Part 1
Duty Delegation
When a man tells you that he got rich through hard work, ask him: “Whose?”
Don Marquis
To schedule patient visits in the office effectively, dentists must decide which procedures various staff members in the office will do. They must schedule each staff member’s time and their own time. Each staff member has a cost and allowable duties associated with their position. Duty delegation means time management. It fits procedures to the appropriate staff position. Dentists are trying to maximize their time by having other people in the office do some procedures or tasks that the dentist could do. They choose to delegate these tasks for any of several reasons, including:
- The dentist has other, more profitable tasks that they could be doing.
- The dentist does not enjoy the tasks and wants someone else to do them.
- A staff member is better at the task or procedure than the dentist.
Everyone in the office (including the dentist) should be busy throughout the day. If not, the office is probably overstaffed, incurring an additional, unneeded expense that decreases profit. To be efficient, dentists need to manage their own time in the office and their staff members’ time. The principles of duty delegation are based on the idea that dentists have additional patients to see or additional work to do in the office. If not, the critical problem is to increase patient visits and decrease costs. Principles of duty delegation therefore become important for the cost‐effective operation of a dental practice.
TYPES OF DENTAL STAFF MEMBERS
Dentists traditionally delegate many tasks in the dental office. They often think only of intraoral tasks when they think about duty delegation. Dentists can direct staff to a broad range of duties that frees their time for other, more lucrative procedures (Box 21.1). They must be sure that the staff member knows how to accomplish their duty and that they are given proper support.
Several types of dental staff members work in a dental practice (Box 21.2). The use of these auxiliary personnel depends mainly on the individual state’s laws regarding what dentists can and cannot delegate to non‐dentist personnel. Their pay rate depends on local market factors (supply and demand of workers), the skills and training necessary for the job, and the certification the job may require. Often one person may serve several functions in the office. Their overlapping roles typically evolve as the practice grows and hires additional staff members. Larger offices usually have more personnel doing more specialized tasks.
CLINICAL STAFF
Mid‐level practitioners have the highest independence. They function between a licensed dentist and a hygienist or other auxiliary who is present in the office. These people may operate independently (without a dentist present). They may do restorative work, prophylaxis, basic extractions, and other common dental procedures. Training requirements and allowed procedures are not standard but are evolving. Often a dentist must be available for consultation or follow‐up care if needed. Some dentists may use these staff members in the office, freeing the dentist to do more complex restorative procedures. Proponents tout them as a solution to the problem of a lack of dentists in underserved areas, mainly rural and impoverished areas. State laws do not commonly allow this type of dental auxiliary, but they are becoming more frequent. This is currently a hot political issue in the dental profession.
State dental law usually allows dental hygienists to do prophylaxis, polishing, and deep scaling on patients, besides taking radiographs. Many states allow hygienists to administer local anesthetic or nitrous oxide conscious sedation if the hygienists have adequate prescribed training and certification. State law describes whether a dental hygienist is subject to general or direct supervision. Most states do not allow hygienists to diagnose intraoral disease, so they generally require some supervision. (A few states allow independent practice for dental hygienists.) They then refer to a licensed dentist for evaluation and treatment of any dental needs that are beyond the scope of their treatment.
Expanded‐duty dental assistants(EDDAs) are the same as expanded‐function dental assistants (EFDAs). Each state is specific regarding what intraoral functions dentists may delegate to EDDAs. EDDAs generally can expose and process radiographs, place amalgam and composite restorations, fabricate temporary crown or bridge restorations, take preliminary or final impressions, and cement restorations. Although some states allow auxiliaries to perform all these tasks, others allow them to do few or none. Some states require formal training and certification for EDDAs, whereas others do not. Depending on the state where a dentist practices, they might delegate a significant part of many routine procedures to these trained auxiliary staff.
Traditional chairside assistants operate chairside, mixing materials and medicaments, passing instruments, and keeping the operating area clean and dry through rinsing and suction. Most states allow chairside assistants to expose and process radiographs if they have had formal training and certification. Formal programs often offer a certificate as a Certified Dental Assistant (CDA) through the Dental Assistants National Board (DNAB). The Commission on Dental Accreditation of the American Dental Association (ADA) accredits dental assisting programs. This shows a higher level of formal training for those who have passed knowledge examinations, and there is an annual continuing education requirement for recertification. Some states require certification, but others do not require this certification to act as a traditional dental assistant.
Many larger dental offices hire someone as a sterilization clerk. Their job is to clean, package, and process instruments for the rest of the team to use while seeing patients. Smaller offices require the dental assistant and often the hygienist to process instruments between patients and during designated times during the day. Although this job is critical to office functioning, it is a low‐skill, low‐training, entry‐level job.
BUSINESS OFFICE STAFF
The number and type of business office staff members depend on the size of the office. As the office sees more patients, it needs more front‐office (business) staff members (Box 21.3). In some offices, these additional staff members share all duties among themselves. More commonly, they specialize and are responsible for specific duties, such as insurance management, account collections, or patient scheduling. This allows staff members more skilled at specific functions to do those functions and decreases those people’s training needs because their jobs become narrower but deeper.
A true office manager runs the business office. One to several business office staff members report to the office manager. The office manager can hire and fire staff, make office policies, and develop operational procedures. There is a continuum of responsibility from an office receptionist to a true office manager.
The office receptionist is responsible for running the business office in smaller dental practices. In larger offices they are often only responsible for patient interactions, telephone communications, scheduling, and computer entry.
Managing patient insurance has become one of the most significant jobs in many dental offices. Even medium‐sized offices will typically assign one person to be an insurance clerk. This person verifies eligibility and finds benefits schedules and benefits used for the year. Although it may not be the dental office’s job, it is often in their best interest to maximize a patient’s insurance benefits.
A bookkeeper is responsible for paying bills and verifying income from the office computer system.
OTHER STAFF
Dental lab technicians fabricate crowns, bridges, removable appliances, and other complex appliances that the dentist cannot easily delegate to clinical staff members. Most dentists have found it easier and more cost‐effective to outsource this function to external laboratories.
LEVELS OF SUPERVISION
Each state has laws that govern the procedures that a staff member may do while in the dental office. Additionally, some states require specific education or certification of different classes of employees. Dentists must know the dental laws of the specific state they practice in, because some states even interpret the definitions of staff differently. (Most state dental boards have a website describing these duties.) However, some general concepts can be applied throughout the nation.
Levels of supervision are critical because they define how much work dentists can have staff members do, freeing the dentists to do other high‐skill duties in the office. For example, dentists can delegate placing and carving restorations and many other procedures if a state allows expanded functions. A dentist with an adequate patient base can have more operatories and staff than in a more restrictive state. Hygienists can give anesthesia in many states, freeing dentists from this task. Some states permit hygienists to operate under general supervision, allowing them to see patients while the dentist is not in the office. Many states are now considering allowing some form of mid‐level practitioner or dental therapist. Depending on the laws regarding the supervision of these paraprofessionals, the dental practice may take different sizes and forms:
- Direct supervision means that the dentist takes full responsibility for the work done. The dentist in the dental office personally diagnoses the condition, authorizes the procedure, and remains in the dental office. At the same time, the staff member completes the procedure and examines the patient before their dismissal. Direct supervision is the most common form of supervision in dental offices in the United States. Many states allow EFDAs to place and carve restorations if the dentist exercises direct supervision. The dentist may inject anesthesia and cut a cavity preparation. The assistant then would place the restoration while the dentist does other procedures in the office. When the EFDA is finished, the dentist evaluates the final product.
- Indirect supervision means the dentist is in the dental office, personally diagnoses the condition, personally authorizes the procedures, and remains in the dental office while the dental auxiliary does the procedure, although the dentist may not evaluate the final product or procedure. As an example, the dentist may authorize a prophylaxis by a hygienist or a lab procedure by a technician. The dentist may remain in the office for the procedure, although they do not evaluate the final product or service.
- General supervision means the dentist has authorized the procedures (often in writing), and the dental auxiliary carries them out according to the dentist’s diagnosis and treatment plan. The dentist does not have to be physically present for the staff member to do the work assigned. For example, in some states a dentist may make rounds at a nursing home and write a prescription that certain patients should have their teeth cleaned by a licensed hygienist. The hygienist may then come to the facility later to do the prophylaxis. Some states allow a hygienist to see patients in the office without the dentist being present. Often this also requires a written prescription. States’ requirements for general supervision vary considerably.
LABOR SUBSTITUTION
In dental practice, the labor cost (i.e. wages and benefits paid to employees) is the largest single expense item. Typically, an individual practicing dentist spends from 25% to 30% of collections to pay staff members. If dentists can decrease this cost, they will see the difference (after substitution expenses) as profit. Two major ways to decrease those costs are to control the number of staff members and the wage rate paid and to substitute other methods for labor. The cost of replacing the labor (over time) must be less than the cost of the labor itself. This results in either decreasing costs or allowing an employee to become more efficient (doing more work), thereby decreasing the cost of hiring an additional employee. Businesses use several common methods to substitute for expensive labor, as listed in Box 21.4 and detailed in this section.
CAPITAL (MACHINERY, COMPUTERS)
Industry commonly uses this method of labor substitution in large manufacturing plants, where machines and robotics have replaced many workers. This involves a higher initial cost but a lower long‐term expense. It is also common in dental practices. For example, buying digital radiographic equipment involves a significant initial cost, but saves staff costs in processing and maintaining radiographic facilities. A new office management computer system (or software upgrade) may allow the existing person to do additional work rather than hiring an additional front‐office person. Other dental examples include purchasing instrument cleaning systems, voice‐activated charting systems, or computer‐aided design and manufacturing (CAD/CAM) restorations.
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