Doctor, is your hygiene department profitable?

Dec. 1, 1996
There`s a lot more to a hygiene department than what it contributes to the bottom line. For example, hygienists can help give patients extra attention, help with patient education and relieve you of having to do prophies in your own schedule. Still, as a practice matures, the hygienist`s contribution to production becomes a significant part of its revenues and expenses. Any practitioner who`s interested in the financial security of the practice has to maximize the profitability of the hygiene de

Here are pointers on how you can improve hygiene profitability and your overall quality of service.

Bill Rossi

There`s a lot more to a hygiene department than what it contributes to the bottom line. For example, hygienists can help give patients extra attention, help with patient education and relieve you of having to do prophies in your own schedule. Still, as a practice matures, the hygienist`s contribution to production becomes a significant part of its revenues and expenses. Any practitioner who`s interested in the financial security of the practice has to maximize the profitability of the hygiene department, just as he/she must with the rest of the practice.

However, most practitioners don`t really manage the hygiene department. Once they hire a hygienist they like, they pretty much say "Hello" to them in the morning and "Good Night" to them in the afternoon (and not much else happens in- between, except for the occasional staff meeting). That`s a shame, because by really leveraging your hygienist`s talents, not only can you increase the hygiene department`s profitability, but also your overall quality of service to patients. The two go hand in hand.

In this article, I`m not going to analyze in detail what the true overhead is in relation to hygiene in a practice. Some advisers will tell you there is no profit at all. This can become an academic enterprise that really accomplishes very little. Wherever you are at now with hygiene profitability, let`s assume you want to improve it. What follows are some pointers on how to do it.

Define Clinical Policies

If I stopped your hygienist in the hallway and asked her, "Quick, what are the doctor`s policies regarding services to patients, such as adult fluorides, sealants, bleaching, cosmetic dentistry, FMXs, perio and crown and bridge?" would she really know? Have you and your hygienist ever defined what you feel is in the best interest of your patients, so she can help discuss these treatments with patients?

Some of the ideas discussed in this article, if taken to the extreme, can be a bad thing and will offend a conscientious hygienist. The problem is that, in most practices, the ideas aren`t discussed. If you look into the items mentioned in this article, you will have a more profitable 1996 and you and your staff will feel better than ever about the treatment your patients are getting.

For example, I ask most doctors and hygienists whether or not they feel adults should get direct fluoride treatments all the time, none of the time, some of the time or rarely. Most providers answer, "Some of the time." Yet, in their day-to-day practice, they rarely are delivering them. This is a classic example of a small-scale service with good long-term benefits, which your hygienist can provide to patients and the practice, but it often is overlooked. If you and your hygienist were questioned in different rooms, would you give the exact same answer to the question, "What patient condition would warrant recommending an adult-fluoride treatment?"

You can ask yourself similar questions about all of the above-mentioned services. You might be really strong in one area, but weak in another. For example, in practices where the hygienists are very active in perio treatment, it can be hard to get their eyes "above the gum line," so they are discussing other treatment matters, too. In this situation, there may be a huge perio production, relatively speaking, and very little happening with crown and bridge.

Speaking of perio, it`s very hard to have a reasonably-profitable hygiene department, if you don`t have a defined perio program. Despite all the seminars and discussion about this over the past 10 years, most practices still don`t have a well-defined perio program. In many cases, perio treatment is being delivered, but is not being called perio or being charged as perio. Not only do you miss out on the additional revenues, but the patient never really "owns the problem," like he/she should for the best long-term response.

One way to check this out is to count the number of exams you do per month and then look at the perio production done through your hygiene department. If your hygiene department isn`t doing at least $10 per exam in perio treatment, it`s not because gum disease does not exist in your practice. Your perio program isn`t really up and running. It`s been my experience that the in-office, perio-consulting programs get the best results.

Another good exercise is to review with your hygienist at least 30 charts of adults recently seen through your hygiene department. Looking at these charts (forgetting about money, insurance coverage and anything but what you feel is in the best interest of the patients), count how many patients are past due for a FMX or panoramic X-ray. There`s a better than 80-percent chance that out of 30 charts, you`ll find at least eight patients who should have had X-rays taken. Think of the lost revenues per month!

So, why isn`t there better coverage? The main concerns your hygienist will have are: (1) There just isn`t time to take them and (2) The patients are afraid of radiation. Both of these problems can be overcome. If you and the hygienist are clear on what`s in the best interest of the patient, use a simple statement such as:

"Mrs. Smith, Dr. Jones and I have reviewed your chart and he has recommended that we take a full-mouth film for you today. This is an important diagnostic tool that helps us to detect potentially serious problems. Are there any questions before we get started?"

I guarantee you that if you just use this phrase, eight out of 10 patients will not have any problem and the others you`ll be able to deal with by respectfully answering their questions and telling them why you feel it`s in their best interest.

You have the time if you want to make it. For example, you can look ahead a day in your schedule and find out who`s due for FMXs and adjust the schedule here and there, accordingly, when you are confirming the appointments...or even better, look ahead a month or so. Or, ask the dental assistant to help out. Where there`s a will, there`s a way!

How about sealants? Again, rather than guessing, I`d recommend that you actually audit 30 or 40 records of children seen previously, to verify that you have good coverage.

Nailing down all the above will take time...but the implications to patient care, revenues and profitability are immense. If you have delivered the above services constantly and each hygienist produces another $50 to $100 per day, almost all it hits your bottom line. It`s well worth taking some time to talk these things over with your hygienist.

Scheduling Appointments

Coverage of additional services isn`t the only thing you can do to increase hygiene-department profitability. The actual scheduling of a hygienist has a big impact, too.

About five years ago, the average hygiene-appointment time length for patients was about 45 minutes. With the advent of more soft-tissue-management programs and OSHA regulations, the times have lengthened. Many practitioners now use a 10-minute book, which is a good idea, since it gives you greater flexibility and accuracy in scheduling the hygienist. In this way, you can take what used to be a 45-minute appointment and allow 50 minutes. And, 50 minutes should be what`s allowed for a standard, adult recall (although I`m sure some hygienists will disagree with me on this). But, by standard adult recall, I mean someone who`s in good shape and has been coming in regularly...not something where you are doing perio, but calling it adult recall or new patients or otherwise more-challenging patients.

It`s not so important that the hygienist thinks of just shorter appointment lengths, but that he/she is customizing his/her appointment lengths. If someone is in better shape, you should schedule less time and vice versa. Sometimes, hygienists and front-desk people lean toward hour-long appointments for adults, not because they need the time, but because it`s easier to schedule.

When you are dealing with 40, 50 and 60-minute appointments, you are more likely to have odds and ends open in the schedule, which can make the person scheduling feel like he/she looks bad. But, it`s those odds-and-ends openings you want to see, because potentially, you could fill them and, hence, have greater productivity. The difference between having 50-minute appointment lengths for a standard-adult recall and 60-minute-appointment lengths is at least a patient a day.

Selecting Your Hygienist

Obviously, the selection of your hygienist is very important. In some markets, it`s hard to find hygiene talent, so you are likely to pick the first person that comes along; but, I urge you not to do that. The truth is that unproductive hygienists are just as expensive as productive ones. Some hygienists are faster, better team players and more flexible than others. By being picky about your choice of hygienists, you can save yourself a lot of hand-wringing and pencil-sharpening when you are trying to figure out how you can get control of your overhead and increase your bottom line. A highly-productive hygienist is well worth top dollar. Whether you are paying a hygienist $22 per hour or $25 per hour doesn`t matter as much as how much he/she produces.

What should be your expectations regarding hygiene hourly production? A rule of thumb that`s been in place a number of years is that hygienists should be producing at least three times their gross salary. In our area, the typical hygiene salary is between $20 and $25 an hour and average production per hour is $65. The range goes from $40 per hour to over $100. Some people are hitting the 3-1 ratio and some aren`t. Do you know what your hygienist`s productivity is per hour? If not, it probably isn`t what it could be.

Hygiene Incentives

What about hygiene incentives? I`ve seen them work beautifully and fail miserably. It`s amazing to see how much more "heads up" a hygienist can be in filling his/her own schedule if he/she is paid a percentage of production...but sometimes, putting a hygienist on a commission basis creates a staff person who isn`t a team player anymore..."I don`t want to attend a staff meeting because I`m not getting any production then." Or, they can actually be too intense with the front-desk people and hassle them because they don`t feel that their schedule is filled enough.

Therefore, I feel, if you are going to go with a hygiene incentive, the best mix is a base salary plus an incent-tive...for example, 25 percent of everything he/she produces over three times gross salary in a given month. In this kind of incentive, the more bonus you are paying, the better ratio you are getting on hygiene production. But, the whole area of incentives can be a very tricky matter and discussion of that is beyond the scope of this article. In short, remember to keep your mind open about incentives.

Contributions to Treatment

Not all of your hygienist`s contributions to practice profitability and well-being are easily measured. The best example of this is the hygienist`s contribution to helping discover and present crown-and-bridge treatment. Almost all of your work is derived from patient exams, and most of those patient exams are recall exams that take place in your hygienist`s area. Your hygienists have more time with your patients than anyone else. Increasingly, the quality of dentistry you deliver is as much a matter of your patients` choices as it is your clinical skills. How much do your hygienists contribute to this process? When you enter the hygiene room and greet the patient, do you ask the hygienist, "What are your findings?" If so, does the hygienist brief you on the following items:

- Any concerns the patient has,

- The patient`s recall prescription,

- The patient`s perio situation,

- Other needs the patient may have (such as crown-and- bridge and cosmetics)

If not, you are missing a terrific opportunity. Not only will this result in more treatment accepted, but it will make your exams go more smoothly. Every patient you see is an opportunity for you and your hygienist to refine your team approach to diagnosis and presentation. Obviously, you have to be the main diagnostician in the practice, but the hygienist can really help by showing the patients likely conditions that will need attention and explaining likely remedies. As we`ve seen in countless practices regarding perio treatment, the hygienists just have to be involved in diagnosis and presentation for these programs to really ripen.

Last, but not least, how good a team player is your hygienist? The first priority of any hygiene downtime should be to assist in recall, confirming or preconfirming their own schedule. Another good use of hygiene downtime is to use it to preview the charts of the patients coming in the following day to make sure that plans are made for recommended adult fluorides, FMXs, seal-ants, etc. If you have more than one hygienist and one hygienist has a cancellation, does she help the other one? It`s not unusual to see a practice where you have two or more hygienists and one of the hygienists is much more productive than the other. When the less-productive hygienist has downtime, is she at least observing the more productive one and trying to pick up a hint or two? Just as you can learn from your fellow doctors, almost every hygienist can learn from another hygienist if he/she keeps an open mind. Indeed, one of the few, nice things about having a turnover in the hygiene department is hygienists often bring a good injection of fresh ideas from other practices, which help keep your practice vital. If you recently hired an experienced hygienist who has worked in other practices, take the time to ask what she has seen and observed through her previous workplaces.

The author has 16 years` experience as a practice-management consultant and speaker. He is president of Advanced Practice Management in Minneapolis, MN, and can be reached at (612) 921-3360.

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