CHAPTER 29 Practice Management
The practice of modern dentistry requires delivery of quality care combined with adherence to excellent business principles. Dentists traditionally trained in the art and science of dentistry must also become skilled in techniques of sound business management. Today’s practitioner must be clinically astute and knowledgeable about all aspects of managing a small business, consumer needs and demands, government regulations, and third-party participation—aspects of dentistry not often addressed thoroughly in the clinical setting of dental school.
The transition from a role of dental student or resident to business owner and manager is an enormous challenge. That transition often begins when the young dentist enters practice and suddenly realizes that dentistry encompasses more than clinical and technical competence. A successful dentist must be concerned with many management concepts, including leadership, delegation, interpersonal relationships, personal style, community image, and time management, as well as the day-to-day operation and fiscal management of a business.
The primary responsibility of a dentist is to provide quality patient care. However, private practice—and, in today’s environment, many school, hospital, and government dental facilities—like any other business, must make a profit to survive. The practitioner must maintain a balance between patient care and business requirements while keeping moral, ethical, legal, familial, and professional responsibilities in proper perspective.
While maintaining this balance, a pediatric dentist must provide a place where children can feel safe, loved, and well cared for; where parents can be educated about how to help their children have a lifetime of good oral health; where the staff know that they are an integral part of the practice, that they are important and appreciated, and that their opinions count. Furthermore, the successful pediatric dental practice is one where other practitioners and health care providers choose to refer patients or call for information concerning young people’s oral health issues; where the community as a whole knows, respects, and appreciates the practice; and where needed changes can be made in any area with better, innovative ideas and methods endorsed and implemented.
Every new dentist begins practice expecting to be successful. Those satisfied with their level of achievement after several years realize that a successful dental practice is composed of three systems: personnel, patient, and operational.
A personable, professional staff is vitally important for practice success. The dentist must invest time, effort, and money to hire, train, and retain quality individuals who can be developed into a team. A team of committed professionals, working together, focused on the patients and the practice, can make the difference between an excellent and a mediocre practice. Therefore, staff development is a sound investment in any practice.
Before becoming an employer, the dentist must be aware of state and federal regulations concerning hiring; employment policies, including Occupational Safety and Health Administration (OSHA) requirements; employee records maintenance and retention; employee discipline and dismissal; and so on. All employment applications, other forms and tests used in the hiring process, and employment policies described in the office manual should be reviewed by an attorney for the practice who is familiar with state and federal laws.
The number of employees in a dental office varies according to the type of practice and patient volume. Pediatric and orthodontic practices usually require more team members than other types of practices.
Initially, the new practitioner may need to hire only one or two staff members. If only one individual is hired at first, a second employee should be added when patient flow increases to the point that this person can no longer assist at the chair and handle the business desk (e.g., collect fees, make appointments, answer the telephone by the third ring, prepare and mail statements on time, and pursue broken appointments). The first employee, who is already knowledgeable about scheduling and practice flow, may move to the business desk. The second employee may serve as a full-time clinical assistant.
The third office employee may be a second clinical assistant or a dental hygienist. When the dentist treats hygiene patients more than 8 hours per week and the state practice act limits the performance of some hygiene duties by a certified dental assistant, a hygienist may be hired. This will allow the dentist to concentrate on other treatments and procedures. Depending on patient volume, the hygienist may be full time or part time. Other employees may then be added as needed.
Additional help may be gained through the use of part-time employees. These employees may job share, a term used to describe the splitting of a full-time position between two people, or a position may need to be filled only part time (i.e., a few hours per day or week).
The business of managing and administering a dental practice has become complex and time consuming for the dentist, even with a well-trained staff. Some larger dental practices now hire well-educated, trained practice administrators. “The key responsibilities of a Practice Administrator could be compared to those of a Chief Executive Officer (CEO) of any corporation1:
Once a practice administrator is on staff, the doctor’s position becomes similar to that of the chairman of the board of directors of a corporation or company, a major policy voice as well as owner of the right of refusal or veto authority. In some cases, several practices may share the services of a practice administrator.
Two of the key positions in a practice with several staff members may be a Clinical Coordinator and a Business Coordinator. A Coordinator is an experienced senior staff member who shows leadership skills and enjoys using her or his initiative. The following outlines may be edited to fit the need of any office.
Every office has a myriad of duties which must be completed on schedule but may not fall into one specific category. The schedule for every office may be different, but among these collateral duties are the following.
Mastery of the interviewing process is difficult but necessary. Hiring begins with attracting well-qualified applicants. Potential employees may come from personal recommendations made by current staff; area technical schools, colleges, and universities; or classified advertisements.
Interviewing becomes easier and more enlightening with repetition. The more opportunities an interviewer has to conduct interviews, the smoother and more productive the sessions. Use of a set of interview questions standardizes the process. These questions should explore the following traits: initiative, organization, conscientiousness, effective communication, ability to work well with others, technical or business training and experience, and the ability to apply previous training and experience to the job. If questions are skillfully posed, an applicant’s answers will indicate strengths or weaknesses in these areas.
Two of the most desirable traits in a dental team member are (1) a warm, empathetic personality and (2) cognitive ability, defined as aptitude for learning and capacity to draw from past experience in new situations. Several excellent instruments are on the market to measure cognitive ability and various aspects of personality and behavioral style (e.g., Cognitive Ability Testing Instrument — Wonderlic Personnel Test, Wonderlic, Inc., Libertyville, IL, www.wonderlic.com; Personality and Behavioral Style Instrument — DiSC Classic [Personal Profile System], Inscape Publishing, Minneapolis, MN, www.inscape.com.)
To maximize efficiency, a well-trained staff member may conduct the first interview. If the candidate is promising, employment tests, a tour of the office, an introduction to other staff members, and a brief conversation with the dentist should be a part of the first interview. References should be checked between the first and second interviews.
The second interview should include a longer conversation with the dentist and office observation or work time. The dentist should pay the applicant for time spent observing and/or working in the office. Inviting the prospective employee to work in the office for a few hours allows staff members to form an opinion about the person’s potential. Likewise, the applicant will better understand office ambiance and patient flow before accepting the job.
Although the final hiring decision rests with the dentist, it is a good idea for certain key staff members to concur. Current employees significantly affect the success or failure of a newly hired staff member because they help train and interact closely with him or her.
An offer may be made after the working interview. If the applicant will not be hired following the first or second interview, he or she may be told at that time or notified by mail within 1 week of either interview. If an applicant is rejected, maintain all applications, test forms, and other paperwork for at least 1 year in case a complaint concerning unfair hiring practices is filed by the rejected applicant.
If testing is part of the application and interviewing process, testing must be standardized, that is, all applicants must be given identical tests. If an applicant is hired, all interview and employment records must be kept for the duration of employment plus 30 years. Employment records and employee medical records should be maintained separately in identical folders or binders and kept in a locked file or kept off site by the dentist.
If the applicant is to be hired, the dentist should offer the job using the term full-time or part-time employment and should avoid using the word permanent, either orally or in writing. Use of the term permanent connotes continuous work with a contractual understanding, regardless of problems that might develop later. If dismissal should become necessary, the employee might claim wrongful dismissal if promised permanent employment.
In The One Minute Manager, a book long-favored by business managers, Blanchard and Johnson wrote, “Most companies spend 50% to 70% of their money on people’s salaries. And yet spend less than 1% of their budget to train their people. Most companies, in fact, spend more time and money on maintaining their buildings and equipment than they do on maintaining and developing people.”2
A new employee must be made to feel welcome and a part of the team. Orientation on the first day of employment and a written training schedule to be followed the first 6 to 8 weeks should be part of this process.
The most effective way to orient new employees is to follow a checklist, which ensures that each new staff member will receive similar information. Fig. 29-1 is an example of an orientation checklist for new employees.
Orientation should include a review of the office manual. An up-to-date office manual (policy and procedural manual) can prevent misunderstandings with current and new staff members and reduce training time for new auxiliaries. An office manual outlines the duties, obligations, and mutual expectations of the employee and employer, and clarifies office policies, employment procedures, benefits, training methods, and office paperwork. Preferably, the dentist writes the manual with input from experienced senior staff members. Prototypes of office manuals are available in print or in software versions to assist in the process. The attorney for the practice should review the manual before implementation.
A training/benefit waiting period may be the first 60 to 90 days of employment, during which time the dentist determines whether there is a match between office needs and a new employee’s skills and personal style. Use of the term training/benefit waiting period rather than probationary or trial period connotes the importance of performance to the new employee, emphasizing that this is considered a time to work diligently, to strive to learn as much as possible.
Much of the responsibility for training new employees can be delegated to current staff. A well-trained veteran staff member may become a Training Coordinator, available to instruct the new employee, answer questions, and check progress. Although one person may efficiently coordinate training, all other team members and the dentist should be involved in the process also. Additionally, the Training Coordinator can maintain training and continuing education (CE) records for the entire staff, thereby assuring CE requirements for licensing recertification are fulfilled.
In the most successful practices, the dentist and team members realize that training is an ongoing process; dental professionals continue to learn about new methods and materials in order to better care for patients and maintain professional licenses. Attendance at CE courses, review of current literature and journals, and group study using audiotapes, DVDs, CDs, and so on are appropriate for continuous training. A portion of each staff meeting can be used for additional training and discussions of new treatment methods and materials. Also, the establishment of an office library makes books, journals, and audiovisual aids easily available to all team members. Learning together strengthens a dental team and encourages pride in personal and professional growth.
Wage and benefit administration is an aspect of practice management lacking clear-cut rules and guidelines. Therefore, many dentists find it a particularly difficult task. There must be a balance between managing payroll costs, sharing practice income and profits equitably with staff members, and maintaining careful control of expenses.
The most successful dentists and managers set high standards for their practice, including top-notch performance and productivity from all team members. In return, these dentists compensate team members well, sharing increased profits with staff members who helped produce the growth. As a result, auxiliaries realize that the better the practice does financially, the better they will do. They also understand that if the practice has an unproductive period in which production, collections, and profits decline, raises and some other benefits may be delayed. Benefiting from growth and increased profits or, conversely, experiencing the pinch of fiscal decline allows auxiliaries to feel responsibility toward the practice that they might not otherwise sense.
Employees receive more than wages; net pay is only one part of a complete compensation package. Although higher take-home pay with fewer benefits may attract some employees, fair wages with expanded benefits generally help retain team members. Each employee should be given an annual total compensation statement listing gross wages, employer-paid taxes, and the dollar value of benefits such as vacation, personal leave, insurance, uniform allowance, and free or reduced-cost dental care. Fig. 29-2 is an example of an individual total compensation statement. Receiving an actual statement of wages and benefits lets employees perceive their full value. The dentist should communicate to staff members how valuable they are to the practice rather than how much they cost the practice. Although it is a subtle difference, such phrasing can boost staff members’ professional pride, dedication, and loyalty to the practice. Auxiliary personnel who are made to feel valued and appreciated are generally more productive than those told what they “cost” the practice.
Wage and benefit administration requires careful planning. A comprehensive salary plan helps retain employees by offering salaries commensurate with community wage scales. It also allows the dentist to evaluate relative pay among employees and to review wages and benefits in a timely and organized manner. If planning is neglected, a dentist may give raises that are too large or too frequent or, conversely, forget about salary reviews for an extended period. The former condition results in excessive wage costs; the latter may cause good employees to quit. A common problem expressed by many dentists in practice for 15 to 20 years is that a long-term staff member’s total compensation package is excessive. The young practitioner can avoid this problem by establishing a salary plan.
To begin a salary plan, the dentist first lists the staff positions in the office, including business positions (e.g., receptionist, scheduling coordinator, patient accounts coordinator), and clinical positions (e.g., clinical assistant, hygienist, sterilization/laboratory assistant). The relative worth of each position to the practice is determined using the following questions:
The dentist should survey similar jobs in other practices in the area to determine minimum and maximum pay ranges. The survey might also include similar businesses such as other health care offices, law offices, banks, and real estate firms. In summary, wages should be commensurate with the community standard and an employee’s value to the office.
Salaries should be evaluated at least yearly; raises are based on merit (positive behavior and work deserving praise), increases in cost of living (inflation), and the overall economic status of the practice.
Pediatric dental practices often employ more personnel than general or some other specialty practices because a number of patients may be scheduled simultaneously, and many children cannot be left alone while in the treatment chair. Generally, labor costs in pediatric dental practices, including payroll taxes, require about 22% to 26% of gross collections. Benefits may add another 2% to 5%, closer to 5% if a retirement plan is funded.
Fair salaries and good benefits are necessary to avoid job dissatisfaction; however, salary and benefits do not necessarily motivate an employee to perform better. Motivated staff members are most often those to whom responsibility is delegated. Their personal and professional growth is encouraged and recognized by the dentist. They are appreciated and told how valuable they are to the office, the dentist, and the patients. In short, motivated staff members are recognized for the contributions they make to the practice, and money is only one way appreciation is shown.
Potentially effective staff members are often dismissed because of poor job performance, which may be the result of the dentist’s failure to define expectations. Employees can be expected to perform optimally only if requirements are clear. Team members must know what they are expected to do, how to do it, and what the criteria are for an acceptable or, better yet, outstanding job performance.
The purpose of performance reviews is to recognize past growth and accomplishments while setting new goals and standards of achievement. Periodic performance appraisals allow the dentist and team members to evaluate personal attributes, job strengths, and areas to be improved so that goals for personal and professional growth can be set. Appraisals should be honest but positive, resulting in better job performance and improved efficiency.
Each staff member should be evaluated according to similar criteria, including competence in performing tasks, work habits, contributions to the team, and behavior toward patients, coworkers, the dentist, and the office. Nebulous topics, such as attitude, poor mannerisms, or personality conflicts should be addressed by listing specific examples of positive or negative instances involving the person. Evaluation forms that can be completed by the staff member and dentist are helpful but not absolutely necessary. Simple notes about strengths, growth opportunities, and the employee’s needs as they match or conflict with the needs of the practice are sufficient for the evaluation conversation. Discussing the staff member’s opinion of his or her own performance often makes the appraisal more meaningful. Performance appraisals should be given regularly to improve job performance and encourage personal growth. An appraisal should be given after completion of the training/benefit waiting period and at least annually thereafter. All appraisal forms and notes should be dated at the time of the appraisal and signed by the dentist and the auxiliary. If the auxiliary refuses to sign, the dentist should so note on the form.
Job skills and work performance should be reviewed separately from salary. A conversation that combines performance review with news of a raise interferes with the staff member’s concentration. An employee may be so interested in hearing about a salary increase that setting goals for performance improvement is relegated to a secondary level of importance.
During the review, strengths should be enumerated first. People listen better when they feel that the appraiser recognizes their strengths rather than only their deficiencies. Use of the term development areas or opportunities for growth rather than weaknesses when discussing areas to be improved connotes positive potential.
Most people respond best when asked to concentrate on no more than three or four areas for development. Hearing about more than three or four points to be improved is overwhelming and may delay the employee’s responsiveness and improvement.
The dentist may offer to help the employee improve in certain areas through additional training, CE courses, and such, thereby giving the staff member a sense of support. The dentist and staff member should agree on realistic goals to be met by a certain date, with regular discussions during the interim to evaluate progress and establish other objectives.
Personnel records are important documents. They are a history of the employee-employer relationship, just as a patient’s chart is a documentation of the patient-dentist relationship. If a problem arises with an employee (e.g., a charge of wrongful dismissal in case of termination), the record will serve as proof that the dentist correctly discharged employer responsibilities.
Records, including job application, interviewing notes, testing forms, performance appraisals, wage and benefit information, training records, unsafe incident logs, and so on, should be maintained for the duration of employment plus at least 30 years following an auxiliary’s departure. Records for OSHA-mandated training must be maintained from the date the training occurred and must include dates of training, contents of the session, and the name and qualifications of the trainer. Check with your state OSHA office for information concerning the number of years that these records must be maintained. Medical records must be maintained in individual locked files separate from other personnel records for the duration of employment plus 30 years and include all appropriate forms with pertinent data.
Personnel records for all employees should be identical in appearance, consistently maintained, and kept confidential, preferably in locked files. A comprehensive employee record could include the following:
Dismissal of an employee is one of the most difficult tasks a dentist may face. Whereas interviewing becomes easier with experience, firing someone does not. There are, however, processes that can make a dismissal less stressful.
Dismissal usually happens because of incompetence in job performance or unacceptable behavior such as patient abuse, sabotage, theft, harassment or substance abuse on the premises. Problems arise often when an employee loses interest and, therefore, effectiveness and/or efficiency in her or his responsibilities. Behavior and performance problems must be addressed; simply ignoring the situation will not make it go away. The dentist and staff member should discuss the problems and ways they can be rectified. After an initial discussion with the employee, it should be absolutely clear to the employee that improved attitude and/or job skill is a requirement for continued employment. The employee and dentist should sign and date notes from the initial and subsequent meetings. A specific date by which behavior and/or skills must improve should be set with the dentist and the staff member meeting frequently in the interim to assess improvements.
When coaching an employee who is trying but is incompetent, a combination of the following procedures may be used. The dentist should write a description of acceptable performance criteria, including skills needed for the job. It is more effective to name specific characteristics and skills needed for the particular position than to enumerate only negatives; i.e., what the person is not doing. The goal is to have the staff member understand the requirements of the job, the ways that she or he fails to meet them, and ways that expectations can be fulfilled.
The dentist then establishes a time frame for improvements; between 1 and 3 months is usually appropriate. The auxiliary and the dentist should discuss, sign, and date the agreement about performance improvements. The dentist should review progress with the employee each week, making notes of these discussions in the employee’s record. If the employee reaches the goal of acceptable job performance within the time allowed, new goals should be set. In this way, a staff member can be coached into continuously improved performance.
If an employee will not or cannot improve behavior or achieve required skill levels, dismissal will probably be necessary. In the dismissal conversation, failure to meet performance improvement may be discussed. The dentist must try to dismiss the person without causing anger and resentment. Although the employee’s skills do not match office needs, often the person can leave without negative feelings if the dismissal conversation is conducted properly.
If an employee is behaving in an unacceptable way (e.g., consistently arriving late, abusing sick leave, or breaching confidentiality requirements), a serious warning may rectify the problem. If an employee is given serious disciplinary warnings before dismissal, the dentist should put the warnings in writing and include a statement to this effect: “Continuation of these actions by this employee may lead to disciplinary measures, up to and including dismissal.” After this statement is explained, the employee and the dentist should sign and date the statement, and it should be retained in that individual’s personnel file.
If an employee refuses to sign and date notes from any discussion, the dentist should so note on the statement and sign and date the document himself/herself. Such a note is an acceptable record that the discussion occurred.
In most states no notice is necessary for dismissal related to unlawful behavior such as stealing, patient mistreatment, or deliberate property damage. The staff member committing such actions can be dismissed immediately if such actions can be proved indisputably. It should be clearly stated in the office manual that such conduct will not be tolerated and will result in immediate dismissal.
Preferably, a dismissed employee leaves immediately after the termination conversation. The dentist may pay severance wages, but payment is not mandatory in all states. (The dentist should check with an attorney about state law and write the policy in the office manual.) It is unwise for an employee who was fired to remain on the job. The dismissed person may sabotage the practice, even unconsciously, and bother other staff members with the details of termination. Thus a dentist may pay a penalty for being kind-hearted enough to let a fired employee keep working until he or she finds another job. If a dismissed employee remains employed while searching for another job, a departure date should be set; otherwise, the job search may be prolonged.
If the dentist is unclear about the proper way to discipline or dismiss an employee, he or she should seek advice from a lawyer versed in labor relations. It is much less costly to pay an attorney than to be involved in a wrongful dismissal lawsuit with a disgruntled employee.
Concern with intraoffice communication is not a novel phenomenon since all human relationships depend on it. Relationships with team members, patients, other health care professionals, family, and friends depend on the ways in which one communicates. Even if the clinical dentistry is superlative, patients can perceive problems and stresses among the staff and/or with the dentist. If the dentist and team members are not functioning as a unit, patients may feel that the entire practice, including the care delivered, is below average. The following steps can be taken to strengthen intraoffice communications: