Over the past few years, many articles have been written about the new age of assisted hygiene. Since every practice is unique and much of the material is written by nonpracticing dental professionals, the assumptions and guarantees are often different than the reality. The assertions stated and financial outcomes promised are all very similar. The idea always sounds attractive and feasible when we read about it, but how does it actually work day-to-day in a busy practice?
What is assisted hygiene? Simply put, it is a concept where the hygienist has his/her own assistant or shares an assistant with another hygienist. This assistant seats and dismisses patients; takes radiographs, intraoral photos, DIAGNOdent readings, and impressions; reviews the medical history; posts treatment; sets the next appointment for recare; cleans and sets up rooms; and sterilizes and sharpens instruments. The goal is to increase hygiene capacity and enable the hygienist to see up to twice as many patients. All of the nonhygiene tasks are done by the hygiene assistant, allowing the hygienist to concentrate solely on hygiene duties. Since the assistant’s wages are less per hour than the hygienist’s, the practice will come out ahead and everyone will live happily ever after. From a strictly business perspective, there is good logic here. The real question is, how does this all really play out?
The first assertion is that the hygiene department is usually a loss leader, or at best, it marginally pays for itself. The promise is that assisted hygiene will immediately turn the hygiene department into a highly profitable part of the practice. On the surface, from a business background, this may appear to be true; but with further dissection, a different reality often appears. While it is true that many hygiene departments may be poorly scheduled and work inefficiently, others are well-run and very profitable. The determining factor is not whether the hygienist has an assistant. Having the appropriate scheduling systems - including scheduling guidelines, scripts, and verbal skills - is the real key to success. Frequently, the difference in perspective on profitability arises from the differing assumptions of what constitutes actual costs and benefits of the hygiene department. A general rule of thumb to begin with is that the hygienist should produce at least three times his/her total compensation, including all benefits, taxes, retirement plan contributions, continuing education, etc. Suggested ranges in daily production vary from $800 to $1,000 for a practice without a perio program, to more than $2,000 for a practice with a highly developed perio program.
Every practice wants to have a highly profitable hygiene department, but the true value of the hygiene department is more than just its daily production. The actual benefit of a well-functioning hygiene department is twofold. First, it helps patients achieve and maintain good oral hygiene and periodontal health. Second, it allows the practice to maintain a base large enough to provide operative or esthetic dentistry that meets the practice’s goals. These can be accomplished by using proper systems and verbal skills, with or without assisted hygiene. The benefit of properly serving enough patients to provide an adequate base for the dentist’s production is one part of the equation that often gets overlooked when examining the usefulness and profitability of the hygiene department.
The needs of each practice differ depending on the practice type and locale. Simply instituting assisted hygiene will not solve other existing systemic problems; it will only magnify them. A poorly run hygiene department can be very costly to the practice, not because of its low productivity, but because the hygienist does not have the training to genuinely listen to the patients’ needs and concerns, recognize disease, and encourage the patients to have the diagnosed dental problems solved. If you feel that your hygiene department is not where it should be, a reputable practice-management consultant can help.
The initial step to take in deciding whether to establish assisted hygiene in your practice is to conduct a chart audit and determine the hygiene needs of your practice. Is your recare system effective, and are the patients being maintained at the proper recare intervals? Is your hygiene department completely scheduled every day, or are there several openings weekly or even daily? Even if the schedule appears full and patients cannot be scheduled for recare visits for several weeks, determine if the appointments are of the proper length to provide maximum capacity. If you are unsure of how to do this or if you discover any inefficiency here, work with a practice-management consultant to correct the problem before moving ahead and adding assisted hygiene. When hygiene is scheduled effectively, more patients will be seen, ultimately leading to higher hygiene production and more restorative diagnosis and production for the doctor. If you have needs for more capacity than you are currently able to provide, consider adding assisted hygiene to your practice. If you have excess capacity, it’s a moot point. Your energy will be better spent marketing your practice, both internally and externally.
Another consideration is space. Each assisted hygienist will need two rooms instead of one. If you have equipped, but unused treatment rooms, or if there are empty rooms that could be equipped, get a quote from your supply house on the cost to equip a new room. Use this information when analyzing the financial implications of assisted hygiene. If there is no room in your present facility, the decision is easy; assisted hygiene is not viable in your office. But it may raise another question: is it time to expand or relocate?
Staffing is another critical component. Do you have an employee who can slide into this position, or do you need to hire and train a new assistant? This is a significant factor. With assisted hygiene, more patients will come through the office every day, which means more time for checking in and out at the front desk and collecting payments, as well as more appointments to be made, confirmed, and refilled. The busyness of the office will change even with a completely digital office and sharing some of these duties between the front and back offices. If there are adequate man-hours and space in the facility to accomplish assisted hygiene, then it remains an option for further deliberation.
Consider also the effect assisted hygiene has on the doctor’s schedule. The addition of more hygiene patients adds more interruptions to the doctor’s schedule for hygiene checks, even when conducted at natural breaks in the doctor’s schedule. If the doctor is already overworked, it is time for some good management consulting, and even the consideration of adding an associate. If the doctor has extra time in the schedule, assisted hygiene continues to be a possibility.
If you have the room in your facility, necessary manpower, the need to boost capacity, and doctor availability, assisted hygiene may be an option for you. The critical decision ultimately will be determined by the need to add hygiene availability, whether to meet present demand or raise demand to fill the doctor’s schedule. The two choices after maximizing your present hygiene capacity are to either add hygiene days or use assisted hygiene on your current hygiene days. How does one decide on the best alternative?
One way is simply to look at the situation analytically. Determine the amount of time the hygienist currently spends with each type of patient: child, young adult, adult, and periodontal patient. If a “normal” adult patient takes 50 minutes, including taking necessary BWs or PAs or adult fluoride treatment, how is the time divided? If preparing the room, seating the patient, taking the radiographs and intraoral photos, posting the treatment, scheduling the next appointment, and dismissing the patient takes 20 minutes, this is time that would be subtracted from the total appointment time, resulting in 30 minutes needed by an assisted hygienist for this patient. Theoretically, the hygienist could see 9.6 patients in an eight-hour workday, and 16 patients with assisted hygiene. Complete this analysis for each type of patient. With children, the assistant may need more time than the hygienist. With scaling and root planing, the hygienist will not save much time.
While doing this analysis, do not simply guess at or ask the hygienist how much time he/she believes each step takes. Have an impartial third party with a stopwatch record these times. Understanding what is presently happening is crucial to the decision-making process. Once these times are determined, do a retrospective analysis of the last two weeks’ hygiene schedule, and see how much time an assistant would have saved the hygienist.
What did we find the reality to be in our office with two hygienists working per day, for a total of eight hygiene days per week? The ideal hygiene day without assisted hygiene was nine to 10 patients per day, depending on the mix. The average number seen per hygienist was nine. The capacity ideally should have increased to 14 to 15 patients per day with assisted hygiene, but actually increased to an average of about 12. On average, the daily hygiene production went up 25 percent per hygienist, which translated into 50 percent of the production of adding a third hygienist - not exactly double the production, but at least an increase. For example, if each hygienist produced $1,000 per day without assisted hygiene and $1,250 with, the result would be a total office increase of $2,000 to $2,500. The effect of the added hygiene checks on the doctor’s schedule was not as disruptive as when we tried three hygienists per day.
The patient experience is also very important. Will the patient feel like he/she is in a fast-paced clinic, or well-cared for by the entire office team? It depends on the office and how it is structured. The patient experience can be good or bad with or without assisted hygiene. If the patient experience is excellent without assisted hygiene, it can be just as excellent with it; it just takes proper staff training in customer service and learning the proper handoffs from one team member to the next. In a fast-food restaurant, the same employee may greet you, take your order, take your payment, assemble the order, give it to you, and bid you farewell. In a five-star restaurant, one person will take your coat, another seat you, another bring water or coffee, another serve your drinks, and still another take your order and bring your entrée. Which environment gives you the feeling of being well attended to? It is not the number of people who care for you, but how they do it that gives the feeling of either individual, undivided attention, or being just one more face in the crowd.
From our experience, using a strictly cost benefit analysis, logic would dictate that adding a third hygienist for at least part of each week would be more cost-effective than adding a hygiene assistant, all things being equal. What we discovered was that there are many hidden benefits of using a hygiene assistant in our practice which will be addressed later in the article.
It is crucial to understand the business concepts of capacity, flow, and bottlenecks. The overall capacity is determined by the capacity in the crunch times, or the bottlenecks that limit the number of patients that can be seen. In many offices, certain times of the day are in higher demand than others, such as early morning or after school, and other times are in less demand. This seems particularly true in the hygiene schedule. A comparable situation is found in the restaurant business. The restaurant will be very busy during the breakfast, lunch, and dinner hours, but mid-morning and afternoon will be slow times no matter how good the restaurant is or how much marketing is done. Capacity is determined by the number of patrons the restaurant can seat during the busiest times and how quickly tables can be turned around. The same is true in the dental office.
A hygiene assistant can help the hygienists during the busiest times to increase capacity without creating overcapacity in the hours of lower demand. During the time not used in assisting the hygienists, the assistant can make recare calls, stock rooms, assist the doctor with emergencies, or fill in as time allows if another employee is absent. This person should be trained to both fill in at the front desk and assist the doctor.
This situation also is beneficial for the hygienists because they do not feel like they are being pushed from one patient to the next all day long. This should eliminate the fear of hygienist burnout. If a patient needs impressions for a bite splint or whitening trays made, this can be completed by the hygiene assistant while the hygienist moves to the next patient who is seated and prepared. This opens the opportunity for more comprehensive patient care with highly individualized attention. Good communication systems and prepared scripts are vital to make this happen, but it can be done.
Following is a list of several unexpected results of implementing assisted hygiene in our office which our staff has labeled “pros” for the patients:
Our primary objective in implementing assisted hygiene was simply to attempt to increase patient capacity, especially at peak times, thus increasing hygiene and practice productivity. While this objective was partially reached, the actual effects on the practice were not exactly what we expected. The hygiene capacity did increase, but not by as much as we expected.
The unexpected benefits turned out to be even more important. Assisted hygiene allows us to provide a better patient experience by improving and increasing our services without putting the hygienists behind or having the patient return for an extra appointment. Patient flow throughout the day has fewer bottlenecks, and this reduces tension for patients and staff. The final result is increased patient production and capacity.
When should you consider adding a hygiene assistant? Add one if all of the office management and scheduling systems are in place, efficient, and well managed, and you need additional hygiene capacity. If there is a shortage of hygienists in your area or if you want to increase capacity only at your peak times, assisted hygiene can be immensely valuable. The implementation process is not easy, but the benefits make the effort worthwhile.Since 1978, Dr. Bradley Dykstra has practiced clinical dentistry full-time in Hudsonville, Mich. His interest in practice management led him to earn his MBA degree. In the process, he learned to apply general business principles to dentistry in a practical and profitable way. Besides work at his practice, he does limited speaking and consulting work through his company - Anchor Dental Consulting - on practice management, integrating technology into the dental office, and integrating the dental laser into everyday practice. He can be contacted by phone at (616) 669-6000, or by e-mail at [email protected].
