Early in my career, my boss, a pediatric dentist, taught me a profound truth. He said, “Linda, every child who comes here has one thought in mind while sitting in our dental chair: ‘When can I go home to Mommy?’ ”
As a dental assistant, dental hygienist, and practice consultant, I would say that same thought is on the mind of all patients, no matter what their age. You may have a good relationship with your patients, and they may seem like they enjoy being with you; but, the bottom line is they all would rather be out pursuing their own lives than be in your office having dental work done. With that truth in mind, I want to discuss eight paradigm shifts which improve efficiency in your clinical area, reduce stress, and keep patients in your office for the shortest amount of time while maintaining quality care.
1. Know how long procedures really take. At best, many practices guess about the chair time for procedures. I find that dentists often underestimate the time needed for a procedure because they only think about the time they spend with the patient. Assistants, on the other hand, may overestimate the time required for a procedure because they factor in the room setup and break down, the OSHA compliance steps (which take approximately five to seven minutes to complete correctly), lab work, and sterilization of instruments between patients.
Action Step: Take a twoweek time audit to determine your true chair time.
2. Train assistants in all expanded duties.The most wasteful time in any dental office is the time when the dentist performs procedures that, by law, an auxiliary could perform. The best dental assistants are generally happiest when they are allowed to perform all tasks that the law allows. Many dentists say they are poor trainers. Time to get over yourself (as Dr. Phil says) and solve the problem. Not solving this one makes you a clinical-efficiency cripple and keeps you from having the best team members in your practice.
Action Step: Get a copy of your state law. Have a meeting with each dental assistant to create a training plan. You may want to consider hiring one of the instructors from a local dental assisting school to come in during her off hours to train your assistants. You could ask your lab tech to teach them to make temporaries or pour great models. See if your favorite orthodontist will let your assistants spend time in his or her practice to learn to take good impressions or to pour and to trim models.
3. Shift to a global paradigm of the clinical area. As a consultant, I have found that dentists and staff members either have a global paradigm or a microscopic paradigm. By global paradigm, I mean they are aware of all the patients in the clinical area and have the ability to understand clinical time management for everyone. This may mean having the office manager periodically walk around and help direct traffic to keep things moving. It may mean the dentist has an assistant place a matrix and etch while he or she either checks a hygiene patient or numbs the next patient on the schedule. Too many dental teams are myopic - they only see what is going on in their own chair. They don’t think about how the entire clinical area is moving patients in and out.
Action Step: Have a staff meeting to discuss a global paradigm of clinical time management. Find a person who will volunteer to get this started. Have everyone agree to listen to the “traffic controller.” Come back together in a staff meeting to make any adjustments or to rotate the person who serves as the traffic director.
4. Have the hygienist ready for exams - ASAP. Unfortunately, many hygienists have a “clean the teeth” paradigm. The first five to 15 minutes of the dental hygiene appointment should be focused on assessment of the patient’s condition. All of the following should be completed and ready for the dentist’s exam ASAP:
- Medical history update
- Oral cancer screening
- Periodontal screening
- Restorative screening, including intraoral camera pictures; review as a co-diagnosis with the patient
- Appropriate radiographs to add to the dentist’s ability to diagnose the patient’s condition(s)
- Home care evaluation
Often, a dentist walks into an exam room and the hygienist has not yet taken a radiograph or an intraoral camera picture of a problem tooth (identified by the patient or hygienist). So, the hygienist must take the radiograph, and the patient must wait for the results or, worse yet, a team member must call the patient at a later time to give the patient the results.
Once the assessment is complete, the hygienist has the information she needs to discuss with the patient during the prophylaxis. She is ready for the dentist to examine the patient any time after the first 15 minutes of the appointment. The patient is happy because there is no excessive wait time in the chair.
Action Step: Create your own assessment checklist of what needs to be completed at the beginning of the hygiene appointment. Discuss how the assessments will be communicated to the dentist - i.e., in a talk over the patient, a check sheet for the dentist to view, or a conversation in the hall.
5. Everybody supports efficient hygiene exams.Dental assistants and dentists often dread seeing the hygienists asking for an exam, yet 60 to 80 percent of the dentistry performed in many practices grows out of the hygiene exams. With a new paradigm, the hygienist is interruptible, and the assistant can queue the dentist to go to hygiene when there is a step in the procedure that the assistant can complete (remember, we have trained our assistants to do all the steps they can). The dentist knows when to stop and turn the procedure over to the assistant. Hygienists can signal the dentist once their assessment is complete.
Action Step: Bring the team together to review the suggestions and create a supportive teamwork paradigm to transition the dentist into the hygiene department efficiently.
6. No dull diamonds! I borrow this phrase from Dr. Pete Dawson. Check all equipment and supplies for efficient utilization. Here are a few dull diamonds I frequently see:
• Not enough tray setups to complete a morning of dentistry or dental hygiene. The investment in trays or cassettes reduces stress when someone is out and you can’t sterilize instruments until lunch, or when the assistants are doing their expanded duties and no one has time to be in sterilization.
• Not using disposable burs, prophy angles, impression trays, diamonds, etc. To squeeze one more use out of some items or to have the staff spend time cleaning out old impression material is inefficient and stressful. Even the best sterilization system dulls sharp things.
• Looking for the curing light. Buy one for each treatment room where you do procedures that need the curing light. I see dental assistants and hygienists running down halls looking for THE light.
• Looking for the digital sensors. Again, I see team members running around looking for THE sensors. Each hygienist should have his or her own set. Maybe the assistants can share. Having each hygienist with his or her own set of sensors supports the completion of the assessment early in the appointment.
• Hygienists scraping, scraping, scraping with hand instruments.. The paradigm changed in the early 1990s to support the ultrasonic as the instrument of choice for ALL dental hygiene procedures - recall and perio - for children and adults. The tips and techniques are efficient and well-tolerated by most patients. Also, the air polisher is best for stains.
• Out-of-date sterilization equipment. Use a cassette system with a large-capacity ultrasonic and sterilizer. Loose instruments that need to be sorted onto trays, tiny ultrasonics that hold only a setup or two of instruments, and small autoclaves that have to be run over and over lead to inefficient sterilization processes, staff frustration, and stress.
7. Have an assistant for every chair. Many offices become inefficient and create team chaos with the “extra chair” paradigm. Somehow, a false belief exists that an extra chair magically creates more efficiency. This paradigm brings about time-management stress for practices that follow it. Most dentists (unless you are an orthodontist) are more efficient with two chairs and two assistants dedicated to those chairs - not “rovers.”
The third chair can be efficient if the chair is what I term a “tertiary” chair. A tertiary chair is staffed by a full-time assistant who is highly trained in all expanded duties and can function almost independently. The dentist visits the chair much like he or she does a hygiene chair for exams. The assistant has a schedule for this chair, though not as full as the hygiene chair. The schedule has openings so that the assistant can see any emergencies (see No. 8). As state laws allows, the assistant can do the in-office bleaching, perform the postop checks, apply sealants, or see children for their prophys, thus filling in the afternoon schedule. In one office that implements this paradigm, the tertiary chair produces more revenue on most days than does the hygienist’s chair.
Action Step: Review your current chair and staffing paradigm and discuss the chair utilization in your practice.
8Handle emergencies efficiently. Many practices become totally derailed by emergencies. First, each practice must determine its own philosophy about emergency patient care. Some practices have a community commitment to see all emergency patients. If so, there is a need to reserve time each day for emergency patient care. Other practices have a commitment to comprehensive care for patients and do not see nonpatients of record for emergencies. The philosophy is up to the dentist, and it should be discussed before adopting procedures from one of the following two models:
Model 1 - Set aside a fixed time each day for emergencies. This time may vary from day to day or be at the same time every day. One of the most common complaints patients have about dentists is that they often are “too busy” to see them when they have an emergency. By having a special time reserved for this purpose, you are taking quality care of your patients.
One option would be to designate a half hour in the morning and a half hour in the afternoon for emergencies. Programming this time before or after lunch gives the doctor a longer lunch break and provides the staff with an opportunity to catch up, if no emergencies occur.
Model 2 - Review the schedule every day to determine the best time to schedule emergency patients. The front office staff then can say to the patient, “Mr. Patient, the doctor met with me this morning and told me to schedule any patients with a special need like yours at ____.”
Next, determine who does what for the emergency patient. Often, the dentist becomes involved in a lengthy conversation with the emergency patient. In all states, communication can be delegated to an auxiliary. Dentists can train their dental assistants to educate patients about treatment choices.
The dental assistant sees the emergency patient and prepares the patient for the dentist’s diagnosis. The dentist reviews the radiograph and the patient’s mouth to diagnose the emergency. He or she then leaves the patient with the assistant to explain the options available and to make any financial arrangements. If the patient stays for treatment, it should be worked into an opening in the schedule, not take time away from regularly scheduled patients. If the patient is reappointed, the dental assistant should use a bonding cement to cover the sharp part of the broken tooth, give the patient a prescription written by the dentist, or place a temporary filling.
Action Step: Establish your practice emergency patient paradigm and set up a specific procedure to see emergency patients. Be sure all staff members understand the emergency philosophy and the emergency patient procedure.
By establishing these eight paradigm shifts, you and your team can become more efficient, as well as reduce stress. Take one action step per month and you will see a big difference in the clinical efficiency of your practice.
Linda Drevenstedt is president of Drevenstedt Consulting, LLC, and has developed a process to assist dental practices in reaching their potential. She has been a practice-management consultant for more than 20 years, has been published in numerous professional journals, and lectures at several major conferences annually. She is a member of the National Speakers Association, the Institute of Management Consultants, and the American Academy of Dental Practice Administration. Contact her at (800) 242-7648, by e-mail at Linda@drevenstedt.com, or visit theWeb at www.drevenstedt.com.