Chapter 15

Maintaining Production

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. Dentists must schedule not only each staff members’ time, but also 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 the use of their time by having other people in the office do some procedures or tasks that the dentist could do. However, dentists choose to delegate these tasks for any of several reasons, including:

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 both their own time in the office and their staff members’ time. The principles of duty delegation are based on the idea dentists have additional patients to see or additional work to do in the office. If not, the key problem is to increase patient visits and decrease costs. Principles of duty delegation, therefore, become important for cost-effective operation of a dental practice.

Types of Dental Staff Members

Several types of dental staff members are found in a dental practice. The use of these auxiliary personnel depends largely on the individual state’s laws regarding what dentists can and cannot delegate to nondentist ­personnel. Their pay rate depends on local market factors (supply and demand of workers), the skill and training necessary for the job, and certification that dentists may require. Often one person may serve several functions in the office. Their overlapping roles often evolve as the practice grows and hires additional staff members. Larger offices usually have more personnel doing more specialized tasks.

Dentists traditionally delegate many tasks in the dental office. They often think only of intraoral tasks when they think about duty delegation. In fact, there is a broad range of duties that dentists can direct staff to do that frees their time for other, more lucrative procedures (Box 15.2). Dentists must be sure that the staff member knows how to accomplish the duty and that he or she is given proper support.

Clinical Staff

Midlevel 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, prophylaxes, basic extractions, and other common dental procedures independently. 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 lack of dentists in underserved areas, particularly 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 for 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 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. So depending on the state in which a dentist practices, he or she 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 Assistants (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, passing knowledge examinations, and annual continuing education requirement for recertification. Some states require certification, but others do not require this certification to act in the role as a traditional dental assistant.

Many larger dental offices hire a person 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 the 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, then it needs more front office (business) staff members (Box 15.3). In some offices, these additional staff members share all duties among themselves. More commonly, they begin to specialize and are responsible for specific duties, such as insurance management, account collections, or patient scheduling. This allows staff members who are more skilled at specific function to do those functions and decreases training needs because their jobs become narrower but deeper.

The office receptionist is responsible for running the business office in smaller dental practices. In larger offices, he or she is often only responsible for patient interactions, telephone communications, scheduling, and computer entry.

Managing the insurance for patients has become one of the largest jobs in many dental offices. Even medium-sized offices will often assign one person to be an insurance clerk. This person verifies eligibility, 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 try to maximize a patient’s insurance benefits.

A bookkeeper is responsible for paying bills and ­verifying income from the office computer system.

A true office manager runs the business office. One to several business office staff members report to the office manager. The office manager has authority to hire and fire staff, to make office policy, and to develop operational procedures. There is a continuum of responsibility from an office receptionist to a true office manager.

Dental lab technicians are responsible for fabricating 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 certain education or certification of different classes of employees. Dentists must know the dental laws of the specific state in which they practice because some states even interpret these definitions differently. (Most state dental boards have a Web site that describes these duties.) However, some general concepts throughout the nation can be applied.

Levels of supervision are important because they define how much work dentists can have staff members do, freeing them to do other high-skill duties in the office. For example, if a state allows expanded functions, dentists can delegate placing and carving restorations and many other procedures. If a dentist has an adequate patient base, he or she can have more operatories and more staff than a more restrictive state. Hygienists can gain anesthesia in many states, freeing dentists from this task. Some states allow hygienists to operate under general supervision, allowing them to see patients while the dentist is not present in the office. Many states are now considering allowing some form of midlevel practitioner or dental therapist. Depending on the laws regarding supervision of these paraprofessionals, the dental practice may take a different size and form.

Direct supervision means the dentist is in the dental office personally diagnoses the condition, personally authorizes the procedure, remains in the dental office while the staff member completes the procedure, and examines the patient before his or her dismissal. The ­dentist takes full responsibility for the work done. For example, many states allow EFDAs to place and carve ­restorations, if the dentist exercises direct supervision. So the dentist may inject and cut a cavity preparation. The assistant then would place the restoration while the ­dentist does other procedures in the office. When the assistant 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 he or she 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 he or she does 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, 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 prophylaxes. Some states allow the hygienist to see patients in the office without the dentist being present. Often this also requires a written prescription. The states’ requirements for general ­supervision vary considerably.

Labor Substitution

In dental practice, the cost of labor (i.e., wages and ­benefits paid to employees) is the largest single item of expense. Typically, a individual practicing dentist spends from 25 to 30 percent of collections to pay staff members. If dentists can decrease this cost, then 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 allows 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 15.4 and detailed in this section.

Capital (Machinery, Computers)

Dentists commonly see this method 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 large initial cost but saves staff costs involved in processing and ­maintenance of 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 CAD/CAM restorations.

Outsourcing

Outsourcing means that instead of hiring an employee, dentists pay another outside company to do the work that the employee would have done. This is especially effective if the work is not a full-time job for someone in a highly skilled position. For example, dentists may hire a laboratory technician to make crowns and bridges in the office, but if the dentist does not do enough crown and bridge cases to keep the person fully employed, then it is more efficient and effective to outsource the laboratory work by sending it to an outside lab. Similarly, the payroll and bookkeeping functions in large offices are often outsourced.

Eliminating Marginal Jobs (Reduction in Workforce)

A common method of labor substitution is to eliminate a staff line (through firings or though attrition). The dentist then assigns that person’s job duties to other people in the office. The work continues to be done but at no additional cost. The down side of this method is that the remaining employees may resent having to do additional work. If the remaining employees were fully busy before, then some part of their job will not be done. So this becomes an appropriate efficiency method if the remaining employees were not fully busy.

Using Lower-Paid Employees

A related technique is to use lower-skilled, lower-paid employees to do the job that higher-paid employees do. This frees the higher-paid (more skilled) employee to do higher margin, more profitable procedures. This is the basis of substituting for dentist time, but it is also applicable to other dental office staff. If two different people in the office can do a job, the lower-paid employee should generally do the job, if the higher-paid employee has other duties that he or she can be doing during the substituted time. Dentists may need to hire a lower-paid employee to do the job. For example, a hygienist can clean instruments and trays. However, if there are enough patients, he or she should see the additional patient, and a lower-paid employee (such as a sterilization clerk) should clean the trays. If there are not enough patients for the hygienist to see an additional patient, then a dentist should not hire the sterilization clerk but should have the hygienist clean trays instead of doing nothing. Likewise, dentists should not hire a hygienist if they will routinely be sitting in their office working the crossword puzzle while the hygienist does the prophylaxis. Many dentists hire high school workers part-time to file charts and do other routine, low-skill jobs, freeing the receptionist or office manager to call insurance ­companies, make collection calls, or arrange financing for patients. Table 15.1 estimates the percent of the ­dentist’s time that a trained and competent staff member could substitute for those procedures in which they are involved.

Table 15.1 Labor Substitution in the Dental Office

EDDA, expanded duty dental assistant

Flexible Staff Time

Using flexible staff time also controls staff costs. Hiring part-time employees instead of full-time employees saves in several ways. Part-time employees may not qualify for employee benefits. Dentists can have them work only peak hours, so that the part-time employees are not “sitting around doing nothing” when the office is not busy. These peak times may occur during the week (Tuesday evenings) or at special times during the year (school holidays or local plant shutdowns). Part-time employees can be hired based on time (e.g., Monday mornings) or based on job duties (e.g., collecting accounts). If more than one employee wants to work part-time, dentists can often allow them to share a job. Job sharing allows the ­individuals flexibility in taking time off for vacations and family issues such as day care. If one employee is present when dentists need them, job sharing can keep excellent employees engaged at the office while meeting their individual time needs.

Principles of Duty Delegation

Before delegating duties and procedures to staff ­members, dentists need to understand the principles of delegation.

Know What the Expected Results Are

Both dentists and the subordinate should have a clear understanding of the expected outcome. This may involve a technical procedure, self-assessment, or interpersonal skills of the auxiliary. There is a line to walk between being a “control freak” who manages every decision and a pushover who does not care the outcome of the decision. With proper training, dentists can let go of the authority to act and follow-up where needed.

Delegate the Authority to Act

Dentists must allow the subordinate to act independently. That implies that the subordinate can decide and act on those decisions without asking the dentist. The dentist sets the boundaries within which the subordinate has the authority to act. However, the dentist must allow and encourage the subordinate to act independently within those boundaries or the delegation will be ­worthless. For example, assume that a dentist wants to delegate to the receptionist the responsibility for ­scheduling emergency patients. First the dentist must decide what constitutes an “emergency” patient (e.g., pain, swelling, hemorrhage). Developing a script for the receptionist to use in determining if a patient is a true emergency helps this. Then the dentist defines rules for how and when to appoint these patients. The dentist must also decide what the receptionist should do when a case does not fit the rules. Finally, the dentist should follow-up with the receptionist to ensure that he or she is acting appropriately within the established boundaries. If the dentist does not let the receptionist act independently in this area, then he or she should schedule all emergency patients.

Dentists Retain Responsibility

Delegating does not mean that dentists are free from responsibility or that the auxiliary has all (or no) responsibility for a bad outcome. Both dentist and the auxiliary share that responsibility. However, because the dentist is the employer and directs the employee to do the task, the dentist is ultimately responsible for the actions or (inactions) of the employee. Therefore, ­dentists must be sure to delegate appropriately to the right person (who has training, abilities, certification, etc.). Dentists must ensure that the work is done ­properly. This means both from a technical standpoint (the procedure is clinically acceptable) and a behavioral standpoint (the auxiliary behaved appropriately while doing the procedure). Whether a dentist delegates an oral prophylaxis on a nursing home patient to a hygienist under general supervision or delegates preliminary impressions to the chairside dental assistant, he or she retains responsibility for correctness of actions of the subordinate.

Use Differential Pay Rates

Different classes of employees earn different rates of pay in the office. This is based on the supply-and-demand considerations of how difficult replacing some­one is. This, in turn, is based on the employee’s abilities, training, and certification (Box 15.5). Hygienists earn more than assistants because hygienists have ­additional training and licenses that assistants do not have. This allows the hygienists to do certain functions in the office (dental prophylaxis) that assistants can not. The hygienist carries a higher financial value. Likewise, an EDDA demands a higher wage in the marketplace than a traditional assistant because they can do more functions. As a rule, dentists should hire at the lowest pay level first, then hire higher pay-level employees as the demand for their service increases.

Delegate to the Lowest Pay Level

For maximum efficiency, dentists should delegate tasks to the lowest level possible. Three factors dictate this. The state dental practice act defines what is legally ­permissible. For example, dentists may not delegate deep ­scaling to someone who does not hold a license as a dental hygienist. Dentists must delegate commensurately with abilities of the staff member. Although delegating placing a composite restoration to an assistant may be legal, if no one has trained them or they cannot do the restoration, then the dentist should not delegate the procedure. Finally, dentists must keep the higher paid employee busy doing higher level tasks. Dentists should not ­delegate dental prophylaxes to a dental hygienist if the dentist does not have other (more ­lucrative) procedures that can be doing during the same time. For example, assume that a dentists’ staff members consists of a hygienist (paid $35 per hour), an expanded duty dental assistant (paid $22 per hour), and a ­chairside assistant (paid $12 per hour). The dentist needs instruments sterilized. Legally, any of the staff can do the procedure. Why pay the hygienist or EDDA to do the procedure, when it can be done less expensively by the assistant? (This assumes that the other staff ­members are doing other, more lucrative procedures.) If a patient needs a scaling procedure, then the dentist can do it or he or she can ­delegate it legally to the hygienist. It is more efficient to delegate, if the dentist have other, higher-value procedures to do while the hygienist is doing the scaling.

Cross-Train When Possible

Cross-training means that a dentist trains a person who holds one job to do the tasks normally done by someone in another job (Box 15.6). Often the replacement will not do as good a job as the original person (because of lack of experience), but he or she can more than adequately substitute for a short time. This is especially useful if a staff member becomes ill or needs to leave work for a time for other reasons. (If the dental assistant can process instruments and the sterilization clerk must leave early, the assistant may fill in.) This helps to avoid paying overtime or using ­temporary employees, both adding to cost in the office. This also promotes teamwork in the office because each employee understands and appreciates other employees’ jobs. A dentist might also find an employee who has hidden ­talents. For example, the dental assistant may have excellent telephone skills and would be interested in expanding his or her duties to include confirming and scheduling patients.

Steps in Delegating in the Dental Office

Dentists should use the following steps to delegate ­procedures in the dental office. Table 15.2 gives an example of a procedure (a two-surface amalgam) and the decisions dentists must make to delegate properly.

Using Delegation in the Dental Practice

Every office delegates some procedures to auxiliary ­personnel. The question usually focuses on the delegation of intraoral procedures, using expanded-function auxiliaries.

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