will not be productive.

Offer the patient two choices, one in the morning and one in the afternoon. If the appointment is during school or work hours, explain that the second appointment can be made later in the day, if that is possible.

Teach your dental team how to use "I" messages and active listening skills to effectively communicate with your patients and each other. These skills are powerful in resolving conflicts and maintaining harmony in the office.

Stress Bomb No. 4

Not having coverage for absent employees.

It always is wise to contact former employees who stay at home or a temporary agency in your area for on-call backup coverage when necessary. The day the office is short-handed is not the time to frantically call around looking for help.

Be prepared. Have all employees cross-trained and ready to step in if your office has an unexpected need. If you have to reschedule patients due to a lack of personnel, you need to rethink your system.

Have a notebook with written instructions for all front-desk operations. If a temporary appointment coordinator should have to fill in, this can serve as a reference tool that she can use to guide her. This will save time and eliminate the need for the clinical staff to answer requests regarding the front desk

Stress Bomb No. 5

Cancellations and changes.

These can kill production and cause chaos in the schedule. Take a tactful, firm, professional (yet compassionate) stand about cancellations and changes. Unless the reason is a dire emergency or a serious problem, communicate to the patient the importance of keeping her appointment. Fear of complications as a result of postponing treatment works well when dealing with difficult patients.

Use prevention. At the initial consultation, be sure you and your staff emphasize the importance of keeping appointments and request a minimum of 24 hours notice for any changes. If you have patients who are not sure of their schedules, ask them if they would like to be put on a short call list.

Review the list of patients who cancel. Are there financial problems? Were they kept waiting too long at their last appointment. Has the office rescheduled them several times? (Rescheduling by the dental office sends a message to your patients that it is OK to cancel.)

Are these patients who cancel afraid of the dentist? Is there a personality conflict with a staff member? Were you or your staff too forceful in "selling" treatment rather than guiding the patient to find value? Were any of the canceling patients emergency patients who were talked into an appointment? Were you too rushed, busy or preoccupied when any of these patients last visited your office?

All broken, no-show and late appointments should be documented in red in the patient`s chart, as well as on the computer. Your office should have a cut-off time after which the patient will need to reschedule. Usually, this is 15 or more minutes into the patient`s appointment, at which point only minimal treatment can be performed. By seating the late patient and running your schedule overtime, prompt patients get the message that your schedule is flexible. It is not fair to the patients who "play by the rules" that the late patients are seen first.

If an unreliable patient truly wishes to have her dental work completed, explain the situation and have her pay a deposit on the next visit. This deposit will be credited to that patient`s account and, if the person does not show, it`s nonrefundable. This is the only fair way to hold time in the schedule and not to have the clinical staff be left "empty-handed.

Stress Bomb No. 6

Patients who forget their premedication.

Prevention is the key! Patients usually do not remember their premedication without a reminder call from the office. A patient who arrives without taking his or her premed kills the schedule for the doctor and the hygienist. Review all charts for the next day and make sure the patient is reminded at the confirmation call. (The word "premed" should be printed in red below the patient`s name in the appointment book.)

Give premed patients a written instruction sheet that explains the medication they are being asked to take and why they cannot be seen if they forget to take it.

Under no circumstances should the office skip the premedication due to a patient`s insistence. No matter how convincing, the doctor must make the patient understand that premedication is critical before any dental treatment that may introduce bacteria in the mouth.

Stress Bomb No. 7

Patients who are not confirmed correctly

In many offices, the appointment coordinator calls the patient on the next day`s schedule, leaves messages on answering machines and never bothers to try to reach the patient directly. This usually results in miscommunication and broken appointments. These can be avoided by using the following guidelines.

Confirm all long appointments two days ahead. If the patient decides to change her appointment, the coordinator has an extra day to fill the time. It is very stressful for the front desk to try to fill unexpected open time at the last minute.

Confirm all appointments early in the morning. Pull charts before calling and make sure the appointment coordinator checks all pertinent information before talking to the patient. (Does the patient need to take premedication, bring in a copayment, insurance form, etc.?)

Make sure the appointment coordinator asks the patient to return the call when confirming. Merely leaving a recorded message does not mean the patient is confirmed. Have the coordinator emphasize that she is waiting for the call-back to make sure the time and date are correct.

Have the coordinator remind patients that the confirmation call is a "courtesy call" and stress that the patient ultimately is responsible for her own appointment.

For the last task in the afternoon, have the coordinator call any patients who could not be reached earlier in the day.

Stress Bomb No. 8

The Emergency Patient.

Emergency patients who are scheduled at a time that delays the treatment of regular patients or who cause an office to reschedule regular patients because of running behind are stress bombs. Emergency patients have a right to receive treatment, but not at the inconvenience of regularly scheduled patients. The appointment coordinator and the clinical staff must establish the correct criteria for a pain emergency (i.e., short exam, X-ray and a P.A. film).

The appointment book needs to be preblocked at the morning huddle, so that the appointment coordinator can schedule the emergency patient quickly and efficiently.

Walk-in emergency new patients should be reappointed later in the day, so that they don`t spend hours in the reception room. If an emergency patient cannot leave work to be seen, it is not a true emergency.

Only a patient of record who calls with a severe "pain" emergency should be looked at as soon as possible. Try to work this person in without inconveniencing patients already waiting in the treatment chairs. If the hygienist has some free time, have her put the emergency patient in her chair and get the X-rays. The patient then can be moved to the first available operative chair and the doctor will have the X-rays available immediately.

Stress Bomb No. 9

Doctor or staff phone calls during patient-care time.

This will not only kill the schedule, but send a message to your patients that you are not focused and concerned about their treatment. The receptionist should take messages so the doctor or staff member can return the call during the lunch break or after work. This is the biggest stress bomb in the day and the one that is the hardest to enforce.

Have a bulletin board put up in the staff lounge or lab and post messages during the day. Unless a staff member is having an emergency, all calls should be returned at lunch or at the end of the day. This also pertains to the business-office staff. Without such a policy, personal calls may take precedence over staff members` daily duties, due to the easy access of telephones.

Stress Bomb No. 10

New patients unscheduled for a complete exam.

You will run behind when there is not enough room in the hygiene room to do a full-treatment plan and make financial arrangements. The hygienist will run behind when her room is tied up during a consultation. The result is a stress bomb!

The appointment coordinator does not have the advantage of scheduling from a completed treatment plan and financial arrangements cannot be made without a complete treatment plan. This is a primary cause of miscommunication with patients. Do not rush through the new-patient process. It will set the tone for the patient`s attitude toward your office. Remember, patients are interviewing you to see if they want to place their trust and confidence (not to mention money) in your practice.

Have a process for entering new patients into your practice. It is for their benefit, your benefit and the hygienist`s benefit. Work with your team to develop a smooth, new-patient exam. Try role-playing the exam to work out any kinks that might arise.

Review all materials that are sent or given to the new patient. Is the paperwork neat and professional-looking?

Do patients receive an informative brochure about the office? Are the instructions clear and upbeat? First impressions are critical. How do yours measure up?

Stress Bomb No. 11

Looking for lost charts.

Lost charts will delay treatment, run the schedule behind and irritate everyone. Legally and ethically, the doctor cannot see a patient without a chart. This means a new chart has to be created while everyone waits. It is a human energy-waster when the office staff goes on a chart hunt or a new chart has to be made.

Make sure all charts are pulled the day before (in the morning), so that a chart can be found if it should get lost. Don`t wait to pull the chart when the patient arrives. If a patient chart should be misplaced, make up a temporary chart for the day. When the original chart is located, transfer the information to the permanent chart. Do not make a duplicate chart. This leads to confusion and additional work when it is time to do the chart audits.

Make up the new patient chart while the patient is present ... do not delay! Do not make up new patient charts until the patient is in the office. If you make up a chart in advance and the patient should cancel and not reschedule the appointment, then the chart is useless.

Stress Bomb No. 12

Inadequately trained. front-desk personnel

Unlike dentists, hygienists and certified dental assistants, there is no formal training school for the business office. Because the front desk is the hub around which the office revolves, it is essential to have experienced, well-trained personnel in that area. Since the doctor and the clinical staff are away from the business desk, it is sometimes a sink-or-swim situation. This is not the place for an untrained or inexperienced person. The doctor must remember that this person is running the business!

Start the new staff member as an "assistant" to a trained staff member for a period of several weeks. This will provide the time needed for the new team member to integrate into the office and become familiar with the guidelines necessary in dealing with patients. If this is not possible, make sure you or your staff give the new front-desk person adequate direction to make the job understandable.

Have a clear "job expectation" list for each position in the office. Review these expectations and update them as needed. Make sure each staff member understands and accepts these expectations. Confused staff members can become demotivated when no one gives them direction or information.

Have a formal training plan for each new front-office person. Make sure front-desk personnel understand dental terminology, insurance procedures and legal-collection tactics. Their actions will reflect back on you as the doctor, because you are the one ultimately responsible for your staff`s actions.

Make sure all staff members are given a chance to attend continuing education courses to advance their knowledge and capabilities. They will appreciate the training, and the doctor will be rewarded with motivated and energized employees.

Stress Bomb No. 13

Moody or difficult team members.

Just as there are no perfect patients, there are no perfect staff members either. Everyone will have a bad day from time to time. The time the office gets hit with a stress bomb is when one team member (and this includes the doctor) decides to make the day miserable for everyone. This can be in the form of a gloomy silence, a temper tantrum or snippy remarks.

Try to remember that everyone has problems, the patients included. No one wants to deal with a sour, grumpy person when sitting in a dental chair. The dental team should treat patients with cheerfulness and conversation, not smart remarks and silence.

If you are upset with a staff member or more than one member of the dental team, you should deal with the situation after hours, not during patient-care time. There is nothing more negative to patients than seeing their dentist berate their favorite dental assistant. They certainly will not feel comfortable placing their care in a professional who does not respect members of his or her own team. Try to temper your reactions and be calm and soothing when patients are present.

Do not attempt to make collection calls if you are having a "bad day." The calls not only will be ineffective, but only will add to your discomfort. Wait a day or so when you can make the calls and be objective and pleasant.

Do any of these 13 stress bombs apply to your office? Try to make a list of problem areas that you might add to the 13 already listed. The more you know about potential stressful situations in your particular office, the better prepared you will be to deal with them. The goal is to have a productive, efficient, unstressed and relaxed atmosphere in which to do quality dentistry on patients who cooperate and appreciate your services.

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