17 Practice management

Chapter 17

Practice management

Laura Mitchell

David A. Mitchell

Lorna McCaul

Contents


Relevant pages in other chapters Contracts, p. 656; biocompatibility of dental materials, p. 644



Principal sources and further reading The BDA have an excellent range of leaflets covering many of the topics in this chapter. GDC 2005 Standards for Dental Professionals; J. O. Forrest 1984 A Guide to Successful Dental Practice, Butterworth Heinemann; K. J. Lewis 1989 Practice Management for Dentists, Butterworth Heinemann; R. Rattan 1996 Making Sense of Dental Practice Management, Radcliffe Medical Press.


Management skills

Management courses are now big business and certainly worth investing in. They can help in developing systems leading to ↑ efficiency, ↓ stress, and ↑ job satisfaction—for the whole dental team. A happy practice environment is not only more pleasant to work in, but the bonhomie will also be transmitted to patients.

Keys to successful management

Good communication:

Good communication skills are essential not only when relating to patients but equally between team members to ensure smooth running of the practice. Joking about the receptionist’s latest boyfriend (strange though he may be) is not communication. It should be remembered, good communication involves the ability to listen as well as talk. An effective complaints/feedback procedure should allow patients to be able to raise concerns openly (however minor) thereby enabling the practice to learn from the issues raised and improve their service.

Staff meetings:

For teamwork to be successful the opportunity for team members to discuss problems and ideas for improvements needs to be created. Regular structured staff meetings should be planned with an agenda prepared in advance to which all team members should be encouraged to contribute. Patient feedback, complaints, changes in guidance/policies should be discussed. Minutes of the meeting should be kept, recording date of meeting, members present, matters discussed and actions taken. The minutes should be accessible to all team members for future reference.

Delegate:

Delegate tasks that do not require your training and expertise. In addition to ↓ stress and freeing time to concentrate of tasks that do require your skills, this also ↑ job satisfaction for ancillary staff, provided they are given the training and time to cope with new responsibilities; e.g. getting the hygienist to do the fieldwork involved in deciding which new ultrasonic scaler to buy.

Teamwork:

The importance of building a mutually supportive team can readily be appreciated by trying to work in an environment where every-one has been forced to protect their corner. Successful leadership involves encouraging staff to develop their potential both as an individual and as a valued member of the team, and encouraging discussion as to what the goals are to be and how to achieve them. Motivation to work as a team can be fostered by monetary incentives linked to the performance of the practice (see below), but it is wise to find out what motivates individual members of the practice as money may not be the most important factor for all employees.

Staff training:

All new staff members should undergo training in practice procedures and policies. A record of training should be kept. Review of all staff training should be carried out annually and development of further skills encouraged allowing delegation of additional tasks where appropriate. To comply with GDC requirements, all dentists and DCPs must carry out CPD (p. 714). Practice owners should ensure reasonable opportunity is given to staff members to undertake CPD and ensure that skills and knowledge are being updated.

A manual of practice procedures, routines and policies should be kept which is freely available to all staff. All members of staff should be involved in reviewing and updating this information. In-house training days with speakers either from within the practice, or invited, are useful especially in areas such as dealing with emergencies and cross infection.

Dentist and DCPs involved in the taking and development of radiographs should have received appropriate training and have this training updated (p. 720). Documented evidence of appropriate training should be kept.

Pay:

Motivation can often be enhanced by financial incentives.1 Therefore by structuring payment to comprise: 1 a fixed hourly rate; 2 an individual bonus, which is related to attendance, sickness record, and productivity paid as a percentage of the hourly rate; and 3 a group bonus which is a fixed proportion of the profits of the practice; all staff have an inducement to reduce overheads and improve efficiency in the practice.

Hiring and firing staff

Hiring

1) Define what tasks the practice team would like the new member of staff to perform (do not limit possible applications only to Superman). Decide on the criteria for an ideal candidate, as this will aid selection later.
2) Draw up a job description and person specification. Consider including details of the practice, role of the new member in the team, required skills, in-job training to be provided, hours of work, pay, and other benefits. Check with local colleges for availability on dental nurse training courses should this be applicable.
3) Advertise post. Use local press/hospitals/internet/professional magazines. Remember to include a realistic closing date for applications.
4) Short-list candidates.
5) Interview, preferably with two or three people on the panel. This should be structured so that candidates are asked the same questions, to aid comparison. Notes should be made, because after several interviews the candidates may begin to merge! Hopefully a suitable person will be found and they should be offered the job in writing, subject to references, and where applicable occupational health screening including proof of Hep B inoculation, proof of registration and professional indemnity. If no-one is acceptable, go back to 1 and reassess requirements.
6) Draw up provisional terms/conditions of employment; include length of any trial period and how assessment is to be carried out at the end of the trial period (usually 6–8 weeks is long enough). Both employee and employer should retain a signed copy. For non-registered dental nurses apply for a place on a training program.
7) Orientate and train the new member of staff, giving plenty of time for feedback in both directions. Both employer and employee should keep a record of training given.
8) Towards end of trial period reassess. If progress is satisfactory draw up formal terms/conditions of employment (p. 656).
9) Do not discriminate on grounds of disability, sex, race, religion, marital situation, or whether they have children or not.

Always put all matters regarding employment in writing.

The BDA have an excellent advice sheet on recruitment.

Firing

The BDA have advice sheets on dismissal and redundancy and the Advisory, Conciliation and Arbitration Service (ACAS) will also give guidance. Both from a practical and emotional point of view, dismissal of staff is not easy and if taken to tribunal, can be expensive. The Trade Union and Labour Relations Acts allows for dismissal relating to capability, conduct, contravention of the law, retirement, and redundancy.

To prevent a claim of unfair dismissal the practice should follow a set disciplinary procedure:

Investigate any allegations re performance/conduct to determine whether a formal disciplinary procedure is indicated.
Notify the employee in writing of a formal hearing to discuss their conduct advising them of the allegation. The employee should be allowed to bring a fellow employee or union representative to the interview.
At the formal meeting, allow the employee opportunity to give an explanation (e.g. inadequate training) and consider this explanation.
Decide on what action to take:

Oral warning

A note of the oral warning should be recorded. The reasons for the oral warning should be given in writing to the employee. Give the employee a timetable for improvement and advise that this is the first stage of the disciplinary procedure.

Written warning

(first/second/final written warning) that if there is no improvement, dismissal will follow.

Written notice

if the employee fails to meet the requirements stated in the written warnings. The amount of notice should concord with that agreed in the employment contract. The minimum statutory notice required depends upon length of service: <1 month = no notice; 1 month to 2yrs = 1 week, 2–12yrs = 1 week for each complete year worked. >12yrs = 12 weeks.

Instant dismissal

Instant dismissal is acceptable where an action is deemed to amount to gross misconduct. Examples of gross misconduct include theft, breach of confidentiality, breach of Health and Safety regulations and alcohol/drug related incapacity.

Redundancy

is dismissal for reasons other than the personal behaviour of the employee. Statutory redundancy payments are required for staff who have been employed continuously for >2yrs (full or part-time). The amount paid depends upon pay, length of service, and age. Staff facing redundancy are also entitled to paid time-off to look for a new job or undergo training.

Health and safety1

Hazard

Anything with the potential to cause harm.

Risk

The likelihood that someone will be harmed by a hazard.

Risk assessment

A systematic evaluation of what could cause harm (e.g. equipment, chemicals, work activities) in the workplace and ensuring precautions are in place to minimize these risks.

Health and Safety at Work Act 1974

The HSW Act aims to protect employers, employees, self-employed contractors and public within the work environment. Failure to comply with the Act could lead to investigation and prosecution by the Health and Safety Executive (HSE), a statutory body responsible for enforcing the HSW act. The HSE has the power to enter premises (with or without notice) and carry out an inspection. If required they can issue an improvement notice (advising of a time by which compliance must be achieved) or a prohibition notice (closing the premises until compliance is achieved) +/− prosecution. Employees are also expected to take reasonable care for their own and other people’s safety—refusal to comply is grounds for dismissal.

Compliance with the HSW Act requires

Equipment and systems of work to be safe and instruction, training, and supervision to be provided.
Maintenance of practice premises, including entrances/exits, in a safe condition.
Safe handling and storage of potentially harmful and dangerous substances.
All practices employing >5 members of staff to have a written Health and Safety policy.

COSHH

The Control of Substances Hazardous to Health regulations 2002 requires employers to identify all substances (e.g. vapours, microorganisms) in the workplace which are potentially hazardous, and take steps to prevent or ↓ any risks to health. The following procedure is recommended:

Assess the risks to health from hazardous substances. Identify who might be harmed by their use and how.
Identify precautions needed e.g. eye/skin protection, ventilation.
Prevent exposure (e.g. don’t use substance) or control exposure (if preventing use is not practicable).
If >5 employees, make and keep a record of the findings of the assessment.
Ensure that measures to control exposure are used and safety procedures followed.
Monitor exposure and carry out health monitoring when indicated by the initial risk assessment.
Prepare a plan to deal with accidents/emergencies involving hazardous substances.
Ensure all employees are properly trained and supervised.

Mercury (Hg)

Encapsulated amalgam should be used in preference to non-encapsulated. Use should be confined to impervious surfaces where any spillage will be limited, ideally a lipped tray lined with foil. Staff should wear gloves when handling Hg-containing substances. Waste should be stored in a sealed, labelled container containing solution to suppress mercury. Disposal of amalgam/mercury and capsules should be by a licensed person. Documentation/contract relating to waste disposal needs to be kept.

Amalgam separators are a legal requirement for all dental practices to ensure amalgam is filtered out of the main water drainage.

Lead from radiographic packets can be used for absorbing small spillages along with a paste of equal parts calcium hydroxide and flowers of sulfur and water, or a proprietary spillage kit can be purchased.

Latex allergy

Affects ~1% of the population and 10% of health-care workers. The range of latex-free products is ↑.1

RIDDOR

The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (1995) places a legal duty upon employers, self employed and people in control of premises to report

Work-related deaths
Major injuries including any injury resulting in admission to hospital >24hrs unless for observation only
Injuries causing individual being unable to work >3days
Work-related diseases
Dangerous occurrences including explosion of e.g. compressor, inhalation/ingestion substance requiring medical treatment

Reporting of such incidents should be carried out immediately to allow the HSE and local authorities to investigate. For injuries leading to >3days off work a report must be made within 10 days. Reports can be made online at inline www.hse.gov.uk/riddor/online.htm, by post on standard form (from HMSO bookshops), or by phone. A written record should be kept of all accidents in the practice documenting date and time of accident, name person affected and their occupation, nature of injury and how accident occurred.

Cross-infection control

—see p. 718.

Hepatitis B/C:

Dentists are responsible for ensuring that any of their staff who carry out procedures that could bring them into contact with blood (e.g. assistants, hygienists, dental nurses) should be immunized against Hepatitis B. Any health-care worker who becomes e-antigen +ve is obliged to cease practising.

Blood/body fluid spillage

The management of this requires written protocols.— see p. 719.

Display screen equipment

— see p. 708.

Disposal of waste

Under the Environmental Protection Act, dentists are responsible for segregating waste, storing it safely, and arranging for its disposal. Practices should have a policy relating to classification and disposal of waste. Clinical waste for incineration should be stored in yellow containers and disposed of by a registered collector. Non-clinical waste should be stored in black containers.

Employers’ liability

A certificate of insurance must be displayed on the premises. PCTs/Health Boards are now empowered to carry out practice inspections—the above issues are likely to be high on the agenda of any such inspection.

First-aid

The Health and Safety (First-Aid) Regulations 1981 require all workplaces to have first-aid provisions. The practice should be assessed to ensure compliance based on number of people employed and the risks associated with the work. Practices <20 employees should have an appointed person in attendance during practice hours. Practices >20 employees must have a qualified ‘first-aider’. First-aid boxes should be appropriate for the number of employees and level of risk.

Medical Devices Directive

A dental prosthesis or orthodontic appliance is now viewed as a custom-made device requiring a written prescription from the dentist. All dental labs need to register with Medical Devices Agency.

Smoking

Practices should display a ‘no-smoking’ sign at the entrance to the premises. The sign should advise that ‘it is against the law to smoke in these premises’.

X-rays/radiography

see p. 720.

Financial management

Find a good accountant and a friendly bank manager, preferably on the recommendation of another practitioner.

It is advisable to develop a structured system for dealing with fees and estimates, tailored to the individual practice, which is understood and adhered to by all staff.

Delegating

many aspects of calculating and collecting fees, to appropriately trained and motivated staff should make the practice more cost-effective. However, failure to monitor the situation adequately can, at best, result in a false sense of security.

Book-keeping

is time-consuming but necessary. Many book-keeping tasks can be performed by computer, either with an integrated practice management system or stand-alone software. Suggested minimum:

Fees due and fees received.
Bank deposits.
Patient lists.
Record units of activity performed compared to monthly targets. Monitor practice and individual performance and address any imbalance early.
Income/expenditure. Every month compile an income/expenditure record to develop a feel for the financial situation. Suitable ledgers (e.g. Admor) can be purchased from stationers. It is wise to seek the advice of your accountant as to the methodology—accurate accounts will make his job easier (and ∴ cheaper).
Petty cash transactions should be recorded, together with all relevant receipts. The money (<£50) is best stored in a separate locked box. For larger sums a practice cheque can be cashed.
Wages.
Staff absences and sickness records.

Banking:

It is helpful to bank all monies at the end of each day, as the bank statement then indicates the daily takings. To encourage settlement of fees, it is wise to accept payment in any form, i.e. cash, cheque, or credit card. Although credit cards incur a commission, patients with cash-flow problems may be happy to accept this form of payment as a face-saver; then their lack of funds becomes the credit company’s problem. It is good policy to negotiate overdraft facilities in advance to cover those occasions where cash-flow problems arise.

Budgeting:

An annual forecast and budget should be prepared jointly with the accountant.

Bad debts:

These can often be prevented by having a definite Practice Payment Policy which is widely advertised to patients and adhered to; e.g. payment in part at the beginning of Rx and the balance on completion; or payment in full, up front. At the examination appointment patients should be given a written estimate and reminded when payment is due. If a patient forgets, at the last visit they should be asked to sign a form confirming that the Rx has been satisfactorily completed and that they agree to pay (£×) within 7 days. If payment is still not forthcoming, reminders should be sent out at 7, 14, and 28 days. If there is still no joy, consider using debt collectors, but beware of a counter claim of negligence.

Tax:

This is really where a good accountant comes in. By providing him with information on income and expenditure on a monthly basis, he will be able to provide advice on what to do before the end of the financial year to minimize the taxman’s percentage.

Insurance:

Essential for property, contents, equipment, indemnity, staff, loss of income, and personal insurance.

Consumer Credit Act 1974 (reformed in 2006)

requires those extending credit to the public by allowing them to pay for goods/service in instalments to obtain a licence. A licence is not required if the business only accepts credit cards provided by another company, or allows customers to pay bills in <4 installments within 1 yr. For further details, contact the Office of Fair Trading and/or obtain legal advice to assess whether a license is required.

Running late

Running late happens occasionally to everyone, usually when you were hoping to finish early and rush off to do something else. A common reaction is to cut corners, a strategy which can misfire and as a result waste even more time.

If running late is becoming a habit, sto/>

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Jan 5, 2015 | Posted by in General Dentistry | Comments Off on 17 Practice management
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