Bridging the Gap between Case Acceptance and Payment

About The Course:

Since dental patients across the country are becoming more service savvy, it is more vital than ever for dentists and staff to create a people-friendly atmosphere while at the same time operating the practice as a business. An appropriate system that addresses payment in this way will help dentists and their team members ensure payment for their services, while creating loyal patients who refer friends and family to the practice.

“Proactive Payment Systems” is a principle-based workshop that provides the guidelines necessary for dentists and their staffs to construct an appropriate payment system for their unique practice. In addition, this course will teach improved process and protocols that create a financially healthy dental practice.

Course Topics:

• Learning how to recognize and develop a financially healthy dental practice
• Setting goals for financial health
• Applying techniques to create an expectancy of payment
• Developing a plan to shift responsibility of insurance payment to the patient
• Accelerating insurance payments
• Enacting solid, proven techniques to communicate effctively with patients
• Helping patients choose payment options that make sense for them and the practice
• Significantly reducing the number of billing statements mailed
• Improving cash flow, reducing accounts receivable, and improvingprofitability!

The attendee will discover proven ways to address these topics successfully in his or her practice, and achieve whatever goals you have set out to accomplish.

Who Should Attend?

The best results will be achieved when doctor and ALL team members attend!

Working Together to Become a Self-Managing Team

Dental practices are confronted with numerous mandates, such as OSHA Compliance, record-keeping and accounting requirements of the tax laws, compliance with the Americans with Disabilities Act, laws pertaining to Equal Employment Opportunity, and the need to manage diverse kinds of risk. It’s no wonder dentists and staffs are being pushed to the point where they have difficulty performing as a team and maintaining a prosperous dental practice.

“Working Together to Become a Self-Managing Team” is designed to help today’s dentist and staff to set principle-based goals, delegate and accept tasks, encourage team responsibility, build mutual accountability, and enhance employee satisfaction.

Course Topics:

• Differentiating between leadership and management
• Prioritizing workloads
• Principle-based goal setting
• Re-engineering mission critical business systems:
  • Determine an appropriate fee schedule
  • Build case acceptance through improved case presentation techniques
  • Integrate effective internal marketing strategies to increase new patients
  • Conduct effective personnel performance reviews
  • Implement reward systems to provide incentive to staff; incentive is somewhat controversial but is fairly widely used and might work here
  • Scheduling for productivity and sanity
  • Reduce and contain supply costs
  • Measure and enhance financial performance

Who Should Attend?

The best results will be achieved when doctor and ALL team members attend!

(Formerly ``Exit Strategies and Transition Planning``)

Do you plan to buy or sell a practice?
Are you thinking about associates?
Do you know what your practice is really worth?

Buying and selling can be complex - and scary. Let the nation’s leading specialist in transitions teach you the information, resources and skills to make yours a success.

As tax laws shift and the economy fluctuates it’s important to understand how your practice is positioned and how you will handle the moving parts of and exit, entry or associate agreement. Pride Institute brings you the foremost experts in the field for this one and a half day course to secure your future.

In any economy, it is essential that both buyer and seller have the very best advice and counsel. This seminar is led by Fred Heppner, a nationally known expert on practice transitions who will acquaint you with proven strategies for selling or acquiring a practice.

You will learn:

• The process used to appraise dental practices
• The options and mechanics of buy-ins and buy-outs
• Complex associateship/partnership structuring
• The tax implications when selling or buying a practice
• Succession planning, practice operations, personal planning and practice entry
• How to maximize practice value to prepare for a profitable transition into retirement
• Post-practice options

Leave with the skills and insight to make your transition a “pain-free” one where everyone involved wins – even your patients

Participants in this lecture course receive 11 hours of continuing education credit from the Academy of General Dentistry.

 

---

"If you are looking for integrity, experience and expertise, I know no one that is more qualified to assist you in your dental practice transition than Fred Heppner. Knowing Fred for over ten years and having worked with him on multiple transactions, he is committed to win/win relationships and has the special knowledge to facilitate any transition. With Fred Heppner, the Pride Institute team and Pride's strategic partners, you can't be in better hands.”

- Hy Smith, Author and Transition Specialist

As a small business owner, a dentist has many responsibilities to keep the business running smoothly; employing staff, maintaining the office equipment, marketing for patient flow to name a few. However, with all the careful planning and attention to detail, there is one aspect that the majority of dentists don’t plan for, which is how to keep the business viable if they are unable to practice. Every year a fellow practitioner may unexpectedly lose the ability to prac- tice due to an unexpected injury or illness. Weeks or months of lost practice time will affect patients, staff and cash flow. Moreover, dis- ability insurance has a waiting period before benefits will be paid, typically three months. In this article, I wish to share events that I have witnessed and ways in which they were handled in hopes that others may benefit through proper planning and organization.

Since 1983 when I first became involved in dentistry, I have worked in nine major metropolitan cities and served clients in countless others. During that time, numerous events occurred that were both sad and frustrating. Dental offices were left stranded without a practitioner for a variety of reasons including: a dentist needing time off for recuperation after emergency surgery, dentists with broken arms or hands, and unexpected death.

In these cases, the dentist wasn’t able to treat patients, the employees in place didn’t know what to do, and the spouse often did not have the business acumen to carry forth the business oper- ations and the business faltered. In the event of death, a practice’s productivity would plummet until a potential buyer arrived with an offer far less than the previously thriving business was worth. Sad, but true, the estate of the deceased dentist may be left with little if any proceeds from the sale of an asset.

Most dentists carry disability insurance, but again the period of time until benefits begin may be far too long to wait for much need- ed funds. This can destroy a fine dental practice. An option to man- aging operating expenses when little income is being generated is to carry office overhead insurance. This policy protects the short-term financial needs of a practice with payments until the disabled den- tist returns to work.

But even overhead insurance has limitations; will the proceeds from insurance enable the office to remain viable, keep the patient base intact, and continue to employ staff until the dentist is able to work again or the practice is sold? Most likely the answers to these posed questions are NO.

Rather than risking harm to a most valuable asset, dentists may consider becoming involved with a group of conscientious dentists in their community who would help preserve a practice if some- thing unexpected happened to one in the group.

I have designed a successful program to help a ‘fallen’ dentist’s practice remain viable. It is based on a simple premise, that the den- tal community is a caring one, willing to volunteer services for fel- low comrades. The program is termed “Inter-Practice Protection”, and it has worked successfully in Arizona since developed in 1997. The concept is straightforward: form groups of like dentists who agree to volunteer coverage for each other in times of illness, short- term disability, trauma, or death. This is not an insurance policy; rather, it is assurance that a practice, the team of employees, and patients will continue to be served. Inter-Practice Protection pro- vides coverage for the practice during a dentist’s absence to ensure that it does not lose production, the team continues to work, and patients continue to receive care.

Since its inception, nearly one hundred dentists in the greater Phoenix Metropolitan Area have formed six separate groups to cover for their practices should an untimely and unexpected mishap occur. These groups are well-structured and organized associations of private practicing dentists who have committed to volunteering a day of their time if a colleague within the group is unable to practice.

Members of the group operate their own private practices and collectively volunteer their time to care for patients and keep the fallen dentist’s office functioning while the doctor rehabilitates, or until the practice is sold. Patient payments for treatment provided by the covering doctors are made to the practice being covered.

After activating groups for a variety of reasons, such as cardiac surgery, a broken arm, a broken hand, and even an untimely fatal heart attack, the coverage specifics have been fine-tuned, with the participating dentists input. In addition, the groups’ dynamics have become stronger with each passing year. Following are guidelines for effective operation of the coverage groups:

• The groups are comprised of about 17 dentists.
• A Chairperson and Vice-Chairperson are elected by the group to function as administrators of group communications, manage annual meetings, and coordinate activation for a doctor needing coverage when necessary.
• The group provides coverage if a member is not capable of providing usual dental services due to non-intentional mishaps, illness, disability, or death. Normal maternity, without complications, substance abuse, and alcoholism shall not be considered a disabil- ity or illness.
• Upon the event of a disability, the member or family member promptly contacts the Chairperson to advise coverage is needed. The Chairperson then calls an activation meeting to be held at the disabled member’s office within 24 hours and creates a coverage schedule with the members of the group.
  Coverage begins no later than 15 days after the date of disability, and continues for a maximum of 12 weeks. Coverage will cease when the disabled member returns to practice, or upon death when the practice is sold.
  Members covering a practice are not responsible for managing, administering, or directing the business of the disabled member’s practice. A personal representative, family member, or other rep- resentative of the practice is responsible. Members may assist without any obligation to do so, but are not liable for any dam- ages.
  The dental team should notify patients of the disability and make known the name of the covering dentist prior to the patient’s appointment. The team will maintain all normal business opera- tions, cooperate and assist the member who is providing coverage, and ensure there are adequate supplies and personnel for the prac- tice of dentistry.
  Members are not obligated to cover more than their allotted number of days. After the entire roster of the group is contacted for coverage, any more additional days of coverage by a member is voluntary.
• Contact your malpractice insurance company and ask them specifically: “In the event of my untimely death, will my policy allow for patients to be treated in my office by my staff under the supervision of a dentist volunteering his time and still provide malpractice coverage?”
• Each member must review their personal information to be sure that the Power of Attorney is delegated to a significant other so that payments for accounts payable and payroll may be made without delay.
• If a member is contracted with an insurance company as a pre- ferred provider, then the member must find out guidelines for each particular plan in the event another doctor, who may or may not be contracted with that insurance company in his or her own practice, treats patients during a covered period. This will ensure payments for treatment rendered to patients are made to the doc- tor’s office receiving coverage.
• Members of the group agree that if a patient of the doctor who is receiving coverage wishes to pursue care from the volunteering dentist, the volunteering dentist will decline to accept the patient in his or her practice until a waiting period has passed. In the event of a disability or illness, one hundred and eighty (180) days shall pass. In the event of death, ninety (90) days shall pass.
• Attendance to an annual or biannual meeting is urged to reunite with fellow members, review past year’s events, and demonstrate commitment to the group.
• Prior to covering at another practice, a schedule may be faxed so that the covering doctor may review the patient load and treat- ment mix. At that time, the covering doctor may consider bring- ing some of his or her own instruments.

Through careful planning and preparation, the groups here in Phoenix were well organized and ready to step in under any circum- stances.

On the evening of July 31st, 2003 around 7 p.m., I received a call from a periodontist who is a member of the “Concerned Periodontists”, an Inter-Practice protection group in Phoenix. He informed me that a fellow periodontist had passed away suddenly and unexpectedly of a heart attack at the age of 41 at his home that morning. By 7:30 a.m. the next day, the coverage group was activat- ed and within a few hours a schedule was created in which eighteen periodontists had volunteered their time over the next sixty days to cover the practice.

I arrived at the deceased periodontist’s practice at 10:30 a.m. and was met with an enormous amount of gratitude and apprecia- tion by the team. To know that the doctor had thought ahead and aligned himself with a conscientious group of practitioners was such a relief to his staff, and to know the practice would be covered in this difficult time lifted a huge weight of concern off their shoul- ders. In the following weeks, patients were treated, the staff contin- ued to work, and the business continued to operate while the sur- viving estate planned for the practice’s sale.

No one really knows what tomorrow brings. We plan for our practices to grow, we plan to maintain a happy and productive team of employees, we plan for retirement, and we hope to have enough insurance coverage to provide financial help in catastrophic situa- tions. Be prepared and have a plan in place so that your practice will continue to be productive when you’re not there.

Fred Heppner is a business management advisor who has served the dental industry since 1983. He has enhanced dental and medical offices across the country in the areas of marketing, practice analysis, strategic planning, insurance management, financial arrangements, accounts receiv- able control, personnel management, and Electronic Data Interchange.

Mr. Heppner’s in-depth knowledge of business management systems and strategies has helped hundreds of practitioners enhance the financial health of their practice. Fred helps doctors and their teams establish and implement solid, proven business techniques that meet both patient and practice needs. He provides practical advice for immediate application and excellent results.

He resides in Phoenix, AZ, with his wife, Susan, and daughters Mary and Rose. His consulting firm specializes in professional, objective prac- tice guidance. Mr. Heppner can be reached at Proactive Practice Management 480-513-0462 or by email fredheppner@cox.net.

PDF Version

"I've had several applicants arrive for interviews whose resumes were impressive but they had tattooed arms, facial piercings and wild hair-dos, so I didn't hire them. Should I have a written policy on professional appearances and if so, what should it contain?"

This is a two-part question because it deals with potential hires and current staff. Unfortunately, you may have let some excellent candidates with “impressive resumes” slip away because there was no office policy regarding personal appearance expectations in place.

Had there been a Personnel Manual listing office policies stating what is expected of employees, the dentist could have hired the interviewee, provided he/she is made aware of the dress code during the hiring process and agrees to follow the standards to which all employees are expected to adhere. I’ll start with pertinent information regarding a Personnel Manual’s worth, and then get into the specifics of office policy dealing with employees’ appearances.

Many dental offices acknowledge the value of having a Personnel Manual with specific policies that clearly define and set forth expectations of employers. Unfortunately, few small businesses actually have such a document in place. Similarly, dentists in private practice often do not have a Personnel Manual because they are unfamiliar with the process of publishing such a book, unique to their practice and beliefs.

A personnel manual is as much a declaration of philosophy and behavioral expectations as it is a written document that provides every employee with the same information about the rules of the workplace. Employees will know what is expected of them, and what they can expect from the employer. The handbook also serves as legal protection if an employee later claims wrongful dismissal. Keeping the handbook current is important as laws change over time.

Purchasing an office manual that is already written and requires limited modification is one way to integrate this important management tool into the practice’s operations; putting one together without a pre-formed template is another way, albeit more difficult. Whether a practice purchases and modifies a pre-written manual, or creates one from scratch, make sure the handbook entails basic fundamental elements, and that it speaks for the uniqueness of the office’s philosophy and practice of dentistry.

Begin by describing the practice’s philosophy of both dentistry and employment protocols. Upholding a fair and safe work environment along with providing equal opportunity for employment are cornerstones of proper employee management. Also, describe the principles that are the foundation of the practice’s philosophy. This may take the form of a mission or vision statement, or even a simple paragraph relating the practice’s philosophy. It is important to make clear that the personnel manual is the property of the practice. A copy is kept in an designated place in the office for easy reference, and it must not be removed from the premises.

It is prudent and sensible for any business, whether large or small, to have guidelines that help employees understand what the appropriate dress and grooming practices are for the workplace. There are several reasons for implementing these standards; such as to present a uniform and professional appearance for patients, to limit distractions caused by offensive, inappropriate, or provocative dressing, and to ensure safety while working. Remember, that employees are representatives of the practice. An employee’s personal appearance, which includes dress, grooming, personal hygiene, make-up, tattoos and piercings affect both the patients’ impression of the office and internal morale among staff. Ultimately having an enforced, nondiscriminatory, dress policy helps to promote a professional and positive working environment for all.

The next step, this is where the employer can be specific as to personal appearances, is to define office and employment policies. This section must express the expectations of the employer, such as assigning and supervising personnel, supporting positive contributions with praise, reprimanding when necessary, and changing office policies as a result of internal circumstances, competitive forces, economic conditions, or to comply with state and federal regulations. The mainstays for this section can include having a strong work ethic, being friendly and courteous to others, adhering to office policies, and working toward solutions of any grievances justly and fairly.

When detailing office and employment policies, the segment covering what is expected in regard to personal appearance standards should remain specific. Here, expectations regarding personal appearance are laid out for the employee to understand. For example, “Employees are expected to maintain a professional appearance, which includes proper grooming and dress. Visible tattoos, and facial piercings, excluding earlobes, are prohibited. Hair needs to be pulled back. Dangling or large pieces of jewelry cannot be worn as they may compromise job performance. Fingernails are to be kept short, and acrylic nails are not allowed. Make-up should be kept to a minimum. If an employee has a question in regard to the dress/appearance policy, the office manager or dentist needs to be contacted so that approval as to the dress code is given prior to the working day.”

Additional elements to consider containing in the General Office and Employment Policies section are how the office handles absenteeism and tardiness, personal time off, smoking, gum chewing, substance abuse, initial training & orientation, performance reviews, resolution protocols, sexual harassment, and serious diseases. Infection Control standards are a lengthy subject, and are usually part of another separate manual with policies and protocols centered on ensuring an aseptic work environment. Simply reference this in the employee manual and direct all issues relating to Infection Control to the separate book.

Once the manual is complete, it is wise to contact a person in the immediate area with legal experience in personnel law to help with specific questions and issues relating to this project. After formal editing and final publishing, circulate the handbook among the employees, and require them to sign a form that acknowledges they have read and agree to the policies set forth. These signed forms should be kept in the individual personnel files of each employee and updated periodically whenever a change in the manual is set forth.

In conclusion, create a dress code and appearance policy specific for your practice that promotes your style of practicing dentistry and represents your business as you see fit. If that includes not allowing body piercing and unsightly tattoos, then so be it.

"I'm interviewing new employees. I've heard checking references is a good idea, what are your recommendations? On the other hand, what am I allowed to say when a prospective employer calls our office for a reference for one of our former employees?"

All too often, I come across a dentist client who avoids contacting references for new employees for a variety of reasons; not the least of which is he or she doesn’t know how to properly contact previous employers in order to obtain valuable information. Although, I’ve never come across someone who has applied for a job and provided a BAD reference! Understandably, people looking for work wouldn’t provide a reference that would give a poor report.

Sure, the most common concern here is how well the previous employer will cooperate with sensible questions that are commonplace with employment practices. Most employers would prefer to shy away from these kinds of phone calls due to the notion that negative statements may come back as a problem later. For the most part, we’re going to discuss contacting previous employers; the material is relevant to receiving reference checks, as well.

According to the Arizona Industrial Commission and Labor Board, no laws in our state of Arizona govern the issue of reference checks and what can or cannot be said. Following basic guidelines will help one decide how to disclose information about former employees and avoid litigation. One can never be too careful in today’s litigious society.

An employer may fear that if any negative statements are made one could be sued for libel (written) or slander (spoken). It is best to stick with the facts and lay aside personal feelings. Keep the information discussed basic and be brief.

In order to avoid defamation, a former employee must prove that information given out was false and that the information harmed his or her reputation. Proving the information given was true dismisses these types of legal battles. For example, disclosing disciplinary action taken during the employment period is justified provided that documentation signed by the former employee is on record. Make sure personnel files reflect fairness, objectivity and honesty; free of unproven gossip.

If an inquiry is made to your office about a former employee applying for a position in another dental office, speak only to the doctor, or the owner of the practice. Ultimately, these people are responsible for hiring, training, reviewing performance, and dismissing employees.

Thinking proactively in your own office, it would be wise to have an employment application that provides consent to contact previous employers. Include with the application simple language providing authorization to check references:

“I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any of the statements checked unless I have indicated to the contrary. I authorize the references listed above, as well as previous employers who you may contact, to provide any and all information concerning my previous employment and any other pertinent information that they may have.

Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information as well as from the use or disclosure of such information by the employer or any of its agents, employ­ees or representatives."

Next, during the initial interview, discuss with the applicant that you will be contacting previous employers, unless he or she objects. If the candidate objects, then ask, “Why?” Discussing this issue up front is smart because an answer the applicant provides along with their body language provides insight into whether or not the applicant will be a good hire.

Once you have the go ahead to contact previous employers, follow a process of asking questions that confirm information on the application. For example, confirm dates of employment and salary range. Ask if job duties and responsibilities were adequately performed. What are the person’s greatest strengths, and weaknesses? Was the former employee terminated or did they resign? And finally, the “Crown Jewel” of all questions that will tell a person most all he or she needs to know about a prospective employee is, “Given the opportunity, would you hire the employee again?” A “yes” or “no” answer speaks volumes. Take it from there.

By the way, in preparation for a telephone call from another person checking on a previous employee, consider the following. Be ready to begin the call by stating that you will be glad to discuss basic information, such as dates of employment, salary range from date of hire to end of employment, and job duties and responsibilities. This sets the stage nicely for what you intend to discuss and what the person on the other end may indeed with to know.

Keep in mind, a previous employer you are contacting may be reluctant to provide any information that may damage the candidates’ ability to seek and acquire employment. Although, some states, such as Kansas, have passed laws that require a person must show “clear and convincing evidence” that the former employer acted in bad faith in providing job-related information. Ask the questions we have discussed here and wait for responses that may clue you in to how anxious, or reluctant, the previous employer is to re-hire the person.

It also pays to be discrete while attending informal gatherings. Don’t speak freely at a meeting or other functions where social and/or business chatter may take place. Among colleagues and employees, disclose the reasons for firing strictly on a need-to-know basis. Limit the announcements to, “Sally has left the practice and we’re seeking a replacement.” Either ‘speak well of the dead’, or say nothing at all. For example, if one believes nothing positive can be said of a former employee, simply state that it is the policy of the practice not to comment on former employees with prospective employers. Airing grievances about someone will likely spread, potentially causing legal complications.

"I definitely need help in setting up an employee manual because I have no idea where to start. What are the main components? What’s important and what isn’t?"

Personnel Management in dental offices requires specific elements to be effective; not the least of which is a manual that clearly spells out the general policies, terms of employment, and compensation & benefits of your office. Handy to have with the manual are documents that help bring clarity to issues and for proper information safekeeping. It is not just another “system”, or important legal document. It is the reference point for how employees are expected to behave and conduct themselves, and how the employer will provide for a safe, professional, and (hopefully) prosperous work environment.

Without this tool and its components, office policies tend to be ambiguous, and employees are left to guess how they’re supposed to behave in certain situations. Even with this in mind, a manual must not rest alone. Proper leadership skills must be orchestrated by the employer along with a written guidebook to ensure successful human resource management.

What I will attempt to do in this article is explain essential background information on human resources that must co-exist with a written guidebook on personnel policies. I’ll finish by providing guidance on how to construct and effectively integrate an employee manual into the workplace.

Truth is, in my experience, ALL dental offices need an employee manual; unfortunately, only a few have a current working guidebook.

But where does one start?

My suggestion is to obtain an employee manual already prepared for dental offices. There are several on the market that are worthwhile and can be purchased at a fair fee. As a service to each of my consulting clients, I have developed a personnel manual that fits specifically into the dental environment. In any case, a proper manual would have the capability of being fine-tuned, or individualized for each dental office, due to the unique qualities found in each practice. The employer should ensure a working environment exists in his or her office that supports fair employment practices. Let’s dive into some of those concepts so that you will have an idea regarding what manual will be a perfect fit for your office.

A cornerstone in business management is providing employees with the reason why things are done a certain way. Establishing principles that will keep a business running effectively while handling any personnel issues is in line with this concept. Employers should make sure time is spent thinking about how their business will be run, and how decisions will be made. For example, if one declares, “We will always respect other people’s time in our office”, then one tends to focus on staying on time during the course of the day. And, appointments that are scheduled are not moved for the convenience of the office, but rather kept for the benefit of the patient.

In terms of personnel management, consider establishing principles that will help make decisions easier to come by. For instance, “We will strive to be fair to the employee in all aspects of human resources” would be a sensible tenet to adopt. In this way, when a situation arises, fairness would be the prevailing principle ensuring an appropriate outcome.

Another consideration may be to incorporate the “Reasonable Man Theory”; an ancient English common law which follows, ‘in any circumstance, a person is expected to know what is real and/or reasonable and do what is prudent’.

When dealing with personnel management issues, one must ask, “From who’s perspective is it reasonable?” In today’s day and age, the employee’s perspective of reasonable is used. In that case, examine each situation through the eyes of the employee. What one risks is the inherent loss to business through decreased productivity from people who are not treated reasonably and prudently in the work place.

In order to keep morale high, remove hurdles to productivity. Here are some suggestions that can help promote good management of people.

• Create a mission statement – define the practice’s “big picture”.
• Help people understand “why” they are doing what they’re doing by explaining standards of care and protocols for each job responsibility.
• Have complete job descriptions - they are the foundation for effective personnel management. And, job descriptions clarify the employee’s responsibilities, wiping out ambiguity in the workplace.
• Build an office where people know how they’re doing: provide objective feedback on performance.
• Develop tools & reports that employees utilize that help them become accountable for their job requirements and work expectations.
• Endeavor to help make all employees feel comfortable and fulfilled in their work.
• Ensure a non-hostile work environment exists that is private and safe.

One important aspect in personnel management, in particular the State of Arizona, is the clear establishment of employment “at will”. In simple, this is employment that lasts as long as both parties will it to last. If one party elects to discontinue the arrangement, then the arrangement is discontinued. Put another way, if the person is employed, the employment lasts as long as both parties agree equally.

Avoid the following common errors and maintain employment “at will”. Don’t promise permanent employment; again, employment lasts as long as both parties agree equally. Next, make “at-will” employment very clear by placing it in the personnel manual and on job applications. Also, avoid any “Termination for Cause” statements in the manual or employment documentation, as this may negate the “at-will” status of employment in the office. Finally, don’t neglect to obtain a signed acknowledgement of receipt of the manual! In this way, employees confirm they have read and understand the manual in its entirety and agree to abide by the policies set forth.

Time has tested the theory that a fantastic team is built around reliable personnel management systems. Hiring protocols are followed so that people with the right skills and temperament are screened and hired properly. They are employed because they know they can perform the duties described in the job description, and references have provided positive reinforcement of their good work history. From their first day on the job, they know what to expect because they’ve read a manual describing how things work in the office and what is expected of them in return. During their time of service, they know how well they’re performing because a formal review process evaluates their work productivity against the employer’s expectations. Consequently, employees are accountable for the results of their actions – good or bad.

In the final analysis, all who work in a dental practice should provide for a profitable and gratifying experience. A personnel manual that is customized to fit the particular aspects of any practice is a must; only then can it be utilized to maximize employee performance. I’ll state the obvious in that just purchasing a manual will not solve personnel issues. Editing the manual to suit the particular nuances of an individual office and incorporating the manual with good employment policies, complete protocols, and sound philosophies are proper business strategies. Following through on what is established within the manual will result in excellent human resources.

An effective employer shows he/she cares with fair employment policies and parameters for continued employment. Use the above suggestions to construct a guidebook or manual that is complementary of the management and business principles of the practice.

"Performance Reviews. I hate doing them; and they're time consuming. Are they really necessary? If so, how do I conduct a meaningful performance review?"
Yes, they're really necessary. And conducting meaningful reviews are not difficult when properly planned and orchestrated.

But before we get started on the subject matter, let's go back to when the employee was first hired. A quick review of the steps to ensure a proper hire are to (1) request a resume with cover letter, (2) have the potential employee complete a thorough employment application and sign it, (3) conduct a brief preliminary interview to collect these items and to get to know the applicant. After the interview, research past work history of the employee by comparing time lines on the resume with the time lines on the employment application; but sure they are consistent. Contact previous employers and ask them the following questions to corroborate the applicant's information; and be sure to ask to speak to the doctor, or owner of the practice!

• Confirm dates of employment: "When did the employee start working and when did employment end?"
• Confirm salary range: "What was the rate of pay when the employee started, and what was it at the end of employment?"
• Job duties and responsibilities; were they adequately performed: "What were the employee's duties and responsibilities? How well were they performed?"
• Strengths, weaknesses: "What would you say are the employee's greatest strengths? What are the employee's weaknesses?"
• Terminated or resigned: "Did the employee resign, or was the employee terminated?"
• Re-hire: "If you had the opportunity, would you hire the employee back to your office?"

Confirm with the application and resume that the dates of employment match up; look for consistency in date ranges and identify any gaps in employment. For example, if the potential employee provided information showing he or she worked from January 2008 until February 2010, yet the previous employer shows dates worked from January 2008 through March 2009, make note and prepare to ask the potential employee about the discrepancy in employment time lines.

Rate of pay is important since you may be interviewing a candidate who is outside your normal range of pay for the position. And, the candidate may claim a higher rate of pay from previous employment to leverage better pay.

The reference may be reluctant to provide any information that may damage the candidates' ability to seek and acquire employment. Although, some states have passed laws that require a person must show "clear and convincing evidence" that the former employer acted in bad faith in providing job-related information. Ask the above questions confidently as they are standard and safe; and wait for responses that will help lead to a decision to hire or not.

In addition to the steps discussed here, an employer may find that conducting a background check of an individual, going beyond a friendly recommendation for hire from a colleague or other respected source. To be too trusting can be a detriment. Embezzlement and fraud in dentistry is rampant; careful hiring starts at the onset.

Once you have an employee in place, performance evaluations are a necessary management tool that will help people achieve and even exceed their potential. It also is the stronghold for an employer to keep tabs on business operations and essential in helping employees realize strengths as well as their shortcomings in order to improve performance. When orchestrated properly, these evaluations are powerful developmental tools.

The following will help guide doctors through a simple performance evaluation in order to gain the most positive experiences for themselves and their employees as well.

The evaluation assesses performance on a yearly basis, but there should be a plan set in place for the day-to-day process as well. This assessment would be applicable for any employee; new or established, especially when people are hired under the right circumstances. Best employment practices follow a standard for other employees to realize this is necessary for their continued employment.

This may feel unnerving to the new employee, but it helps keep expectations high, in the same way as keeping an existing employee from not becoming complacent. Therefore, for new employees, provide an evaluation at the end of a 90-day orientation period; yearly for the established employee. Both doctor and employee will come to the meeting with their ideas on performance thus far and ways to improve performance; usually this information is in the form of a templated employee review form.

If an event occurs that requires immediate attention, don't wait for the scheduled "Performance Review" to discuss this situation; address it immediately. If this is a repeat offense, the disciplinary process must be instituted. This process should be followed exactly as your Employee Manual specifies; usually an anecdotal write-up that a formal verbal discussion was held, including the employee behaviors and recommendations for correction that were discussed. If problems continue, a formal report listing documented incidents, recommended solutions, and disciplinary actions set forth should be made and become part of the permanent employee file. This report must be reviewed and signed by both employer and employee. When documenting employee behaviors, be certain that you remain objective. Never contain subjective documentation.

For a subjective example; 'Julie seemed aggravated and snapped at a patient'. An objective example; 'Julie stated "You have to sign this" pushed papers across the console quickly toward the patient and left the room. Upon leaving the office, the patient exclaimed, "Wow, that was rude!"'

In addition to documenting objectively, make sure that the date, time, and patient initials are included so that during the performance review or disciplinary process the facts are clear.

Structure the evaluation as part of an ongoing process, rather than a solitary event.
Although formal performance evaluations are structured to occur on a scheduled basis, as stated previously, employee behavior and job performance should be evaluated daily. This is an ongoing process; tedious, yes, but valuable. It will be the keystone in the continuous supervisory cycle of refining job descriptions, setting goals, providing constant feedback, and coaching. Doctors must be actively engaged in these supervisory duties and not take the path of least resistance. If gone unresolved, unacceptable activity or behavior that causes stress and frustration may fester not only with the doctor but with other staff members. Eventually tempers flare.

Make anecdotal notes during the period.
When staff members perform well, make a written note of these events as well as when poor performance is observed. Write down specific actions, results, and dates in an informal file. Use a spiral notebook and label it "Anecdotal Notes", have a space for each employee, and keep it in a locked desk drawer. These notes are not part of the "official" personnel file. Over the course of a year, since one has developed a trained eye for these matters, there should be dozens of written anecdotes that will assist in accurate recall.

Have available the date, time, and specific issue or behavior that occurred. Here is an example of an incorrect note:

"Sometime before lunch last week, overheard employee cursing under her breath; showed anger in front of patients."

"Observed {Staff Member} being a team player."

Here is an example of a correct note:

"1/9/2011: 10:35 a.m. Used the profanity 'shit' within earshot of patients, slammed down telephone receiver."

"2/12/11: 9:30 a.m. Overheard {staff member} ask other team members, "I'm all caught up with my work; is there anything I can do to help you?"

Focus on the relationship and specific job duties; not the paper evaluation form.
Don't let the written evaluation form become a restriction; use it as a guide. Consider adding questions not listed on a form that pertains to the individual's job description or duties. This may provide for a more meaningful evaluation for the team member.

Schedule the meeting in advance; provide a blank copy of the evaluation.
Block out time in your day to conduct performance evaluations. Yes, productivity is sacrificed; but these meetings are important and are vital to the future performance of the practice. Remember the management edict, "Work ON your business (dental practice), not just IN your business." Give a blank copy of the evaluation and ask the employee to evaluate his or her own performance. Attach a copy of the job description for reference. Suggest the employee consider assembling notes on the following:

• Achievements and/or successes
• Ways to improve upon performance (including perceived barriers to change)
• How well the employee believes they work with others
• Special skills acquired during the period that add value to the practice
• Plans to enhance performance through continuing education of interest in the coming year

Let enough time pass before the evaluation for both the employee and doctor to assemble their information; usually a week will suffice. Be punctual! It sends the wrong message to employees when performance reviews are late or cancelled.

Keep it private.
Conduct the review in a private area of the office. Focused communication as well as confidentiality is required. If the facility doesn't have a private place, consider a neutral site that is quiet where interruptions are avoided, other than a true emergency.

Be objective; "Just the Facts"; listen carefully.
Make sure that the information you give on an employee's performance is strictly objective. In other words, provide only the facts as you have documented them during the period. Keep your language forthright and clear. If the performance is outstanding or unacceptable, say so. Computer management reports may aid in demonstrating exceptional or poor performance; use them if applicable. Allow the employee to share his or her views of performance, listening carefully to the other side of the story. This helps the employee take an active role in the evaluation without diminishing the authority of the employer.

This part of the session is the most important part of the evaluation. Again, it is extremely important to view issues objectively with evidence.

Eventually, the employment review will end with the two performance evaluations signed by both parties. An action plan agreed upon by the employer and employee that will help the employee improve performance and focus on the future goals of the practice must accompany the signed documents.

Both the employee and employer must sign and date the evaluation. This will become a permanent part of the employee's personnel file. At this time, introduce a merit increase, if applicable, or bonus for exemplary performance. Remember that the act of conducting a performance review does not imply a merit increase or bonus.

Performance evaluations can be stressful. And, some people shy away from this important personnel management tool in order to avoid confrontation. The evaluation must be truthful; otherwise if a problem employee is dismissed and all evaluations showed good quality performance, the disgruntled employee might find justification in pursuing legal action because of wrongful termination.

Use these tips to become more proactive in handling performance reviews, and create an environment that reduces stress during the evaluation. Continue to work on ways that will enhance people and practice performance.

As my employees do so much for me and work hard every day, I would like them to know the value I provide them in terms of compensation and benefits. Do you have any advice on how to do this in a constructive, positive way?

Hard working employees in a dental office that achieve results are deserving of good pay and fringe benefits. Sometimes the hard work these diligent employees put forth goes unnoticed and unfortunately unappreciated, at times. Get your pencil sharpened and we’ll run through an easy and effective exercise to help everyone understand the total value of the compensation and benefits you provide to your well-deserving team.

First, I recommend using the trailing 12 months of payroll and benefits data. In this way, the information can be examined over a reasonable period of time.

Tabulate the gross salary and/or hourly pay and overtime wages. Include, if any, employer contributions such as Social Security, Medicare taxes paid (FICA), Federal Unemployment Tax (FUTA), State Unemployment Insurance, and any other taxes paid by the employer on behalf of the employee.

Next, include any employer paid benefits such as a bonus or productivity award, continuing education, life insurance premium, health and/or major medical insurance, vision coverage, covered parking slip, health club membership, uniform allowance, child care assistance, and pension and/or profit sharing plan contribution and match (if any). Tabulate at the usual and customary fee that would normally be charged any dental treatment provided to the employee and/or family members as an employee benefit. Subtract any fees paid by the employee for lab or co-payments.

Now, put together the amount of time benefits paid including holiday pay, vacation pay, sick/wellness pay, and any paid time off that was provided to the employee.

If you get the idea, we’re putting together all of the paid compensation and dollar value of the benefits provided the employee. Add these amounts together and put them to the side.

Finally, from payroll records, compile all hours worked by the employee during the 12-month period. Include total hours the employee actually worked, and total hours taken for paid time off, holiday, vacation, etc.

Divide the total compensation and benefits in dollars by the number of hours the employee actually worked. This amount is the effective value of the employee’s hourly pay. It will shock you, so be ready!

The good news here is that the study will demonstrate that excellent employees who put together a hard days work, who get great results from their efforts, are very well paid; rightly so. It may also reveal that employees that are not getting the results you expect may be paid more than they are worth.

Another element to this study is the battle some employers have with employees who come to them and say, “I know a dental office down the street will pay me $14 per hour; I’m only making $10 per hour. You’ll have to match the $14 or I’m heading down the road.”

Holding an employer hostage to supposed better pay is an awful way to negotiate compensation. One solution is to let the person move on down the road and test the water in greener pastures. Another solution to this problem is to prepare and present the compensation and benefits summary described in this article. If the amounts are different, consider what next steps to take. Be careful; since this subject has come up with one employee, chances are, it will come up with another.

Alternatively, you may suggest a sit down meeting to discuss what expectations you have that are not being met, or how well the employee is performing and that the compensation is “right along the lines of $14 per hour, all totaled”.

I’d very much like to suggest that for each employee in the office, conduct regular performance reviews and include this compensation and benefits summary to demonstrate pay provided for the work performed. It will assist in discussing how to proceed with pay commensurate with work and results.

From the Author: For an easy to use worksheet for this process, send an e-mail to fred@azda.org and request an “Annual Compensation Summary”.

“Within the past year or so, I’ve noticed more people have had economic trouble and are slow in paying, or aren’t paying on their past due accounts. I’m hoping you can shed some light on how to handle this situation.”

It certainly is a sign of the times that people are experiencing troublesome economic conditions in their personal lives. This certainly impacts the dental industry, as we’ve seen some practices declining in revenue, laying off workers, and having a hard time gaining acceptance to treatment from patients. Even when patients accept treatment, making good sound financial arrangements may not be as dependable as in the past.
First step is to be sure the basic elements of the practice’s financial policy are strong and orchestrated in a consistent, professional manner. To review the three key principles of sound payment systems are:

1. Always practice financially arranged dentistry. Inform patients of the fee and make specific arrangements for payment before any treatment begins.
2. Don’t be a bank. Avoid making arrangements that allow the patient to make payments over time. Often, this is called an “Open Account”. Sending statements to patients hoping they follow through with the “three equal installments we arranged” without any sort of written contract or debiting method is setting the practice up for disaster. And, the “half at prep, half at seat” has its pitfalls also. Patients may not return for the final delivery because they don’t have the money. Offices must finish treatment that was started regardless of the patient’s ability to pay.
3. Offer flexible but firm payment options. Offer a variety of options that will meet most people’s financial needs. Consider a reduced fee for payment made in advance and a courtesy for cash payment, third party financing (CareCredit, for example), and major credit cards. A good option is to employ a written payment agreement that locks in payments on a credit card; there isn’t the likelihood of patients not performing their part of the bargain when the office controls the payment process in this way.

Having a written financial policy comes in handy when discussing payment with patients. In addition, making payment arrangements in a private place rather than the treatment room (before treatment begins) helps in forming a good understanding as to how payment is handled and tends to produce positive outcomes.

What happens if these methods are used and the account goes bad? For instance, a patient has treatment that was financially arranged, a co-payment is made by the patient, insurance is submitted and eventually pays a portion of the charges, and the end result may be an existing balance. (This may also happen in the case of a patient who has treatment, does not have dental insurance, and a balance is still due.) Now the fun part: The person who is the guarantor has lost their job, or a spouse isn’t working any longer, and money isn’t available to pay the existing balance.

Now what!?

Here are some steps to consider when managing this state of affairs. First, send a statement. Shortly thereafter, say a few days, call and talk directly to the guarantor (or patient, if one in the same). Indicate insurance has paid, and the balance is their responsibility. Be as gentle as possible; use soft yet direct language such as, “Can you make a payment of any sort?”

The important aspect of this step is to open a dialogue and try as best you can to get the patient on some sort of automatic debiting process on a major credit card. Mention to the person, “We can work with you by spreading your payments out over the next few months by debiting your credit card monthly”. If it is declined once, make contact and work with the person. If it is declined twice, then send the account to the agency, attorney, or company that will initiate collection proceedings.

Out of embarrassment, patients tend to ignore statements and phone calls. Using pre-collection letters on colored paper (bright pink, orange and yellow) has proven effective. Here’s an example of the first letter that sends a gentle reminder of payment.

Will you please give me a few minutes of your time?

Serving you, our patient, is our number one priority at {Practice Name}. We want to make sure that all of our patients are completely satisfied with our office. Since your account balance is now overdue, we wanted to contact you.

On the other hand, if you’ve simply overlooked paying this balance on your account, just send payment via personal check or major credit card. If you need help with payment, we will gladly work with you to make arrangements that meet your needs.

Thank you for your attention, we look forward to your call.

Follow up a few days later with a phone call to again attempt to form a dialogue with the patient.

The next letter may be nicknamed, “The Expedite Payment Letter”. This will use similar text as the first letter mentioned earlier, but must be a bit firmer. If after two weeks there is no response, send a firm collection letter, accompanied by a collection phone call. The message on an answering system may be something like, “This is a phone call to collect an unpaid debt.”

If after two more weeks there is no response, then send the account to collections.

It is also very important to have patients and guarantors become aware of any fees charged for past due balances and for any collection fees which are to be paid by the patient and/or guarantor. A disclaimer for payment of fees charged could read something like this:

I have read and understand the above financial policy for {Practice Name}. I also understand that I am responsible for all charges which my insurance company may or may not cover at the level anticipated.
Should collection procedures become necessary, I agree to pay all collection agency costs, (amount charged by collection agency), and/or reasonable attorney’s fees including late fees.

Put this in the written financial policy and/or in the financial arrangements section of the treatment plan produced by the office’s practice management software.

Be clear about how the office handles insurance; use something like:

We are happy to file the forms necessary to see that you receive the full benefits of your coverage; however we do not guarantee any estimated coverage. Because the insurance policy is an agreement between the patient and the insurance company, we ask that all patients be directly responsible for all charges. Please know that we will do everything possible to see that you receive the full benefits of your policy.

Have the financial policy signed up front, by the patient during their first visit. Include it as part of the patient file. Scan the document for the record, or include it in the chart.

Consider adding a missed appointment policy where you feel it would be beneficial to charge for missed appointments. An office can charge for missed appointments, but cannot collect on these charges as they are not a bad debt. The charges can be written off if uncollectable; however, if and when the patient returns, collect the fee at that time.

Another question that comes up is, “Can we send a patient to collections if they haven’t paid their full portion and the crown isn’t seated yet?” Or, better yet, “Do we have to seat the final restoration if they are unable to make a full payment?”

First and foremost, a dentist must finish that which he or she started – regardless of the ability the patient has to make full payment for services. This gives a lot of credence to having the patient pay in full at the preparation appointment rather than making arrangements such as asking for “½ at prep; ½ at seat”, or some other arrangement which runs the risk of having the office finish treatment without being paid in full.

If a patient has a balance due on an account, remind him or her of the amount owed when making the confirmation call. Politely inform the patient that the balance will be due when arriving for the next appointment:

“Just confirming your appointment for tomorrow. The balance due for your treatment is $300. Please bring a method of payment; we’ll see you then.”

Do not leave this on a messaging system; due to HIPAA regulations, your voice mail message should be something like:

“Hi, this is Vicki, I’m calling from Dr. Smith’s office regarding your dental appointment. Please call back as soon as possible; our phone number is 555-1212”.

Make sure the conversation regarding payment is made directly on the line with the patient/guarantor, or parent if the patient is a minor.

On the collection call, make sure you identify yourself and where you are calling from; that is, the name of the office or of the dentist. If you’re not speaking to the patient because the patient is a minor, confirm you are speaking with the parent or whoever signed to be responsible for payment of the account. Confirm with that person their name, date of birth, and their address.

Incidentally, there is some question as to who is responsible for a minor brought in for treatment. On occasion, mom will bring her child and complete the paperwork indicating dad is the responsible party. Not true. Dad may very well be the responsible party outside of the practice; however, the person who signs the financial policy at the time of admitting the patient to the practice is responsible for payment. As another example, grandma brings this same child to the dentist’s office, mom didn’t drive but signs the paperwork, and claims dad is responsible. In this case, mom signs the paperwork; mom’s responsible.

Managing payment during tough economic times can cause stress and frustration. Use these methods to ward off potential conflicts before they become serious problems and your office will run smoothly.

I’m looking for some help in how to let my team know what I expect of them and how I’d like them to participate in reducing stress in the workplace.

Wow, you have stress in the workplace? Welcome to the real world!

No matter how many employers a person has over their career, it’s inevitable he/she will have conflict; it’s human nature. Managing conflict in such a way that it creates an alliance, rather than an obstacle, is the result of successful management and people techniques.

At times, the education and experience of the worker and manager are different. Take a dental office, for example. The new employee may have had to “pull themselves up by the bootstraps” and has endured many obstacles in their personal and professional lives. This may have given them much experience in the school of hard knocks and they may have witnessed different management styles along the way; even though the employee may have no formal education after high school. On the other hand, a dentist who owns their own practice may not have pursued any formal business or people management training, and may have never learned the art of diplomacy. This connection with a new employee and dentist may result in frustration, anxiety, and stress.

Building a great relationship with people on both sides is key to good management and ever more important in today’s changing times. A sluggish economy has forced layoffs and other cutbacks in businesses of all sizes, resulting in high stress, low morale, and concerns about job security. People have fewer options in terms of walking away and keeping a job has more to do with balancing technical and interpersonal skills. During the late 1990’s, dentistry was experiencing wide spread growth and prosperity. In comparison, it’s more difficult to sustain growth and profit today.

When a small business such as a dental office relies on outstanding people performance, management and people skills go a long way towards weathering the storm. One must avoid loosing ones temper, being defensive and controlling emotions in general in order to be constructive in dealing with workplace conflict and performance.

A dentist who by default has become a manager of people must be able to get as much from his or her employee’s as possible; but no employee should be a doormat. Realistic expectations of job performance and behavior must be clarified up front. For example, an agreement to “go the extra mile” when a patient calls with an immediate concern and must be seen right away should be discussed. As a result, it is then understood that occasionally, the office must stay open and workers may have to stay late to tend to the needy patient. Agreed, it should not be the normal operating event.

Keeping the practice’s big picture in mind is vital, too. Dentists as managers must share with the team the vision of the office and have it become a component of day-to-day activities.

Flexibility with events and embracing change is important. Good employees, for example, will try to handle all they can and resolve those things that are causing patient service problems during the course of a busy day. Staying calm, thinking things through, and being fair will most often help everyone come to a sensible solution.

In answer to your original question, here are some down-to-earth approaches that dentists as managers can impart to their employees that will help resolve conflict and stress in the workplace. Perhaps this is a “cut-out” that can be the agenda topic for the next team meeting.

1. Understand what the dentist wants.
   1. Develop a knack for reading the dentist’s mind; pay attention to feedback and address any concerns immediately.
2. Keep the dentist in the loop
   1. They don’t like surprises and embarrassment. When things are going well, a short message or conversation, would suffice. When a problem arises, don’t hide it; explain and offer solutions.
3. Don’t waste his/her time.
   1. Write down what you need, be ready to answer questions, then leave if the reply isn’t appropriately forthcoming. Follow up with a reminder memo, if necessary at a later date.
4. Be a rock.
   1. Show up early, meet deadlines and volunteer for work when you have free time.
5. Don’t take criticism personally.
   1. Keep an open mind, control your emotions and always stand up for yourself, politely, but firmly.
6. Don’t play games.
   1. Never criticize or gossip about a co-worker, and mind your own business.
7. Know his/her quirks and accommodate them.
   1. Does he/she prefer notes, formal memos, or straight up communication – face-to-face?
8. Pitch ideas.
   1. Make sure they’re reasoned, solution-oriented and don’t add to the workload of others while somehow skipping yours.

Consider these successful management techniques as tools of the business. Work them into your practice and proactively ward off stress and conflict in your practice.

Saying Thank You Before the Thought Fades Away..

Several years ago, I recall a client of mine who was running a very profitable general dentistry practice and contacted me questioning his giving of annual bonus’ to his employees. He based the bonus on length of time served in the practice, overall productivity of the office, and pay scales of the employees. Through all the years he had been paying bonus checks, only two employees had ever said "thank you." Neither was still with the company. One moved to the east coast, and the other retired to a small town within the state where the doctor practices.

My client was so disappointed with this lack of etiquette that he discontinued the incentive bonus program, and if anyone had the guts to complain, he would quickly retort, "I have been paying bonus’ for several years, and no one has bothered to say thank you. When one of you takes the initiative and says thank you, I might consider bringing back a bonus program.”

I sat back and pondered this dilemma and what came to my mind were the gifts I would receive as a child from friends for my birthday or Christmas, and also gifts from my grandparents. It wasn’t the gifts that came to mind, per se, it was the lesson from my mom and dad to send thank you cards and acknowledge the gifts received. Besides, grandparents and others may have wondered, what happened? Was the gift lost in the mail? Did the poor thing lose the power of speech or the use of his writing hand?

I’m sure there are countless stories out there of people who have sent a birthday check and not heard a word back. Perhaps the only evidence that the gift was received is found among the pile of canceled checks returned from the bank! Oh well, the benefactor must think…”hope they bought something nice for herself.

On occasion, I’ll receive exceptional service in a restaurant and leave a larger than normal tip, hoping that the server would realize a larger tip is a sign that I enjoyed the experience and would like to return, particularly if my generosity is acknowledged. This hasn’t happened yet: the server hasn’t followed me out and said, “Hey, I just wanted to thank you for your generous tip, I really appreciate you showing how much you enjoyed my service this evening. When you return next time, ask for me, I look forward to seeing you again!” Right: what world am I living in?

If you're a dentist and have recently completed a large case that the patient either pre-paid, or paid in full, what have you done to make that patient know how you feel about it? It’s great to bank the money and have an above average month in collections because of the huge case you just completed, but what about the patient who received the treatment and is now part of your success story in dentistry?

A thank you just makes sense. A prompt thank you is easy to say, a lot easier to say than “Gosh Mrs. Jones, I neglected to tell you how much I appreciate you as a patient,” or “How've you been after all this time?”

In New York City, several years ago, the police are enforcing the quality-of-life laws and then Mayor Giulianni is even calling for the city’s cabdrivers and waiters to improve their manners, pointing out that rudeness is not a great civic selling point. It seems to be working. Crime is down. Tourism is up. And, the city is on a roll!

Many dental offices wait until the holidays to say thank you. A Thanksgiving card to patients is a common form of marketing this time of year. Nothing wrong with that, but why wait? Seize the moment, and be more responsive by saying the magic words the moment it’s appropriate. Stay away from the “corporate logo” stuff, those are fine for advertising, but it’s not a gift.

I try to tell my clients, day in and day out, the best gift a dentist can give to his or her patients or team members, have no monetary value. They are the hand written cards that say, “Thank you for being such a great patient. It’s people like you that make me proud to be a dentist.” Additionally, a telephone call on the evening of treatment to make sure patients are well is a tremendous way dentists can show how much they care about the well-being of their clientele; although not an outright “thank you”, but a powerful gesture nonetheless.

I recently received a note from a dentist client of mine saying, “Thanks, Fred. I couldn’t have done this (transitioned his practice) without you!” Needless to say, I was on cloud nine for days!

Imagine what would happen if you caught someone who works for you doing something exceptional and you say to him or her, “Thank you, I really appreciate you being here. You’re a fantastic team member in this office!” Believe me, an action of this sort will be extremely well received.

Sure, it’s a two way street. You’d like your employees to do the same when they are given a bonus or rewarded for exceptional performance. Part of leadership is doing those things you would hope your employees would do as well. Lead by example, then. Say “thank you” more often when the occasion presents itself; you’ll see it come back in many ways.

"I read your article last month on backing up data properly to guard against computer crashes and other events. Can you give me some more information on Online Backups?"

As it turns out, during an interview with a vendor of on-line backup services to prepare information on this article, the vendor related a story of a dentist who called late in the day prior to my discussion. The office manager was performing “Month End”, a regularly recommended accounting and practice management routine in Dentrix. By the way, Dentrix recommends the office perform a backup of the data prior to running this utility. After running Month End, the program reported an error and the dentist noted a significant loss of data, in particular, a large portion of the appointments, production information, accounting information, and claims was gone!

The dentist asked the vendor, “Did I perform that On-Line back-up we were talking about?” The vendor responded, “No, you have not subscribed to the On-Line version of our back-up services; all of your data is backed up on tape drives.” The vendor then recommended the dentist find out what tape was used for the most recent backup, place it in the tape drive, and together they will try to restore the data from that point. As it turns out, the tapes were not labeled, and the dentist and office manager spent considerable time trying to discover which tapes were used; unfortunately by trial and error! Once the correct tape was found, it took nearly seven hours to restore the data from the backup tape. Then, all of the information from practice operations over the previous 24 hours that was lost had to be reconstructed, primarily from memory, and then manually entered back into Dentrix.

OUCH!

Authors Note: Okay, so now all of you out there in dental land are going to pay attention and implement or confirm that a sensible and consistent backup routine is protecting the valuable data in your office! This event doesn’t even take into account something that would be out of one’s control, i.e., fire, theft, thunderstorm, electrical power surges, etc.

While we're on the subject, in the dental industry, Management Software failure and operator error are the common culprits in losing data. Hardware failure comes next, then conversion from a previous practice management software program to new management software contribute to data loss and or corruption.

In the past, dentists may have conducted full backups on tape as a daily routine. This was not recommended in the past and is not now. Here’s why: a corrupted file or program may kill important data and information; the daily full backup routine then wipes out all of the good data and replaces it with corrupted data. Without careful inspection each time a backup is performed, in this case daily, one would backup corrupted data until the error is discovered somewhere down the line. It begs the question, “How much data have I lost, and what do I do now?”

Over the years, technology has advanced to the point where there has been a logical progression for small and large businesses wanting a remote off site location to backup data. Online backups became noteworthy as early as 2005 as the capability to acquire faster and higher quality Internet speed, commonly knows as bandwidth, brought on the ability to upload and download data faster than usual. Additionally, storage mediums, as they exist today and existed only a few years ago, are a problem. Traditional backup systems were faulty in that a tape cartridge could fail, or if one were to drop an external hard drive, or HD, loaded with valuable data, it’s toast. Even if one takes perfect care of a backup device (tape or external HD), if one small element of the device becomes de-magnetized, the whole backup may fail.

Hardware companies also expanded their ability to produce products that will store huge amounts of data at a much lower cost; in some cases, a computer used by a company who provides on-line backup systems can store up to 30 terabytes of information. Just to clarify for you non-byte heads, one terabyte is equal to 1,000 gigabytes; and one gigabyte is 1,000 megabytes; and one megabyte is 1 million bytes of data. Okay, that’s a lot.

These events removed most of the barriers to entry for small businesses to utilize components, high-speed Internet and large storage devices, for remote backup services.

In the internal workings of a dental practice for example, data changes frequently – every minute of every working hour of every working day. And an office that has a database that changes frequently and wishes to back the data up regularly will encounter a bottleneck: bandwidth; in particular when uploading or sending files out of the system. More often than not, uploading files can be as much as 10% slower than downloads (bringing data in). This can pose a huge problem for dental office with large databases, some which may exceed 150 gigabytes (150 billion bytes of data), containing digital x-rays and digital images (pictures). If the connection/bandwidth is slow going out, it’ll seem to take forever and a day to backup online! My suggestion is to test the upload speed of the Internet service. Contact the Internet Service Provider (ISP) and ask them to test the connection speeds for uploading and downloading data. If it’s slow on either end, ask for a quote on upgrading and determine if it will be cost effective to upgrade or stay with the current configuration.

What was missing from the equation but is now available with high speed Internet and large storage devices is software that allows one server, the main computer in the business, to communicate with another server, a large storage computer off site. This type of application allows the customer to install software on the computer at the dentist’s office that collects data, images and all other information, and sends it over the Internet encrypted to a remote off site server, or computer, for storage. The data transferred would appear as folders with letters and numbers that cannot be deciphered by the online backup services company. This, of course, complies with HIPAA requirements to protect private information.

Where online backups can be useful is when documents of a much smaller size in Dentrix or QuickBooks, for example, can be backed up quickly and frequently. These include the appointment book, patient notes, the ledger, the QB data file, just to name a few.

Some software will also keep record of modified files in the history – keeping previous versions of files.

Timeliness is an essential element in backing up data. In most cases, one would have a removable HD system to handle large databases (i.e., x-rays, and digital images), with one cartridge for every day, removed off site each day in a rotation. Human error may enter into the event; the person responsible may forget to take the cartridge home, the backup may fail unbeknownst to them, or the employee leaves the same cartridge in day after day.
Redundancy, or concurrent backups, is a strategy where one configures the backup of critical data during down time (evenings) while the database isn’t being used, and then uploaded to an off site server. Further, the backup system of choice usually can be configured so that the system only backs up when the system is idle – in most cases, this occurs during the evening hours when the system isn’t being utilized.

Most backup systems can run concurrently. For example, an office could run a backup system using an external HD and set a window of 11 pm to start, and an online function to begin from 8 pm to 6 am; both won’t conflict with each other, and the backups will function together.

An opinion regarding online backups is that it would not be a suitable backup solution for extremely large databases (images, x-rays, etc.). Some advanced restorative dentists who collect many digital extra-oral images, digital x-rays, etc., create such large databases that the online backup systems may cause a problem when transmitting these large files of data. In addition, to retrieve a significantly large database in case of a crash, or to restore missing information, can be very slow and take a considerable amount of time. An alternative, and a significant advantage to online backups provided by some vendors, is after the first initial backup of all data on the client’s server, only additions, changes, deletions, and modifications may be backed up. This will save considerable time when conducting routine backups on a daily basis in that smaller amounts of data are transferred and backed up, rather than regularly backing up the entire database.

The vender of online backup services has a choice to put their servers used for online backup in Data Centers. These typically provide government rated security with key card and biometric entry, and lock and key cabinets for safeguarding the data. In other words, the only way to access the computer with the data stored from your dental office is for the person to have an electronic key card, a thumbprint of the vendor, and a key to open the lock on the cabinet where the computer is stationed. Pretty secure, I’d say.

Finally, what happens if “operator error”, a hardware crash, or other catastrophe falls upon the dental office? Using a reputable vendor will assist in retrieving your data in case something happens. One potential “fly in the ointment” is that downloading data from the remote source in an attempt to restore the data may take a considerable amount of time due to the large file size being transferred. Sure, this is one negative aspect of backing up information remotely. However, a good vendor will be able to retrieve the data and place it on a portable storage device and hand deliver it to the office and conduct the restore function on-site.

Pricing. Traditional backup services have been a “pay for amount service”; the more you backup, the more you pay. Recent innovations offer a much more reasonable solution, in terms of pricing, with no limits to the amount one can backup.

Reasonable industry rates seem to be in the neighborhood of $2 per gigabyte backed up. Fees can vary from $50 per year, to $25 per month up to $55 per month for larger databases with added services, such as recovering lost data by bringing the backup to the office and assisting with restoring.

Summary. The main advantages of online backup is there are no tapes to worry about, no worries about a CD or DVD being scratched or cracked, no external HD to worry about malfunctioning, or any storage device being left behind in the car during the sizzling hot summer months. And did I mention this earlier? Any backup function that involves people is open to human error; which happens to be the most common culprit.
A business, dental office is no exception, without proactive backup and recovery policies will face considerable hardship in lost business and revenue; and may face the risk of being out of business within a short period of time following a major computer disaster. Loss of business data may ruin a company’s reputation and/or may lead to expensive litigation as a result of not properly protecting important information.
Make sure the vendor who provides online backup services provides details of what is included. Ask if application data is being backed up, such as Dentrix, QuickBooks, MS Office, digital imaging applications (Dentrix Image, Dexis, Kodak, TigerView, etc.). Also, what kind of communication is sent back once a backup routine is performed; such as e-mail’s sent nightly to the customer, and messages if the backup failed or if a problem occurred. If data is lost at the dental office, will the company come to the office and assist with the restore process to be sure the business doesn’t lose valuable time, data, and money.

Databases are becoming larger every day. Data such as e-mail's, accounting entries, and patient appointments, change daily. One can never have too many redundancies in backup up critical data. Hiring a competent computer technician is a good idea to help with the Information Technology aspect of a dental practice. Be Proactive, and don't get caught with a computer crash or human error causing a problem where a good backup routine was missing or inefficient.

There is a NEED FOR EMPLOYERS to have appropriate protection in maintaining customer relationships after an employee leaves. In general, courts recognize this. The two basic types of restrictive covenants are "noncompete," which precludes a former employee from working in the same business as the employer for a certain period of time, and "nonsolicitation," which restricts the former employee from soliciting customers of his or her former employer or from providing services to those customers.

All this said, only reasonable restraints will be enforced. Typically, restrictions must be no broader than the employer’s legitimately protectable business interests. Those covenants not to compete that are overly broad, overreaching, or lack necessary consideration are not enforceable. Normally, the burden is on the party that wishes to enforce the covenant to demonstrate that the restraint is no greater than necessary to protect the employer’s legitimate interest, and that such interest is not outweighed by any hardship to the employee or any likely injury to the public.

Since early English common law, there has been a strong judicial disfavor toward a bond or covenant that prevents employees from pursuing their profession or trade after termination of employment. Historically, covenants not to compete were viewed as restraints of trade and were invalid. Eventually, reasonableness came to the rescue.

Covenants given in connection with the sale of a business are viewed with greater favor because courts recognize the need to protect business goodwill.

An additional factor to be considered is the likelihood of injury to the public if the restraint is allowed. For example, an oral surgeon (employee) may be restricted from practicing oral surgery in the geographic area surrounding the employer’s practice, but the oral surgeon (employee) may still provide hospital-based services as a public service in the ER where he or she has privileges, even though it is within the geographic area, when the services are not directly connected with the employer’s oral surgery practice.

General thoughts and considerations

A covenant not to compete is only enforceable if it is reasonable in intent and there is a legitimate business reason to enforce it, such as protecting customers or confidential information. To determine if a covenant not to compete is enforceable, three aspects must be considered:

1. SCOPE. The covenant must be very precise as to what the people involved can and cannot do.
2. GEOGRAPHY. The geographic area must be reasonable, and what must be studied is where the employer’s patient base comes from and where the employee works.
3. TIME. This portion of a covenant is litigated often due to its being the most misunderstood. In essence, the covenant must be in force only long enough to get a replacement employee up and running. However, the replacement employee could in fact be the owner where the business cannot sustain an extra employee for whatever reason. Circumstances often dictate the time period. It likely will be different for an employee (shorter) than for a seller (longer).

Nonsolicitation

In cases where a contract has a nonsolicitation clause, the clause must be reasonable and must clarify "What is solicitation?" If people want to seek out a health-care provider of their choice, then a contract with a nonsolicitation clause cannot limit these people’s desire to seek care with whomever they wish. A good illustration is a grade school dance. On one side of the gym are the boys, and on the other side are the girls. One asks the other to dance. Who is soliciting? The person who initiated the contact is soliciting.

A final aspect of covenants is proving damages. Using the example of a patient who wishes to seek out a previous employee for dental care and does not wish to return to the employer’s practice, for whatever reason, what are the damages to the employer if the patient wasn’t going to return anyway?

In closing, restrictive covenants through employment and business purchases or sales are a complex legal matter and must be handled with care. Consult a good attorney who works closely with dentists.

Restrictive Covenants As seen in Dental Economics Magazine

“Employees Behaving Badly: Give us your best advice on how to deal with them!”

We’ve all heard the horror stories; some are NOT urban legend!

Some more frequent stories of “Employees Behaving Badly”, unfortunately, involve social networking. How about learning that an employee:

• Constantly texting friends and family during office hours
• Updating “facebook” while on the clock
• Chatting long-distance on Friday, the “admin day”, while no one else is around (supposed to be working on filling hygiene, confirming patients for the next Monday, contacting an insurance company to speed payment on claims, etc.)
• Surfing the internet during work hours

The more egregious typically involve theft and embezzlement; most often an employee is caught:

• Absconding funds from the office
• Writing false prescriptions for personal consumption
• Stealing product (bleaching gels, electronic toothbrushes)

Taking half the money received from a vendor for re-cycled precious metals (gold) and distributing the balance to the rest of the team (in an obvious effort to secure naive accomplices)

Dealing with “Employees Behaving Badly” begins with setting up an environment with good personnel management systems that proactively defuses improprieties before they happen. When they do happen, it’s important to take action right away.

No matter how many employees a person hires and fires over their career, it’s inevitable events will occur where people do something wrong which will without doubt result in conflict; it’s human nature. Managing poor behavior with corrective action and discipline, and controlling conflict in such a way that it creates an alliance rather than an obstacle, is the result of well-orchestrated people management techniques.

Often times, the education and experience of the worker and manager are different. For instance, the new employee may have had to “pull themselves up by the bootstraps” and has endured many obstacles in their personal and professional lives. This may have given them invaluable experience in the school of hard knocks and they most probably witnessed different management styles from previous employers along the way. On the other hand, a dentist acquiring their own practice and becoming a manager of people for the first time may not have pursued any formal business or personnel management training, and may not have learned the art of diplomacy. This imbalanced connection with a new employee and new manager may very well result in frustration, anxiety, and stress.

Building a great relationship with people on both sides is key to good management, and is ever more important in today’s changing times. A sluggish economy has forced layoffs and other cutbacks in businesses of all sizes, resulting in high stress, low morale, and concerns about job security. People have fewer options when they consider walking away from a current position. As a result, keeping a job has more to do with balancing technical and interpersonal skills.

During the late 1990’s, dentistry was experiencing wide spread growth and prosperity. In comparison, it’s more difficult to sustain growth and profit in dentistry today.

When a small business such as a dental office relies on outstanding people performance, management and people skills go a long way towards weathering the storm. One must avoid losing ones temper, not be defensive, and control their emotions in general in order to be constructive in dealing with workplace conflict and poor performance.

A manager must be able to get as much from his or her employee as possible; but no employee should be a doormat. Realistic expectations of job performance and behavior must be clarified up front. For example, a dentist would be wise to discuss with employees what will happen when a patient calls with an immediate and urgent dental need towards the end of the day. Instilling a “we will go the extra mile” principle clarifies the issue before it becomes a problem. It is wise to make clear that occasionally the office will stay open and a worker or two must stay late to tend to patients in need. Agreed, it is not the normal operating event, but it happens once in a while. Another example would be to make it clear that cel phone usage, for personal calls, texting, internet surfing, are not allowed during patient care hours; using a cel phone while clocked out during lunch, at the beginning of the day, and at the end of the day is permissible.

Keeping the practice’s big picture in mind is vital, too. Dentists must share with the team the vision they have of the office so that it becomes a component of day-to-day activities. For instance, “We will always put the patient’s comfort first” may be a valued business operating principle that can be used as a foundation for establishing patient services policy.

Good employees will try to handle all they can and resolve those things that are causing patient service problems on their own. Sometimes, the boss needs to step in to provide constructive criticism, most likely because the employee did not handle the situation properly and made a mistake. Reprimanding an employee for unacceptable behavior is hard at first, but the skills can be learned.

Suggestions for Reprimand

If an incident occurs where an employee misbehaves, violates a company policy, or otherwise causes a problem, follow these guidelines.

• Do not reprimand in front of other team members or patients
• Choose a time where a professional and private meeting can take place
• One witness to the reprimand, other than the guilty party, is sensible but not required
• Be specific about the event (date, time, policy violated, behavior, etc.)
• Ask, “Why did this happen?”
• Allow the employee to respond; there are always two sides to every story
• Determine if in fact the employee is in the wrong, or if the behavior was misconstrued
• If it turns out the employee was in the wrong, tell them why, and discuss how the event should not happen again in the future
• If appropriate, determine a disciplinary course of action – for example, sending the employee home for the rest of the day with pay for only hours worked.
• Be sure to include a written reprimand, signed by the employee and employer, in the employee’s personnel file. Consider these elements:
  • Employee name, date and time of incident
  • Explanation of what happened
  • Employee Statement
  • Employer Statement
  • Affirmation from the employee: “I re-affirm my commitment to adhere to the policies and standards of conduct for the company. I understand that a further infraction may be interpreted as a voluntary resignation from employment.”

Thinking of discharging an employee for bad behavior?

Although employers have good cause for discharging an employee, they do not keep adequate records to substantiate good cause for the discharge. This is a common problem throughout the dental community.

When one wishes to discharge an employee, follow a similar course of discussion as with the previously discussed reprimand. As soon as it is determined that the employee was in the wrong and it is clear employment must be terminated, dismiss the employee right away. Something simple, such as, “Based on the circumstances we’ve discussed, you’re employment ends right now.” Or, “You’re fired” works just fine.

It is very important at this point to record everything that has happened, including discussions, events, witnesses, dates, and times. Not only is this good management, events are well-documented and easy to reproduce just in case the employer must prepare to protest the payment of Unemployment Insurance Benefits. Ultimately, it is the doctor’s responsibility to provide supporting evidence to justify the discharge.

Here is a reminder list of some of the most overlooked information needed in the employee’s personnel file to justify dismissal from employment:

1. Keep records of all misconduct including dates, witnesses and specifically, what the employee did wrong.
2. Keep accurate records of all warnings both verbal and written, including when warned, who did the warning, and why the employee was warned.
3. Have an accurate statement of the final incident that caused the employee to be discharged including when, why and any witnesses to the event.
   Inaccurate and incomplete employee records are common reasons why employers do not receive favorable rulings when protesting an Unemployment Insurance claim made by a former employee.

At-Will Employment Review

Keep in mind that Arizona is a right-to-work state, where employment is at-will. Meaning, an employee may be dismissed, with or without notice, at the discretion of the owner/employer for any reason or no reason, at any time. Just the same, an employee may leave a place of business at any time, for no reason, or any reason. In either case, common business courtesy would suggest providing reasonable notice of termination or resignation, although this is not required.

The exception is when an employment contract states specifically in writing the terms of employment and dismissal protocols. This overrides at-will employment. Such a contract typically includes terms and conditions of how and when both parties will provide notice of termination or resignation.

Help the team understand what they can do better!

Here are some down-to-earth approaches that employers can impart to employees that will help resolve conflict and stress in the workplace:

1. Understand what the dentist wants: Develop a knack for interpreting how he or she will respond to situations; pay attention to feedback from him or her and address any concerns immediately.
2. Keep the doctor in the loop: Dentists don’t like surprises and embarrassment. When things are going well, a short message or conversation, would suffice. When a problem arises, don’t hide it; explain and offer solutions.
3. Don’t waste his or her time: Write down what you need, be ready to answer questions, and then leave if the reply isn’t immediately forthcoming. Follow up with a reminder memo, if necessary at a later date.
4. Be a rock: Show up early, meet deadlines and volunteer for work when you have free time.
5. Don’t take criticism personally: Keep an open mind, control your emotions and if appropriate, stand up for yourself, politely, but firmly.
6. Don’t play games: Don’t criticize or gossip about a co-worker, or anything for that matter, and mind your own business.
7. Know his or her quirks and accommodate them: Does the dentist prefer notes, formal memos, or straight up communication face-to-face?
8. Pitch ideas: Make sure they’re reasoned, solution-oriented and don’t add to the workload of others while somehow skipping yours.

It may never happen in your office, but Employees Behave Badly! If events take place, act swiftly and come to a sensible and fair solution. Establish reasonable personnel management systems that will ward off problems before they arise. The practice will become less stressful, and employees will serve you and your patients well.

“We have a patient who sometimes ‘misbehaves’ during visits by either playing practical jokes on the staff or making inappropriate sexual and politically incorrect comments. What are the steps we should take up to and including dismissal?”

As the employer, you are shouldered with the responsibility to provide a work environment that is safe and free of discrimination, intimidation, and hostility. If you witness behavior first-hand that is unacceptable from a patient, the best scenario is to approach the patient immediately and ask that this behavior not continue as you feel it is inappropriate. If a member of your team brings the behavior to your attention, then you must provide direction and take action to correct the problem. In today’s article, I’ll provide suggestions to handle this appropriately.

People have different thresholds of tolerance. What might seem a bit funny to one may be intolerable to another. What might seem acceptable to some may be offensive to others. For instance, a highly recognized sports magazine publishes a swimsuit edition each year where bikini clad women are photographed in exotic locations. The issue appeals to some men (and some women), yet is scorned by some women (and some men). If a patient were to bring this into the office and use it as a basis of conversation regarding sexuality, a person may be offended.

Another example may be a person who comes to the office and recites a joke that has sexual or inappropriate implications. Some may be offended by this conduct; others find it amusing. There are venues for blue comedy or offhand remarks such as comedy clubs. However, a workplace is just that, a place to work and provide services. And again, as the employer, you must make certain that the workplace is safe and free of harassment, intimidation, and discrimination.

In particular to the question posed for this article, harassment is a form of discrimination that violates Title VII of the Civil Rights Act of 1964. Work Environment harassment occurs when unwelcome comments or conduct based on sex or race interferes with an employee’s work performance or creates an intimidating, hostile or offensive work environment.

Anyone might commit this type of harassment such as a co-worker, or non-employee, such as a contractor, vendor, guest, or even a patient of record. The victim can be anyone affected by the conduct, not just the individual at whom the offensive conduct is directed.

Harassment in today’s day and age has become broad-based. Some examples include but are not limited to:

• telling sexual or lewd jokes;
• leering;
• touching in a way that makes the person uncomfortable such as patting, pinching, or intentional brushing against another’s body;
• making offensive remarks about looks, clothing, or body parts;
• use of racially derogatory words, phrases, or epithets;
• making disparaging remarks about an individual’s gender or race;
• negative comments about an employee’s religious beliefs (or lack of religious beliefs;
• negative comments regarding an employee’s age;
• sending, forwarding or soliciting sexually suggestive letters, notes, emails, or images; and
• derogatory or intimidating references to a person’s mental or physical impairment.

When an event occurs that creates unease in the office, the first step to take is to act immediately. Bring the team together at the first possible moment where patient services are not interrupted. This may be right before a lunch break, or at the end of the day before anyone leaves the office to go home. Talk about what happened, and then review the office’s policy regarding what is considered harassment. Every person in the office should know what is considered inappropriate behavior.

It is advisable to have a strong, enforceable policy prohibiting harassment, sexual harassment, sexual discrimination, and inappropriate behavior. This policy should be contained in the office’s Employee or Personnel Policy Manual. A signed acknowledgement form stating the employee has read and understands the office’s policies should be included in each employee’s personnel file.

On some rare occasions, the guest or patient may not be entirely at fault. Try to discern if employee actions encouraged the misbehavior from the patient, without singling out team-members. If you have determined it was a team-member’s encouragement and dismissed it originally as just teasing, that was a mistake. The correct approach is to take the employee aside and discuss the issue in private. Come to an agreement on policy and how these situations are not tolerated. Agree to move forward in a positive light agreeing that events like these are avoided in the future.

To provide a bit of guidance regarding how an employee manual would stipulate the office’s policy on Sexual Harassment, consider the following:

Sexual Harassment:

The employer is committed to providing a work environment free of discrimina­tion. In keeping with this commitment, the employer maintains a strict policy prohibiting sexual harassment. This policy applies to all employer agents and employees, including management. Sexual harassment includes: flirtations, touching, propositions, verbal abuse of a sexual nature, graphic or suggestive comments about an individual’s dress or body or actual or perceived sexual orientation, the display of sexually suggestive objects or pictures, including nude photographs.

Sexual harassment also includes, but is not limited to unwanted sexual advances and requests for sexual favors where either (1) submission to such conduct is made an explicit or implicit term or condition of employment; (2) sub­mission to or rejection of such conduct by an individual is used as the basis for employment decisions affecting such individual; or (3) such conduct has the purpose or effect of substantially interfering with an individual’s work perfor­mance or creating an intimidating, hostile, or offensive working environment. Employees who violate this policy are subject to disciplinary action, including dismissal.

Any incident of harassment, including work-related harassment between employees, patients, or any other persons, should be reported immediately to the employer and/or to the designated individual. Employees will be given the name and or title of the individual so selected. A prompt investiga­tion will be conducted as discreetly as possible. Obviously, no employee reporting any such harassment will be subject to any sort of retaliatory action. Any employee accused of prohibited conduct will have the opportunity to explain the conduct in question. In the case of our employees, if harassment is proven, the offender will be disciplined, up to and including termination. It is the responsibility of every employee to conscientiously follow this policy.

Conclusion

Inappropriate behavior between co-workers, employers & workers, vendors, and patients may happen. Discuss with your team how you will handle this issue. Establish a policy that is professional, sensible, and in line with your dental practice’s fundamental principles. Regardless of how patients conduct themselves, your team must know the office’s policies and behave in a responsible, professional manner within the work environment.

Next Month:
How to appropriately dismiss patients from the practice.

“I want to be sure I'm following the right"ethical" path when delegating tasks and duties to my team. What recommendations do you have to keep me on the straight and narrow?”

Since I’m not an attorney, this article is not meant to provide legal advice on business ethics. And, since I am not a licensed dentist in Arizona, I don’t possess the clinical expertise to evaluate a person’s skill level when providing dental services. My experience as a practice management consultant and broker for dentists and dental practices has given me the opportunity to develop an extensive knowledge and understanding of the business of dentistry. As a result, I will provide recommendations that I have found reasonable, prudent, and successful in developing a standard of excellence in managing the business aspect of dental practices relating to delegation of duty.

As a matter of course, it’s important to be knowledgeable and understand the code regulating dentistry as it relates to unethical conduct. My first recommendation is to reference Arizona Revised Statues §32-1263 Grounds for disciplinary action; definition, for an explanation of the code. For the purpose of this article, I would like to point out the area that meant the most to me when I researched the stature:

§32-1263:
D. For the purposes of this section, “unethical conduct” means the following acts occurring in this state or elsewhere:
15. Engaging in any conduct or practice that constitutes a danger to the health, welfare or safety of the patient or the public.

Since 1983, I have been extremely fortunate to work with exceptional dentists and team members in Arizona and across the country who embrace the principle imbedded in this statute. In order to accomplish realistic goals for the development of a successful dental practice, a foundation in principle must be laid. Basing these principles on the fundamental concept that what a person is doing must trace back to the thought of providing services that bring health, welfare, and safety to the patient and the public is vital to good business and practice management.

With this in mind, consider how a dentist may delegate duties to the team so that the practice grows and ensures that patients become healthy in a safe, professional, and comfortable environment.

Dentists have long wrestled with balancing the duties of a clinician with those of a manager. And as a dental practice grows, so do the tasks and responsibilities needed to sustain growth in such a competitive profession. Effective delegation can dramatically improve the efficiency of a practice by helping to build teamwork within the staff. And cooperation and teamwork can contribute to helping staff members to reach their full potential.

One of the reasons why people hesitate to delegate is that they believe they can do things better themselves. However, market forces such as managing the financial aspects of a dental practice, dealing with managed care, ensuring compliance with governmental infection control standards, leading a team of workers, ensuring the practice is following a code of ethical conduct, and sustaining growth in a competitive environment take dentists away from productive treatment time. These factors necessitate the proper distribution of responsibility in such a way that it is embraced and accepted by the staff.

But don’t confuse delegating with dumping. If an employee feels he or she is being dumped on, then that is probably because a task has been delegated without adequate authority to carry it out. It’s all in the way one delegates. Yes, there’s an element of risk in delegating authority. But if one doesn’t feel comfortable with that risk, it probably means that the task is being delegated to the wrong person. And if the right person to delegate to doesn’t exist, it’s time to hire better people.

Here are some tips on implementing distributed responsibility effectively:

a) Remember that the ultimate goal of delegation is neither to get rid of the work; nor is it just to keep employees busy. The ultimate goal is to increase the output of the team and the practice.

b) Don’t delegate the method delegate the task. Let the person you delegate to determine the method.

c) Make sure that the person delegated to “buys in” to the task, agrees to the time frame, and accepts the responsibility. If one is unwilling to delegate the responsibility, one shouldn’t bother delegating the task.

d) Make sure the person delegated to has input into what constitutes accomplishment. Goals should be measurable.

e) Once the task is assigned, keep your distance. It’s okay to ask for updates, but don’t snoop or pry. If you feel you must, you’ve delegated to the wrong person.

f) Require reporting, but not excessive reporting.

g) Follow up only on target dates, or when the project is finished, or when it should be finished.

h) Make sure the person delegated to is accountable for his or her success or failure. Applaud and reward success, discuss and document failure. If necessary, develop a plan together to improve performance.

i) Beware of over delegation to superstars. If one employee is relied upon too heavily, then there is a superstar shortage. And there may be a bigger superstar shortage if the overloaded superstar’s workload is not balanced.

Finally, do not confuse the “delegatee” with the “gofer”.

Gofers “go fer” because they have to.
Delegatees “go fer” because they want to.

In summary, the basis of effective delegation is trust. If one doesn’t trust, then one can’t delegate. Prepare a plan to carry out the work, implement the plan, and measure progress. Keep to the principle of ethics that is the foundation of management and conduct in the practice. Effective distribution of responsibility will yield leverage by allowing the dentist to become more productive with their time. Enjoy distributing responsibilities effectively and witness increased staff productivity, enhanced practice performance and increased profit.

“Is it a good idea to have an associate work in my practice for a time before selling the practice?”

When a dental practice creates enough demand from patients for more doctor hours, it’s a good idea to think about what direction to take regarding the future of the practice. In one sense, referring out treatment to specialists that the doctor doesn’t enjoy providing makes room for patients who are committed to the treatment the doctor enjoys. On the other hand, bringing on another doctor to fulfill the unmet demand for dentistry can help the practice grow and ultimately position a new doctor for a partnership or transition.

It’s very important here to note that the practice must sustain enough demand for dentistry for two doctors; it isn’t enough to suggest that just “bringing on an associate” is a good idea when there isn’t enough business to keep one doctor busy every day.

From the associate’s perspective, working in a dental office as an employee or independent contractor is necessary in order to earn a living as it may not be feasible, for whatever reason, to purchase a practice right away. As it is with the employer, making sure there is enough demand to fill a full-time schedule for all parties involved is the key. Often times, an associate dentist is introduced to the practice when the demand does not justify a full-time position. The result is a disappointed associate who may not stay and seek work elsewhere.

Another point of view is that of a dentist who may wish to work in a practice before making a decision about purchasing. On the surface, this seems to be a reasonable request, but what are the benefits to the owner or the buyer, and what are the risks?

From the buyer’s point of view, he or she would prefer to become knowledgeable about the day to day operations of the practice, how patients who frequent the practice are treated, and business systems and philosophy of the practice, to see if these characteristics match his or her ideals. In addition, the buyer may wish to learn if he or she is like-minded with the employees working in the office. The buyer may also wish to learn about the range of procedures performed in the practice and whether or not he or she is capable of keeping up with the pace of the owner who is more often than not more experienced and skilled. Finally, the buyer may want to know if he or she is matched well to the socioeconomic profile of the patients of record.

On the other hand, the seller may want to learn more about the personality of the buyer and determine if he or she can manage the practice. A question in the seller’s mind may be, “Can this buyer generate the production and resulting income necessary to meet the current expenses and the debt required to purchase the practice?” It’s also a good idea for the seller before the sale to train the buyer on the unique characteristics and business systems of the practice to help assure the quality of services delivered in the past continues.

Both points of view are important to each party in a practice purchase or sale, however, the risks are much greater for the owner and may have a significant negative impact upon the practice value. For example:

1. Patients and staff may be unnerved by the sudden arrival, and departure, of the associate dentist, and some patients may even choose to go elsewhere as a result.
   1. With a specialty practice, the referring doctors may abandon ship and begin to refer to other specialists due to the change in practitioner.
2. The owner is required to explain to patients, or referring sources, that he or she will be resuming the care of the patients in the practice. This in most cases results in a loss of income while the owner and staff are burdened with the task of damage control - explaining the short-term change of practitioner.
3. The owner may have reduced income hours while feeding patients to the buyer to form the impression that the practice is busy. In uncertain economic times, decreased patient flow can only be spread around so much.
4. Marketing and introductions of the new associate dentist may have to be retracted, causing more suspicions or questions from the community of patients and / or referring doctors.

It may be necessary to consider such a transition plan when, for example, a specialty practice located in a remote area has few other buyers to seriously consider purchasing the practice. All this being said, working as an associate to buy-in is not recommended for the aforementioned reasons; the risks are too great to the seller.

“I feel as if my team is well-versed in patient payment arrangements, but I know we could do better. Sometimes, patients aren’t clear about how they can pay for dental services and that they have options available to them that may help them move ahead with needed treatment without creating a financial burden. What would you suggest to make sure we are ensuring a high case acceptance rate and getting paid for services?”

Great question; and of course a timely inquiry in these economic times. Patients are looking carefully at the value they receive for their dollars spent; in any place – dental office, clothing store, auto dealership, etc.

In my experiences recently while working with dental offices, the issue about patient payment for services continues to be a relevant topic. Most dental team members understand the fundamentals of a good patient payment system, and in most cases they do a fine job of getting patients to pay.

Once in a while, I come across an office that boasts excellent statistics on patient payment; but something’s wrong. The office isn’t growing, patients are not accepting treatment, and the doctor and team are frustrated. This occurred recently in a client’s office where the office was solid, but case acceptance was down, production was down, and cash flow was thin. Looking deeper into the situation, I found a payment system that had done okay, but was missing a few key elements. Once in place, case acceptance picked up, the practice was productive once more, and cash flow was beginning to roll all over again.

So what was the deal? The office had become too strict on payment arrangements, they were not using a written financial policy that once was in place and had served the practice well, and the team had lost the edge with their verbal skills.

Back to the drawing board? Maybe not.

Throw the baby out with the bath water? Not yet.

Get back to basics? Yes, now we’re talking!

If it hasn’t been done recently, re-visit the patient payment process in your practice. The key here is to make sure all the resources you have available are being used with great communication skills so that patients will say “Yes!” to treatment and money doesn’t get in the way.

Dental patients across the country are service savvy. They want to be sure their investment in healthcare provides them with the benefits of good oral health: looking good, feeling good, having strong teeth and gums, and enjoying their natural teeth for a lifetime.

Imagine for a moment how many hours of continuing education was logged during 2008 that covered clinical care, treatment methods, and materials? Now, how many hours were recorded on business related courses regarding communication skills and systems development for patient payment arrangements?

Often overlooked is the need to keep up with the changing marketplace regarding payment. It’s not a surprise to me that, on occasion, some offices lose the edge and their mainstay systems such as patient payment arrangements may begin to hinder practice growth.

Studies conducted in practices recently show a similar pattern than in years past: dental consumers continue to pay for approximately one half of all dental treatment out of their own pockets.

In today’s economic climate, unless patients know their options to pay for services, they may choose not to go ahead with treatment. In fact, sensible payment options and good communication skills will help the patient make informed decisions that will lead to enhanced case acceptance. Moreover, if you haven’t re-visited your payment options during the last year, your payment systems may not be sensible in these days and times.

Back to Basics!
Three simple ground rules will help your practice cope with these changing times. Follow, or re-visit if the case may be, these rules diligently; make them the foundation upon which you build your payment systems. In this way, you can experience payment success in your practice.
Ground Rule #1: “Discuss Fees Prior to Treatment.” Patients should be informed of all fees, and specific arrangements should be made for payment before any treatment begins.

Ground Rule #2: “Don’t be a bank.” When patients are allowed to pay for their care over an extended period of time, you are actually loaning them money! And, you run the risk of alienating a patient; they may not return to the office knowing they owe money and haven’t been diligent about paying.

Ground Rule #3: “We will provide a variety of payment options.” “Not paying” is not one of them!. It is a reality that, while people generally want the best possible care, they often need some form of financing. The best way to solve this problem, without breaking Ground Rule #2, is to provide a variety of payment options for your patients.

What kinds of payment methods are available? Of course it’s preferred to have payment in full for services rendered. But for those hard to manage situations, here are some back-up methods.

Offer a cash courtesy for treatment paid for in advance. This is a great way for patients to save money, and a way for the practice to secure payment. An added benefit to the practice is patients tend to keep appointments for which they have already paid! Be mindful however, of insurance contracts that require proper documentation of discounts or courtesies.

Make better use of major credit cards as a payment option. One approach, which could be used more, is the process of spreading payments out over time using a signature on file for credit cards. There are forms available that provide structure to this system. But exceptional presentation skills must be used with this payment option. Consider this type of language when presenting credit card debiting:

“We have a great way for you to handle payment for your treatment. So that you don’t have to pay for the services all at once, you can make payments over time, interest free. All we need is your permission to debit your credit card once a month for an amount we agree upon and only for the amount of services provided. That way, you can have the dental treatment needed to get well, and you can make payments over time. Which credit card would work better for you, MasterCard, VISA, American Express, or Discover?”

Offer this to patients who have established themselves in the practice and have a track record of timely payment and attendance; that is, people who regularly pay well and keep their appointments.

In all cases, it is important to make sure your patients know you accept payment by credit card, and they can make payments over time with their credit card. Tell them! Don’t rely on a sign at the front desk or a note on the billing statement. Use good old face-to-face communication.

Use a dedicated healthcare financing company for patients in need of financing. Here, you receive payment up front, and the patient can make low monthly payments. A definite win-win for the patient and the practice. Again, make sure the verbal communication skills are at the forefront. Please, use words that highlight the benefits the patient will receive when using an outside finance company; such as:

“We have a wonderful way for you to handle payment for your dental care. The good news is, you don’t have to pay for your treatment all at once, you can make payments over time, and it’s interest free!”

It’s strongly advised, in either of the case of credit card debiting or using an outside finance company, to inform the patient of what their monthly payment will be. For example,

“We can split that up into four payments of $750 each. Which credit card would work for you, MasterCard, VISA, American Express, or Discover?”

And,

“If you use the six-month interest free option, your monthly payment will be $250 per month. When would you like to get started with your treatment?”

Here’s where a simple, straightforward, one page written financial policy which explains the various payment methods you have elected to accept in the practice comes in to play. With this tool, describe the various payment methods in a positive manner, and be sure to describe the benefit the patient receive under each option:

“We’re very excited about helping you get well and become as dentally healthy as possible. We have a variety of payment options to choose from, let’s go over them and you can decide which would be best for you.

You may handle payment by pre-paying for services; we offer a pre-payment courtesy of 5% when payment is made before treatment begins; your savings would be $500.

Or, you may choose to use a major credit card, we accept MasterCard, VISA, American Express, or Discover.

For our patients, upon approved credit, may be able to make payments over time, interest free, for up to six, 12, even 24 months.

Which of these payment options would work best for you?”

Use these recommendations (and the Written Financial Policy I have included) to build payment systems that work for your patients. Work on the verbal communication skills mentioned here as times have changed. Dental offices must re-visit systems in the practice regularly to make sure the system is serving the practice; especially during changing economic times. In the final analysis, patients deserve the very best care you can deliver, and you deserve to be paid!

We realize that every person’s financial situation is different. For this reason we have worked hard to provide a variety of payment options to help you receive the dental care needed to enjoy a healthy and confident smile with respect to your budget.

DENTAL INSURANCE:

We are happy to file the forms necessary to see that you receive the full benefits of your coverage; however we can make no guarantee of any estimated coverage. Because the insurance policy is an agreement between you and the insurance company, we ask that all patients be directly responsible for all charges. Please know that we will do everything possible to see that you receive the full benefits of your policy. If for some reason your insurance company has not paid their portion within 60 days from the date of treatment, you are responsible for payment at that time.

PAYMENT OPTIONS:

Cash or Check
We are happy to offer a pre-payment courtesy for all treatment paid in full prior to treatment.

Credit Cards
For your convenience we have made arrangements to accept payment by MasterCard, VISA, American Express, and Discover.

Payment Plans
Creditworthy patients who have extended treatment may be eligible for financing. We will work closely with you to customize a plan to suit your needs.

Our goal with each of our patients is to help them enjoy the benefits of good oral health. With proper care, they may be able to have strong teeth and gums, a healthy and attractive smile, and keep their own natural teeth all their life.

“I read the article by Erin Raden in Inscriptions, “Dental Practice Act Summary of Changes” in September 2008. From what I understand, if I provide a discount or fee reduction as a courtesy or promotion, I might need to change the way I submit insurance claims when I’m contracted with an insurance company as a participating provider. What is your take, and your recommendation?”

First, let’s get the disclaimer out of the way: I am not an attorney, and any information provided in this article is not meant to deliver legal advice.

>>WHEW<< Glad that’s done! Now, down to business.

I’m very familiar with the article, and thanks Erin for bringing these changes to our attention. Sad truth is that most dentists aren’t as familiar as they should be with the laws governing the profession. Since her article was written, I’ve casually surveyed dentists as recently as early March at the Western Regional Dental Convention and found that an overwhelming majority was surprised to know about the changes. Specifically, Section 191 Definitions, regarding “Irregularities in Billing”; take a look from Erin’s Summary (I’ve underlined some of the words for reference later in this article):

“Irregularities in Billing” defines the submitting of any claim, bills, or government assistance claim to any patient, responsible party, or third party payor for dental services rendered that is materially false with the intent to receive unearned income and as evidenced by any of the following:

• (a) Charges for services not rendered.
• (b) Any treatment date that does not accurately reflect the date when the service and procedures were actually completed.
• (c) Any description of a dental service or procedure that does not actually reflect the actual work completed.
• (d) Any charge for a service or procedure that cannot be clinically justified or determined to be necessary.
• (e) Any statement that is material to the claim and that the licensee knows is false or misleading.
• (f) An abrogation of the co-payment provisions of a dental insurance contract by a waiver of all or part of the co-payment from the patient if this results in an excessive or fraudulent charge to a third party or if the waiver is used as an enticement to receive dental services from that provider. This subdivision does not interfere with the contractual relationship between a third party payor and a licensee or a business entity registered with the board.

 

These changes to the Dental Practice Act regarding “Irregularities in Billing” impact Arizona dentists in several ways, and I’d like to point out a few that are important when it comes to advertising, discounts, and abrogating, or forgiving, the co-payment. As I indicated in the first part of this article with words that were underlined and in bold print, one cannot submit an insurance claim that is materially false with the intent to fraudulently receive unearned income.

The first few sub-paragraphs, (a) through (e) are specific enough so as not to be confusing, I trust. Just a quick example will help shed light on the subject matter of these first few items.

A patient arrives at the office in mid-December with four upper anterior teeth that are to be treated with full coverage crowns. Due to the yearly maximum benefit, the patient may ask that the dentist restore two teeth prior to the first of the year, and the other two after the first of the year. The dentist may recommend that in order to match the teeth with the proper shade and provide the best possible treatment, all four teeth should be restored at the same time. Treatment proceeds, all four teeth are prepared, and in an attempt to help the patient financially, the treatment for two teeth are billed to the insurance company at the preparation date prior to the end of the year, and the treatment for the other two teeth are billed on the seat date after the first of the year.

This is an obvious billing irregularity, as the insurance claim forms submitted do not reflect the treatment provided and the fees charged on the dates of service.

Now, let’s deal with the real meaty stuff in sub-paragraph (f). “Abrogating”, or waiving, all or part of the co-payment while under contract with an insurance company, and submitting a materially false claim with the intent to fraudulently receive unearned income will get a dentist into trouble.

Delta Dental of Arizona provides examples of non-compliance with their Participating Dentist Agreement to be:

• Misrepresentation of dates of service, services performed or fees changed on a claim form submitted to Delta Dental
• Misrepresentation of usual, customary and reasonable prefiled or charged fees on a confidential fee listing form
• Waiver of part of all of applicable contract copayments and deductibles
• Discounting of fees – agreeing to schedules lower than the dentist’s filed fees with Delta
• Dental (submitting full fees on claims to Delta Dental)
• Other activities involving claim forms or fee data which results in inaccurate information being submitted to Delta Dental which can cause actual or potential detriment to Delta Dental or a Delta Dental subscriber

Delta goes on to further inform dentists that they must indicate any discounts given to the patient clearly on the face of the claim form or in the notes field of the electronic claim. The discount must be applied so that the net fee submitted to Delta and the net fee charged to the patient are both reduced. The dentist may offer patients discount coupons for services or procedures. However, the claims submitted must reflect the discounted fees. Regularly offering discounts or coupons can affect the usual fee. Failure to disclose discounts or the use of coupons is one of the unacceptable billing practices reviewed during the claim verification process. Failure to disclose discounts or coupons can result in overpayments that are recoverable. If a claim form is intentionally submitted without disclosed discounts or coupon use, it can be considered a fraudulent attempt to gain overpayment of benefits.

An example given by Delta Dental on how to disclose patient discounts on claim forms is this:

Suppose your usual fee for a complete maxillary denture is $1000, but you offer a patient a $100 discount. There are two ways to indicate the discount on the claim form. You must use one of the following:

1. State the discounted amount of $900 in the box 31 fee section.
2. State your usual fee of $1000 in the box 31 fee section and use the Remarks Section to identify the discount amount of $100.

The Arizona Department of Insurance was a great resource of information regarding these issues and Insurance Fraud. Yes, Insurance Fraud is a crime, a class six felony that can mean 10 years in jail and a maximum fine of $150,000.

A person who commits either of the following “with the intent to injure, defraud, or deceive an insurance company,” is guilty of a felony. The most common types of insurance fraud include claim fraud, premium fraud, and vender (or provider) fraud. Incomplete or inaccurate information on a claim form or application does not necessarily represent insurance fraud. For insurance fraud to exist, four key elements need to be present:

1. Intent to defraud: The person(s) must intentionally and deliberately deceive the insurer(s).
2. Knowledge: The person(s) must have knowledge that what they are doing is wrong, or is a false statement of fact.
3. Misrepresentation: The person(s) creates or assists in making a false impression that leads the insurer to pay a claim.
4. Reliance: The insurer would not have paid the claim but for the misrepresentation.

Let’s jump back into the day-to-day operations of the dental office. Here are three examples to show what this all means:

Example #1: Pre-Payment Courtesy or Discount
My proven payment program, “Proactive Payment Systems” routinely recommends a pre-payment courtesy, or discount, for payment made in advance on major treatment. Let’s consider a patient who accepts treatment for several units of crown and bridge that total $3000. A pre-payment courtesy of 5% would provide $150 in savings to the patient if paid for in advance. Once the treatment is provided, normally, the insurance claim form is generated electronically with little effort and sent to the insurance company for payment. But Wait! You’re a Delta Dental contracted provider! Was that claim submitted to Delta Dental with the proper notation and fees regarding the discount? If you are to provide a discount as in this example to your patients, as a Delta Dental Provider, the claim must be submitted with notes indicating the discount provided; easy fix!

Example #2: {Direct Mail Piece} “New Patient Exam, Bite-Wing X-rays, and Examination - $49. Regular value, $155!”
(Note: There is no indication on the advertising piece that this is only available for cash paying patients; insurance patients are not specifically excluded.)

In this example, yes you are a Delta Dental provider, the patient arrives at the office for their new patient visit, and yes, they have Delta Dental insurance. The fee of $49 is paid, and the insurance claim form is submitted. OOPS! Was the claim submitted with the proper notation and fees regarding the discount?

Example #3: Professional Courtesy
In this example, you are not a contracted participating provider with any insurance company and a friend of yours, Bill, arrives at the office for his new patient examination, complete x-rays, and since Bill is healthy without any signs of periodontal disease, he has his teeth cleaned. For whatever reason, you elect to provide Bill a Professional Courtesy by reducing the fee $35 from the usual $235 to an even $200. Bill pays by credit card, bids you farewell, and off he goes. Are you in compliance? Yes. You provided services, charged a fee, and you received payment. The contract in this case is with the insurance company and the employer or patient, not the dentist. You are not obligated to submit a claim form; you may as a courtesy to Bill, and in fact would enter your usual fee for services rendered on the claim. Since you are not contracted with the insurance company, you may process payment from Bill and submit the claim normally. If you accept assignment of benefits, process the claim according to your normal and correct billing procedures.

A heartfelt dentist can have the patient’s best interest in mind, and on occasion, be pulled by their purse strings, yet acts of kindness could cause the practice to falter without knowledge of the laws that govern the profession.

If you contractually participate with an insurance company, read the contract! If you can’t find the contract in your office, call the Provider Relations contact at the insurance company, request your signed copy, and start a file. The ADA provides, as a member service, Contract Analysis. Contact AzDA here in Arizona for more information.

What is very important to note is that waiving or abrogating the co-payment is a non-issue if a dentist does not contractually participate with any insurance company. Yes, they must follow proper billing protocols; that goes without saying. But discounts, professional courtesies, are all in line when a dentist is not under contract.

Staying on top of everything that occurs in a dental practice’s day-to-day operations is time consuming. Fulfilling the professional responsibility to keep abreast of the legal parameters of the profession, unfortunately, is not always accomplished. By that I mean dentists stay current on procedures, materials, and techniques to keep patients in the highest level of oral health. As a result, the business side of dentistry often suffers. In that respect, dentists may not be aware of changes to the laws that govern their profession. From my experience, it’s not intentional, it just happens – for whatever reason.

Further, the Arizona Board of Dental Examiners, in particular Dr. Sam Palmer, indicated to me that an overwhelming majority, well over 95%, of complaints from people to the Board about dentists is not treatment based per se, but communications based; people don’t feel like they were taken care of properly as a person. Yes, this includes the ways in which billing and account administration is handled. The treatment provided is often not the basis of the initial complaint.

Generally speaking, most dentists and their staff do an excellent job of taking care of people, healing their dental conditions, billing properly, and creating a loyal following of patients in the community that refer other people for care. Some dentists are not as competent in their profession at taking care of people, and for this reason the laws are established to protect the public from harm.

Be proactive by staying in tune and be aware of changes to the laws that govern the dental profession. Make your team aware of the ways that could put the practice in harms way by incorrectly billing when contractually participating with an insurance company.

For more information, go to www.azleg.state.az.us/arizonarevisedstatutes.asp.

“I’m still trying to configure a budget for 2009. I wonder which expenses I should really focus on to create a healthy profit. One of my first thoughts is to consider how to pay staff for attending Continuing Education courses, especially since the Western Regional Dental Convention is coming up. What is your recommendation?”

Believe it or not, I have come across dentists who want to save money by eliminating all C.E. course benefits for their staff. In my opinion, this is not a wise move to create more profit. The argument that was brought up by one particular dentist was that since hygienists have a requirement for a certain number of C.E. hours to keep their licenses current, the cost factor should fall on their shoulders. It is their responsibility to fulfill requirements in order to remain valid practitioners.

Sure, it’s true that employees need to be responsible for keeping licenses current, but what example does not assisting with C.E. costs set? I feel it shows that “doing the bare minimum, just to squeak by license requirements is fine by me.” A better example for all employees is “I believe in your talents, and I want to make an investment in all of you to not only better and empower yourselves, but to also benefit our patients. Attending continuing education courses helps to assure that we are providing care and service to the best of our abilities.”

Team members must be made aware that continuing education is an important part of career and practice development. It is also an important investment in time on their part and resources on the part of the practice. Together, the employer and team will benefit from C.E. when approached sensibly.

All this being said, there are some tips I can share regarding expectations not only about C.E. reimbursement, hourly pay for staff to attend, but also expectations for employees.

The issue regarding pay and travel for continuing education comes up quite a bit, and since there is no “rule” or industry standard, a dentist or employer should consider an approach based on what the business can afford financially and what philosophy the owner has regarding C.E., while being fair and reasonable. Once a protocol or policy is formed, commit it to paper and have each member of the staff acknowledge and sign off on the policy. Finally, include it as part of the office’s personnel policy manual.

A general “rule of thumb” to follow is if one requires an employee to attend a lecture, meeting or training seminar, then expect to pay for that employee’s time. Situations in which paying for the employee’s time would be an option are if:

• The employee attends the event outside of his or her regular working hours.
• Attendance is voluntary.
• The instruction session isn’t directly related to the employee’s job.
• The employee doesn’t perform any productive work during the instruction session.

With this background information, here are a few recommendations.

How much should I compensate my employees for Continuing Education?

When the team is required to participate in continuing education either during regular working hours or outside the normal schedule and they are not utilizing their core competencies and not creating revenue, compensate employees at a Continuing Education, or C.E., rate of 50% of their regular pay. Each employee will be responsible to note on his/her time log the hours that are accumulated for C.E., and travel time if away from the office. If an employee is salaried, the compensation remains the same, regardless of when the continuing education course is in session.

For hygienists and employee dentists, I suggest offering to help pay for courses they need to complete their requirements, but not compensate them for time spent while at the course. Require pre-approval of the course, and offer tuition reimbursement for hygienists; say up to $200 annually. Use your own discretion as to how much reimbursement you wish to make available for employee dentists. Again, this is optional, and is dependent upon the employer, his or her philosophy, and budget. In reality, the employer is assisting in keeping employee dentists and hygienists up to date with CE and licensure compliance, which is ultimately the responsibility of these professionals, and in turn they accept the day off without pay.

How should I handle continuing education away from home, especially when travel is involved?

For continuing education courses where travel outside of the immediate metropolitan area is necessary, and the course takes place outside the normal business schedule, consider these guidelines.

When a significant investment in continuing education and travel is made and the employee’s are reasonable and cooperative, then the employer may elect to pay course tuition, travel expenses including airfare, ground transportation to and from the hotel, lodging, any meals sponsored by the employer, and a $40 per day allowance for supplementary expenses to each employee, including hygienists. The per-day allowance will also help cover gas to and from the airport. Under these circumstances, wages for hours worked will not be paid.

The employee will be responsible for travel to and from the airport. If group shuttle arrangements can be made, then encourage employees to car pool to and from either the airport or the course venue.

How would I handle a “Hands On” course when I consider one of my employees as my patient for the restorative dentistry?

On occasion, doctors have taken employees to courses and provided them with a significant amount of restorative dentistry; even “Smile Designs” in some instances. The employee becomes a great spokesperson for restorative and cosmetic dentistry and patients take well to witnessing the excellent results from the doctor’s work. Unfortunately, I witnessed an occurrence where after a short period of time, an employee decided, “The commute to the office is too far” and quit because she “found an office closer to home”. <>

Without any prior formal arrangement, the employee is certainly free to go; but it’s discouraging to know a person would be selfish enough to take advantage of the generosity of the employer by leaving shortly after major restorative work was done for free. Strange, the employee had no qualms making the commute prior to the course (and major restorative treatment provided) and didn’t mention any concern over travel time to and from the work place.

To ensure employees stay on board after a significant investment in continuing education is made, I suggest considering a policy where the employee agrees to remain employed with the office for a period of one full year after the course is completed. If the employer terminates the employee because of a violation of company policy, or the employee resigns, then the employer may, at his or her sole discretion, require the employee to reimburse part of or the entire cost of tuition, lodging, and airfare.

Prepare this policy in clear terms and in writing ahead of time, prior to leaving for the course. Supplement your employee manual with the new policy. Make sure employees acknowledge and sign off that they understand the policy.

I’m not trying to overstate the obvious, but one aspect of the employee’s job is time spent learning how to improve his/her own performance so that the business will grow and develop along with the entire team’s performance.

What if an employee chooses not to participate in a continuing education “trip” away from home?

It may occur that an employee chooses not to participate in a continuing education trip away from home. Certainly, family issues, health issues, or personal reasons may result in the employee choosing not to attend. In this case, the employee must take time off from work if the course is during normal working hours. They may choose to use their accrued and unused paid time off to receive pay, or not work and not be paid.

An alternative is to allow the employee to work in the office, if the course takes place during the normal work schedule, and receive the regular rate of pay. However, be precise as to what is required of the employee, make a list of tasks that must be completed, and require the employee to be accountable for completing the tasks. A good idea is to have a briefing of what is to be accomplished prior to leaving, and what was accomplished on the first business day back from the course. If the tasks were completed, “Hooray!” Recognize the employee for a job well done. If the tasks were not completed, discuss this with the employee and find out why the work was not completed as required. The privilege to work unsupervised should not be offered to this individual in the future.

I trust my staff to go to courses, be responsible adults and not duck out early while claiming they attended the entire course. Am I being naive?

I have to play the devil’s advocate, and hopefully this does not pertain to any employee in your office! We all want to believe in staff honesty, but let’s face it; unless there are stipulations in place to show attendance, time spent at conferences can be iffy. If the dentist and staff travel to each event together, there of course is no question, but if the staff members are off on their own, then steps can be taken to get the most out of your continuing education dollars.

After the convention, meeting, or C.E. course, require a short presentation from each person and each course attended. The presentations could be the focus of an office meeting pre-scheduled the week following the course or convention. Allow each team member adequate time to present their portion, say five to ten minutes, and allow time for discussion, questions and answers. Use the material from the team’s presentations to initiate new policies or procedures to help better the practice and apply them as soon as possible.

In addition, if it is expected that the staff circulate among the booths at the convention, have a “shopping list” for items and require business cards to be brought back, with names of the representatives at the booths that they spoke to, even requiring the staff to explain what was unique about each company and how each company could benefit the practice. Make sure that the staff understands the importance of company representation at dental conventions by showing good taste and exercising good manners

To sum up, examine your own practice in regards to continuing education benefits. Consider your philosophy of practice and how it can be supported with useful C.E. and what courses would help make your business plan come to fruition. Consider your financial resources and prepare a budget for how much money the practice will invest in 2009 and beyond for C.E. Construct clear policies regarding C.E. and how the team is compensated. If courses require a significant investment in time and resources, prepare a policy ahead of time and obtain the acknowledgement of the team, so there are no surprises. Have a meeting shortly after the course or convention and put into action recommendations that will help better your business.

Here’s to seeing you at the 2009 Western Regional Dental Convention!

“My business has been doing quite well over the last several years. But now, I’m not alone in finding times are tough. I thought I could weather the storm, but the down economy is hitting me, like it is other dentists, I’m sure. What do you recommend a dentist do in a down economy to boost his or her business?”

Let me take you back in time, for a moment…

In the not too distant past, dental practices were beyond thriving. There was an abundance of new patients, who along with the existing patient base, were willing to follow through on recommended major restorative work as well as opting for elective cosmetic procedures. These patients either had the money or were willing to utilize third party financing and pay the balance off “interest free” over time.

The first storm that dentists had to weather occurred after 9/11. This catastrophic event created uncertainty in the minds of many, and as a result made patients more reluctant to go forward with major treatment, or jump on the cosmetic “smile makeover” bandwagon, as did their friends. But even as the trouble in the Middle East continued to brew, there was a small but not too significant drop in production for some dental offices. It became apparent that these events had an impact on the dental industry.

Ahh, but then dateline 2004: Our home values are climbing; Arizona is one of the most sought after locations in the country to live in; people are flocking to our state to enjoy the riches this land can offer. People are buying homes left and right! Dentists are setting up “scratch start” practices in communities destined to bring thousands of new homes and people with teeth to work on! Even though dental offices worked diligently to keep patients’ teeth healthy, it became much easier to rest on one’s laurels without having production slump.

Fast-forward to 2007: The beginning of the housing market decline. The bubble burst! Thankfully, not as big a burst as some other areas in the country, but it happened here in our own back yard. As a result, patients who “would have been” aren’t coming to the dentist’s door because mortgages have gone sour, over time their home isn’t built; sometimes foundations haven’t even been poured. Consequently, new dental practices in the anticipated high growth areas of the state began to dry up. Unfortunately, we haven’t recovered and the economy is setting records for being the direst in decades.

Sorry, this is reliving the nightmares that have been keeping us awake. But, reality is that we are facing a very unique series of events, which requires action on the part of dental practices in order to maintain previous profit levels or even to recover. Something must be done to keep the business vibrant, growing, and profitable, but what?

Staying afloat and even growing your practice in an economic slump can be accomplished, but you must realize you can’t go on doing the same things and expect to achieve different results. Change is necessary in that people who run a business must be willing to adapt to new concepts as well as re-committing to fundamental management principles and proven systems in order to bring themselves back up to previous productive levels.

The preeminent “Practice Pointer” in a down economy is, DON’T ASSUME! Don’t assume that the economy is affecting every patient across the board and “nobody can afford anything.” How do you know what the patient will say ahead of time? You don’t. Sure, there may be plenty of patients that will say something to the tune of, “Oh, times are tough, I can’t afford it.” But there are others willing to go ahead with treatment, including complete dentistry, and even smile designs. Know that patients may say “no”, but keep them engaged in the practice; don’t lose them long term. Leave the door open with an approach such as, “We’re here for you; when you’re ready (resources have rebounded, time is right, pain won’t go away, etc.) Call us. We’ll make room for you right away.”

Several of my management consulting client dentists in the Greater Phoenix area are keeping steady or have demonstrated better numbers this year than last year; …in a down economy! Proof positive that patients are saying, “Yes” to treatment even today.

The next thing to remember is obvious; continue doing what you do best, which is diagnosing disease conditions and recommending treatment that will solve the problem and make the patient well. Don’t compromise complete diagnosis and complete care. The doctor and entire team must continue with patient education and compelling case presentations for each patient. Are you confident that your staff members are skilled and even excel at case presentations? If the answer is no, now is not the time to save money and throttle back on continuing education. Keeping staff at peak performance levels can only enhance and advance the practice.

The backbone of general practice is the hygiene department. Without a Periodontal Maintenance system that is well organized and diligently orchestrated, an office will witness a decline in patient visits resulting in a decline in income. Moreover, in uncertain economic times, it’s very important to advance prevention as a method to keep patients in the practice. Consider the difficulty in trying to convince someone to come in for extensive treatment that they have already said, “No, I don’t have the money, the economy is terrible, …”. Re-direct the energy into encouraging them to maintain their current state of health with a routine (prophy, periodontal maintenance/exam/call-it-what-you-will) visit. It goes without saying, do not turn a blinds eye to the treatment that is still pending, keep encouraging the patient to remedy their dental malady albeit in a friendly, professional manner.

During these times, a meticulous inspection of the program in your office must commence immediately. First, don’t assume each and every patient in your practice has been contacted for his or her preventive care or periodontal maintenance visit. Inspect each patient’s history either through the physical chart or computer record to be sure they haven’t “slipped through the cracks”. Next, establish a program that will contact each patient and ensure an appointment is made to keep him or her on a maintenance schedule.

In my travels, I have found practice management software systems that have a recall program that assists the office in managing patient continuing care. I have also found that these systems are not watertight and patients slip through the cracks at times perhaps because people are running the software. Further, team members may leave the practice for one reason or another only to leave a system that was orchestrated properly in the hands of someone who doesn’t know it as well, used a different software program, or has a different way of running recall. Don’t Assume! Learn your software program and how it manages recall, inside and out. And if that means hiring an experienced trainer to come in and seal up the cracks, then do so. Then, be certain all patients are included in the database with their correct maintenance interval. If this means a physical chart audit to confirm the database is complete, so be it. You said your office had slowed down, right? What else is your team doing?

The next step is where the rubber hits the road. The old adage rings true today,

“Ideas are a dime a dozen; people who put them into action are priceless”!

Direct your team to contact each patient who is not yet scheduled encouraging them to maintain their current state of dental health and make an appointment! Begin with a phone call first; and consider calling at a time of day that stands the best chance of reaching the patient. Yes, that means late afternoon and early evening. Have the right dialogue in place, rehearsed, so that the telephone contact has impact and positive results. A written script is handy, one that is encouraging without being too overly zealous. Second step is a postcard, sent two days after the first phone call. Third is another phone call made no more than one week after the postcard. Last contact is a nice letter that asks the patient to contact the office when they are able to confirm contact information and active status. Send this letter out the week following the second phone call.

Make a commitment to this project and be sure to follow a tight schedule. Don’t let a lot of time pass between phone calls and written correspondence. Additionally, depending on the size of the practice it may be prudent to begin with a block of patients and work through 50 or so at a time.

I trust the thought behind this is obvious to you. You are investing in time, which you certainly have on your hands. And, patients are more willing to come to the office for a routine “cleaning and check-up” since their out-of-pocket investment in these services is less than it would be for major treatment. Wouldn’t you agree it’s more difficult to get people today to come in for six implants and 14 units of crown and bridge than it is for a cleaning?

Lastly, in today’s uncertain economic times, non-productive use of time is not allowed, and not an option! Heck, this should apply whether the economy is down or not! Dental team members are getting an hourly salary to work, not read magazines or make personal phone calls. If you have a “Morning Huddle” spend time discussing what needs to be done during down time in the schedule. The dentist or office manager should keep a list of work items that could be accomplished so that jobs can be directed right away.

Supply use, if not monitored correctly, can be a drain on a practice. Having the staff be frugal in what is used can be a money saver. Designate one employee who is responsible not only for ordering supplies, but also in overseeing usage over the course of the ordering period. Taking note of the inventory of supplies already on the shelves so as not to over-order is important too.

Re-visit Internal Marketing

The dental team must be diligent in core internal marketing techniques. Three mainstays are asking for referrals, re-visiting previously diagnosed conditions that require treatment, and performing care-calls. Here is a helpful guide on these three to make sure the techniques pay off right away.

When asking for referrals, have an idea of what you will say so that when the occasion presents itself, it’s not foreign. Try to formulate your own style behind these sample scripts:

“Mrs. Herbert, thank you for the trust and confidence you place in us for your care. Please know that we always welcome new faces in our practice. If there is anyone you know that may benefit from modern dentistry, please direct them our way. We will take great care of them.”

Or,

“Mrs. Herbert, I’d like to ask your help. As you know, our goal is to help as many people become as healthy as possible. Sadly, the American Dental Association reports that 50% of the adult population does not visit the dentist regularly. If you happen to know someone that could benefit from modern dentistry, please send them our way. We will take great care of them. Thanks for your help”

Also, after a patient has completed treatment, use the occasion to praise their commitment and parlay that into a marketing opportunity:

“Mrs. Herbert, now that we have completed treatment, let me commend you for making a commitment to your health. It would be great to help other people like you. We always welcome new patients to the practice, feel free to refer our office to your friends and neighbors, we’ll take great care of them.”

Lastly, look for an opportunity to suggest referring patients to the practice. Have you ever had a patient who compliments you, a team member, or commented positively on their experience in the practice? If so, turn it into an opportunity,

“That’s so nice of you, thanks very much. And if you know of anyone who is looking for a great dentist, send them our way and make sure they tell us you sent them, we’ll take great care of them.”

When patients return to the office, for any reason, be it for periodontal maintenance, for completion of treatment in progress, or for further treatment as planned, re-visit previous treatment by following this guide:

1. 1. Ask the patient specifically about the treatment performed on their last visit.
2. “Mr. Smith, last time you were in, we took care of that tooth that was bothering you on the lower left side; how’s that feeling today?”
3. 2. Clarify that the treatment performed was satisfactory and the patient is pleased with the outcome: “Oh, my, yes, I totally forgot that you put a crown on that tooth; it feels great!”
4. 3. Document this conversation in the patient’s record to show the treatment was successful.

In most cases, the patient will be happy and indicate they are satisfied with the work. Use this as an opportunity to recommend referring someone to the practice. Then, continue the appointment. In the unlikely event the patient is not happy, spend whatever time is necessary to ensure their concerns are documented and understood. Then, work immediately to resolve the issue before beginning any further treatment.

By far, the most successful form of internal marketing is calling patients on the evening of treatment, or placing care-calls. Call any patient who has received an injection in your office on the evening of their treatment. This is a 30 second public relations phone conversation that must be made by the doctor:

“Mrs. Jones, this is Dr. Herbert calling. It was nice to see you today; how are you feeling?”

Harvey Mackay, who wrote “How To Swim With The Sharks Without Being Eaten Alive”, and “Beware the Naked Man Who Tries To Sell You His Shirt”, said it best,

“People don’t care how much you know, until they know how much you care about them.”

The entire purpose of this call is to demonstrate to patients that you care about them. Don’t consider calling only difficult treatment patients; I strongly recommend calling any patient who has received an injection. Most patients will be very pleasantly surprised by the call. Most likely, their doctor before has never called them! The obvious message is that you care about them.

To sum up, there is camaraderie amongst dentists, so don’t hesitate to talk to fellow practitioners; you may be able to pick up on some worthwhile tips and good advice can be shared between offices. It is also important to keep abreast of the news to keep yourself and the staff on their toes. But don’t stress too much, worrying about the news and the daily stock report will do nothing to change it. Put the energy that you would have spent worrying into action instead.

“Recently I came across a colleague who was dealing with a complaint regarding a breach in privacy among a patient in his practice. How can I be sure that all of the HIPAA Guidelines are being followed in my office? What systems do I have in place that could jeopardize the Privacy Act?”

This is a timely question, as Susan and I had the opportunity to visit healthcare facilities including hospitals, emergency clinics, specialty physicians, and physical therapy clinics for both our daughters this past summer (Rose’s split-open knee has healed nicely, and Mary’s torn ankle ligament is on the mend). During our visits, we witnessed multiple violations of HIPAA, and wondered how often this is occurring in dental offices.

The Health Insurance Portability and Accountability Act of 1996, the privacy provisions of the federal law, applies to health information created or maintained by health care providers. This Act went into effect on April 14, 2001, with a Rule of Compliance deadline on April 14, 2003.

In dental and medical offices, back in 2002-2003, there were analyses and well thought out plans in order to become compliant with the new HIPAA regulations. Five years later, how sure are you that your office has remained compliant? Sure, it is easy to push the Notice of Privacy Practice Sheet and Acknowledgement Form under the rest of the new patient paperwork, make sure the form is signed and dated, and clip it into the chart. But what happens beyond this initial step? How careful is the office to keep faithful to the rest of the privacy stipulations? Has your office become lax in following the “letter of the law” or have policies been instituted in your office that make patient privacy turnkey?

Dental offices that transmit any health information in electronic form, either directly or indirectly through a vendor or billing service, need to appropriately safeguard and disclose protected health information in compliance with federal requirements.

Failure to comply with the Privacy Rule can subject dentists to severe sanctions for violations, including both civil (fines) and criminal penalties. Civil penalties are $100 per violation, up to $25,000 per person, per year for each requirement or prohibition violated. Federal criminal penalties are up to $50,000 and one year in prison for obtaining or disclosing protected health information; up to $100,000 and up to five years in prison for obtaining protected health information under “false pretenses”; and up to $250,000 and up to 10 years in prison for obtaining or disclosing protected health information with the intent to sell, transfer or use it for commercial advantage, personal gain or malicious harm.

What should my office be doing?

•  Be vigilant that privacy practice policies and procedures are being followed
• Have in place a privacy compliance program that includes internal auditing of privacy procedures, with training of new employees so that the staff understands the practice’s privacy procedures
• Designate a “Privacy Officer” (can be the office manager or a spouse) to be responsible for overseeing that privacy procedures are adopted and followed
• Maintain reasonable and appropriate administrative, technical and physical safeguards to ensure the integrity and confidentiality of patient health information
• Protect against reasonably anticipated threats to the security or integrity of patient health information
• Protect against unauthorized uses of disclosures of patient health information
• Make sure that patients cannot see each other’s health information
• Ensure that only those employees who need to see patients’ health information in the course of their jobs can do so
• Take “reasonable precautions” to minimize the chance of inadvertent disclosure of a patients’ personal health information via oral communication to others who may be near
• Establish “Business Associate” contracts with labs, consulting firms, e-claims clearinghouses, collection agencies, and computer software/hardware vendors to protect private health information
• Provide information to patients about the privacy rights and how their personal health information can be used.

What will HIPAA privacy regulations not allow me to do?

• Prohibit dentists from talking to each other and to their patients (Health and Human Services guidance recognizes that providers understand the sensitivity of oral information, and acknowledge the importance of oral communications occurring freely and quickly in treatment settings)
• Prevent an insurance carrier from verifying patient eligibility when contacted by a dental office
• Prevent an insurance carrier from reporting the status of a pending claim to a dental office when contacted by the office
• Prevent a dentist from sending appointment reminder cards to patients
• Prevent dentists from having a sign-in sheet at the front desk, however the reason for the appointment should not be listed on the sign in sheet
• Prevent dentists from engaging in billing and collections activities, including the use of collection agencies
• Require dentists to obtain written consent from patients for disclosure of health information. Dentists and other providers will be required only to make a good-faith effort to give patients written notice of privacy practices and patients’ privacy rights.

Where am I now?

1. Make sure all existing consent and authorization forms are up to date and continue to comply with the regulation. Continue to have patients read and sign visually separate consents for assignment of benefits and use of healthcare information.
2. If you’re using protected health information for any purpose other than treatment, payment, or operations, make sure you have a special authorization form that conforms to the requirements of the privacy regulation.
3. Draw a diagram of your facility and plot each point where consent for information use might be obtained in your organization. Make certain that you provide an environment where patients can privately review and ask questions about the consent and how you will use their personal health information.
4. Draw another diagram of your facility and plot the locations where protected information could be inadvertently released by paper, phone, fax, and computer. Implement strict policies and processes for employees who work in these locations. Besides mail, fax, and electronic communications, don’t forget about wired and wireless phones as a high-risk medium. Make sure that your staff protects phone conversations from being overheard by patients and visitors in reception areas and corridors.
5. Inventory all of your business associates whom you disclose protected health information to, describe the information you disclose, and explain the business purpose for which disclosures are made. Execute business associate agreements with those business associates.
6. Determine that your policy and process for documenting and tracking any disclosures of health information for reasons other than payment, treatment, and healthcare operation is being followed and secure.

After doing a thorough check that your policies and procedures are intact, it would be wise to have an office meeting to revisit HIPAA regulations, discuss the following insert as well as have each employee sign and keep this form in the permanent employee record:

Patient & Records Confidentiality

We make available to each employee certain information, including patients’ names, dental history and addresses, communications, files, bills and payment records, office forms or manuals, etc. These items are of substantial value, highly confidential, constitute the professional and trade secrets of the doctor and are provided and disclosed to the employee solely for use in connection with your employment. We ask our employees to:

• regard and preserve practice information as highly confidential and the trade secrets of the employer. Such information must not be discussed away from the premises or within hearing distance of any patient or unauthorized person.
• not disclose, or permit to be disclosed, any of this information to any person or entity
• not photocopy or duplicate, and not permit any person to photocopy or duplicate, any of the information without the employer’s consent and approval.
• not make use of the information for your own benefit or the benefit of any person or entity other than the employer.
• continue to keep any information confidential even after termination of employment with the office.
• release personal information about other team members-phone num­ber, address etc.- only with the team member’s specific and prior approval in writing.

Employees who handle confidential information are responsible for its security. Extreme care should be exercised to ensure it is safeguarded to protect the practice, each team member, the suppliers, the patients, and the employer. Any employee who violates this confidentiality and disclosure policy is subject to disciplinary action up to and including discharge and in extreme cases, legal action.

It is very easy to become complacent in the day-to-day operation of any workplace. But it is wise to be on the look out for possible gaps in a seemingly well run practice and safeguard against unfortunate events that could arise.

Should I compensate my employees for continuing education courses away from our hometown? How about courses in town? What if they choose not to attend CE courses that I subsidize and ask for them to attend?

The issue regarding pay and travel for continuing education comes up quite a bit, and since there is no “rule” or industry standard, a dentist or employer should consider an approach based on what the business can afford financially. Once a policy is initiated and the protocol set, commit it to a formal written document, and have each member of the staff acknowledge and sign off agreement with the policy. Finally, include this document as part of the office’s personnel policy manual.

A general “rule of thumb” to follow is if an employee is required to attend a lecture, meeting or training seminar, the employee should be reimbursed for his/her time.

Situations in which paying for the employee’s time would be an option are:

• The employee chooses to attend a CE event, which is not required, outside of his or her regular working hours.
• Attendance is voluntary.
• The instruction session isn’t directly related to the employee’s job.
• The employee doesn’t perform any productive work during the instruction session.

How much should I compensate my employees for Continuing Education?

When the team is required to participate in continuing education either during regular working hours or outside the normal schedule and they are not creating revenue, compensate employees at a Continuing Education, or CE, rate of 50% of their regular pay. Each employee will be responsible to note on his/her time log the hours that are accumulated for CE, and travel time if away from the office. If an employee is salaried, their compensation remains the same, regardless of when the continuing education course is in session.

For hygienists and employee dentists, I suggest offering to help pay for courses they need to complete their requirements, but not compensate them for time spent while at the course. Require pre-approval of the course, and offer full tuition reimbursement of up to $200 annually for hygienists, and use your own discretion as to how much reimbursement you wish to make available for employee dentists. This is optional, and is dependent upon the employer and budget. In reality, the employer is assisting in keeping employee dentists and hygienists up to date with CE and licensure compliance, which is ultimately the responsibility of these professionals, and in turn they accept the day off without pay.

Continuing Education Away from Home

For continuing education courses where travel outside of the immediate metropolitan area is necessary, and the course takes place outside the normal business schedule, consider these guidelines:

The employer will pay course tuition, travel expenses including airfare, ground transportation to and from the hotel, lodging, any meals sponsored by the employer, and a $40 per day allowance for supplementary expenses to each employee, including hygienists. The per day allowance will also help cover gas to and from the airport. Transportation from home to and from the airport will be the responsibility of the employee. If group shuttle arrangements are more reasonable and accommodating, then the employer may elect to arrange and pay for group transportation. Under these circumstances, wages for hours worked will not be paid.

When a significant investment in continuing education and travel is made on the employee’s behalf, I suggest considering a policy where the employee agrees to remain employed with the office for a period of one full year after the course is completed. If the employer terminates the employee because of a violation of company policy, or the employee resigns, then the employer may, at his or her sole discretion, require the employee to reimburse the cost of tuition, lodging, and airfare.

It is highly recommended that team members are aware that continuing education is an important part of career and practice development. State this in the personnel manual and make sure employees sign an acknowledgement form that they understand one aspect of their job will be time spent learning how to improve their own performance so that the business will grow and develop along with the entire team’s performance.

What if an employee chooses not to participate in a continuing education “trip” away from home?

It may occur that an employee chooses not to participate in a continuing education trip away from home. Certainly, family issues, health issues, or personal reasons may result in the employee choosing not to attend. In this case, the employee must take time off from work if the course is during normal working hours. They may choose to use their accrued and unused paid time off to receive pay, or not work and not be paid. An alternative is to allow the employee to work in the office, if the course takes place during the normal work schedule and receive their normal rate of pay. However, be precise as to what is required of the employee, make a list of tasks that must be completed, and require the employee to be accountable for completing the tasks. A good idea is to have a briefing of what was accomplished on the first day returning from the course. If the tasks were not completed, this privilege to work unsupervised may not be offered to this individual in the future.

What if I don’t want to pay my employees for continuing education?

This is an option for an employer. In that case, I suggest creating a policy within the practice that requires employee acknowledgement. Use a form with the following verbiage.

Voluntary Participation For Continuing Education

Training sessions are attended on a voluntary basis and employees are not paid for their time. Please sign this statement of voluntary participation to avoid misunderstandings.

I am voluntarily attending: ____________________

Scheduled for (date and time): __________________

I understand I will not receive wages for the hours attending.

Employee signature _____________

Date _________

Summary

In conclusion, make sure employees understand the basis of the recommendations for this policy:

• The employee is engaging in a group session to educate the team on enhancing people and practice performance.
• They are not performing productive work during the session.
• It is an integral part of the business plan to support an educated and organized team.
• A significant investment has been made on their behalf to advance their knowledge and skills.
• The skills learned and camaraderie created amongst the team will benefit the patients of the practice well into the future.

Continuing education is necessary in today’s changing environment. Enhancing people and practice performance leads to enhanced patient services, and as a result, improved productivity and profit. Provide employees with a reasonable package for continuing education and travel so that the team is encouraged to advance their skills and put forth improved expertise.

Author’s Note:
In order to keep identities private I have removed names from this e-mail I received not long ago.

“I don’t know if you remember me or not but I worked with (a local area dentist) several years ago and I am currently working with another dentist now who does not want me to tell (his/her) patients when they have credit balances. (He/she) wants me to just act as though the patient doesn’t have a credit on account. Some of the credits are in the hundreds (of dollars). I know that you can keep credit running on account until all treatment is done but what then? I personally feel this is unethical because in a sense we are stealing money that is owed back to the patient. I was also told by Arizona law that the doctor does not have to return any money owed to the patient if it is under $50 dollars and then just adjust it off under miscellaneous adjustment. I am having a hard time believing this. And because the patient is never made aware of the credit then they are not given the opportunity to decide what to do with the money. What a mess this is. I am really struggling with this. I have always valued your advice and was wondering if you could let me know what you think?”

Of course you give the money back; it’s the right thing to do!

In terms of public relations, it’s a practice builder to let people know the account is overpaid and they have money coming back because you’ve caught it early – before they find out. It’ll sink a practice if people know you’re keeping their money for your own benefit.

More often than not, a credit balance is the result of an over-payment by either the patient/guarantor or a third party. The patient/guarantor may have paid in advance for treatment that was not completed for some reason, or an insurance payment was received over and above the estimated amount at the time of the co-payment by the patient. Either way, we have a patient services issue on our hands and it must be resolved professionally and ethically.

Let’s examine the possible insurance over-payment. Researching this issue with insurance companies revealed a few interesting concerns. First, the fact that the patient has a credit balance leads some to believe that the estimated insurance payment was incorrect. By under-estimating the insurance benefit, be it the deductible or the co-insurance amount, the patient portion was incorrectly estimated to be higher than it should have been. The end result is more money was collected than expected.

Now, if the practitioner is a contracted preferred provider with an insurance company, the doctor typically cannot charge more than the allowed fee. This is of course dependent on the contract the doctor signed with the insurance company, and contracts vary in terms and conditions. If the doctor is not a contracted preferred provider, then charging the doctor’s usual fee is fine, and the portion not paid by the insurance can be billed to the patient. If payment from the patient is collected up front for the co-insurance and deductible, and the subsequent insurance payment creates a credit balance, then a refund to the patient is obligatory.

Also, it’s not out of the realm of possibility that the insurance company may not have been accurate in its payment and paid an incorrect amount for the claim submitted. For example, the claim was for a sealant and the insurance company paid the benefit for an all porcelain anterior crown.

Yeah, right; surely, I jest. But you get the point. It could have even been the insurance company entered the incorrect CDT code resulting in payment in excess of the claim amount. In these cases, the over-payment is due back to the insurance company. My recommendation here is to contact the insurance company either by phone or mail and request assistance in resolving the over-payment. Cover your bases by keeping track of your correspondence.

Another situation that may result in an over-payment and credit balance is when the patient has dual insurance. The primary pays their allowable benefit on the claim. The secondary insurance company may pay an amount that results in total payments more than the original charges. In this case, we probably don’t know what the contract terms and conditions are with the employer of the insured and the insurance company. It may be that the employer contract specifically states that the insured may not profit in excess of the allowed benefit. In other words, the treatment is $100, the insurance company allows $90. That’s all you get, and if you receive more money, then you have to send it back; you can’t bank it.

So, we’ve hashed through some of the more common events when the patient has insurance. But what if the patient doesn’t have insurance, or the practice doesn’t participate as a contracted preferred provider, or doesn’t accept assignment of insurance benefits at all? Realistically this can happen when a treatment plan is presented, the patient pays in advance, and some of the treatment paid for is not provided, or charges for treatment are less that what was originally quoted. Result: over-payment by the patient, and a credit balance.

Take another element in to play, say the patient uses a finance company, such as CareCredit. A good example may be that the patient qualifies for a 12-month interest free arrangement and CareCredit sends the office $3000 for the treatment plan amount. If the amount is not used towards treatment and it is agreed that a credit balance exists, do not send the money to the patient; they cannot use the funds for anything other than the agreed upon dental services. According to CareCredit, it is important to treat this as a credit similar in scope to a credit card charge back. In other words, rebate CareCredit the amount. CareCredit, if applicable to the arrangement, will then provide a rebate when the balance is returned for the portion of the merchant rate paid by the dentist.

In terms of the statement regarding the Arizona Law that allows for a business to adjust off an amount under $50 and not send the money back to the customer, I doubt very much that such a law exists; it just doesn’t make sense. Especially when laws are made to protect the consumer – how does this protect the consumer?

Well, we can’t assume this is true unless we research it. I searched the Arizona Revised Statutes and found nothing. The only reference to over-payment is in the tax code; nothing in the dental section of the statutes. I phoned the Arizona Attorney General’s office and was connected to the law library. The person there helped search for statutes that relate to over-payment and refunds and found nothing in the dental section as well. She did, humorously enough, find that fertilizer was mentioned under agriculture regarding refunds. Hmmm, so if you pay for more &%$# that you use, you can get your money back?!

My take on this issue is unless someone can provide you with chapter and verse of the law don’t buy it. If they produce the law in writing, have them send me a copy; then and only then will I eat my words.

The basis of law, according to my sources, is that reasonable and prudent judgment is at the forefront of any issue. In other words, “What would be a reasonable and prudent way to handle this?”

This really leaves us with the dilemma of figuring out what to do with money owed the patient. Ask the question, “If the patient found out the money was due them, and the practice just wrote it off and didn’t say anything, what reaction would you expect from the patient?” Would one really risk a potential complaint made by the patient to the Board of Dental Examiners against the doctor?

Okay. The credit balance is on the books and we know what happened because we’ve witnessed the event unfurl at the office. But there may be credit balances on the books where we don’t know the history and we must be sure there is a refund due. Diligence must be taken to ensure the accounting is correct.

First things first, find out what we’re up against. Run a Credit Balance Report from the Account Aging or Accounts Receivable section of your management system. See if the program will sort from the largest balance first. You’ll find 80% of the amount of money in credit balances linked to about 20% of all of the accounts in the report. Focus your efforts on the few accounts that have the largest amount of money due.

Work the accounts, audit for insurance payments and adjustments, patient payments and adjustments, and make sure the account balance is accurate.

Once verified, inspect the patient’s chart or computer record and determine if the patient has a scheduled appointment, if there is any uncompleted treatment, or if the patient is past due for their periodontal maintenance visit. If an appointment is scheduled in the not too distant future, make a note in the record that you will have a conversation with them at that time. If an appointment is not scheduled for treatment or periodontal maintenance, and the audit reveals a true credit balance, contact the patient to schedule an appointment for care and apply their credit to future treatment.

Follow a friendly dialogue like the one that follows:

“Mrs. Herbert, I have great news! There is a credit balance on your account, and after reviewing your record I found {you still have dental treatment that has not been completed/you are past due for your periodic examination and periodontal service}. We can go ahead and apply this to your next visit. I have a couple of appointments available this week, one is on Tuesday at 11:00 am, or Wednesday at 3:30 pm, which would be more convenient for you?”

Be prepared, if the subject comes up or the patient asks, to explain how the account has a balance in their favor.

If the patient is current with their periodontal maintenance and recommended treatment is complete, ask the patient if they would prefer that the doctor refund their over-payment, or to keep the credit balance on their account for the future. Ask them how they would like to handle it, let them choose, and proceed accordingly. If the patient wishes to obtain a refund, mention that you would gladly write them a check.

Don’t delay writing the check! Nothing will create ill will more than if a person is expecting their money in the mail and it doesn’t arrive in a timely fashion.

For insurance companies, whether or not they are due a refund depends upon the statute of limitations they place on their claims processing. My recommendation is to first complete this project for patient balances; then examine on a case-by-case basis those accounts that have been overpaid by insurance and contact the insurance company as stated earlier.

Be careful not to let this project slide by the wayside. Again, patients who discover they have a credit balance and nothing has been done to refund their money may become upset and discouraged with the level of service you provide. Don’t let this happen; move quickly to resolve current credit balance accounts, and proactively manage them monthly.

If someone does call the office asking about a credit that may be on their account, let them know that you’d be happy to audit their account right away and respond within 24 hours. Take a number where the person can be reached during the day and be punctual with your follow up.

Referring back to the person who submitted the question for this month’s article, it’s entirely up to the owner of the practice regarding what he/she does with the money. If the owner chooses to do something that is against your principles, it is probably a good idea to make a decision to find a practice that is more in line with your main beliefs. Not a tough call, really; keep to your principles of good business and professional service and find a practice in which you feel comfortable working and can feel proud that you are a patient advocate.

My staff seems to just 'go through the motions' throughout the day. I want them to see the big picture of making the office work, to be more accountable for their actions, in order to make the office run more smoothly and be more productive. What is the best way to institute a change?

Accountability, or reporting back on the results of specific activities, is a key method of ensuring the practice is moving closer to its goals. The doctor’s time is better spent when people report back on their performance instead of requiring the doctor to pour over management reports and track down a team member during the course of a busy day to try to find out why a particular objective has not been achieved.

The doctor must foster the opportunity to celebrate good performance and address poor performance. This is best done in the form of a short, regular meeting with staff responsible for business systems.

Vital Signs: Reporting back on Monthly Performance
At the end of each month, staff must prepare the necessary reports that review practice performance, preferably condensed to a single summary page. Practice Vital Signs is one example, a one page synopsis of key performance criteria.

Included in this report will be production, adjustments, payments, ending accounts receivable, same day payments (collections “over-the-counter”), pending insurance, days worked, new patients and current number of active patients. The names of the criteria may be slightly different depending on the practice management software used in the office. For instance, “Production” and “Adjustments” in Kodak/SoftDent will be termed “Charges” and “Reductions” in Dentrix.

Keep in mind, this is not a drill to transpose numbers from computer generated management reports onto a worksheet and hand to the doctor for him/her to study. It is an important function of accountability. I will include a copy of the Practice Vital Signs sheet I use for my clients at the end of this article. Feel free to modify the worksheet for your particular needs.

Staff must make sure the results of their activity during the course of the month or period, contained in Vital Signs, represent a positive direction towards the practices’ goals. If it doesn’t, then they must prepare information and/or documentation that will propose a plan to correct poor performance.

During a brief five to ten-minute meeting, the doctor must ask the staff member to report on the previous month’s performance. Questions may be broad based, or detailed to pinpoint specific areas. For example,:

“How did we do last month?”
or,
“Based on our goal, how did we do last month in terms of production?”

“We were trying to hit an average of $5500 in production per day, how did we do?”

“I noticed our payments were below charges; what happened?”

“The adjustments seem a bit high; could you give me the details?”

{Were they professional discounts, bad debt, reductions for insurance plan participation, family courtesy, staff dentistry?}

“How does our accounts receivable compare to last month?”

“I noticed the aged accounts over 60 days have gone up, what happened?”

“The insurance over 60 days looks a bit high, what’s hindering your ability to get the claims paid? What’s your plan to reduce the balance?”

“New patients looked healthy, where did they come from?”

Remember to ask for details. Don’t accept a hunch or a guess when it relates to answering a question about a specific issue. For instance, when asking a staff member about an increase in accounts past due over 60 days without a payment, don’t accept an answer such as, “Oh, that’s mostly insurance.” Often times this type of response is not based on fact, it is merely an assumption that we are doing a good job of collecting and the insurance is holding up the process.

Rather, ask for a printed report of all accounts past due over 60 days that haven’t made a payment in 60 days and identify exactly which accounts are pending insurance payment, and which accounts are slow at paying. Then, review the practice’s payment system making sure the practice is following prudent payment protocols. Finally, review the practices’ collection sequence and verify that proper steps are being taken to address past due accounts.

With this approach, one will be able to help the staff member examine data instead of guessing. Once the real reason is revealed, formulate a plan with the team member to address the issue and ask them to provide details in the future for better justification, rather than assuming.

The old adage, “Pale ink is better than a short memory” comes to mind when documentation is discussed. Make certain notes are taken at the meetings and log them for future reference. In this way, we can trace our activity and follow up on assignments and track progress towards positive results.

Establish a proactive approach to build the practice and ward off problems by having the staff track performance, document results, and be accountable for the outcome thru reporting back to the doctor each month. Institute this approach and performance will not only be measured but the staff will be more knowledgeable regarding their efforts that will promote excitement in the workplace, creating a positive result. The staff will get into the moment rather than going through the motions.

We hired a contract hygienist to work in our practice for the past year. Now that the contract is up, the hygienist is filing for unemployment benefits. What are the hygienist’s chances for collecting?

When first read, the answer seems simple, “No chance in h-e-double-hockey-sticks!” A contract is a contract, and the hygienist was well aware that a year commitment was the deal. Now force the point with the Internal Revenue Service.

The IRS recognizes two types of workers; the independent contractor and the employee. In the dental field, most independent contractors are sole proprietorships. Any working individual with a Social Security number has the default tax status as sole proprietor. Sole proprietors can use his/her Social Security number as the federal tax identification number, but there are significant differences regarding taxation between employees and sole proprietors. As a sole proprietor, one must pay both the employer’s and employee’s share of federal payroll taxes. The Self Employment Tax requires that the individual pay both since the independent contractor is both employer and employee. In a usual worker/employer situation, the employer pays half of the FICA tax and the employee is responsible for the other half. Despite having to be accountable for both shares, the sole proprietor reaps the benefit of tax advantages, such as deducting legitimate business expenses, special retirement plans that offer tax-deferred retirement contributions, and having more tax breaks than regular employees are able to spend more of their wages tax-free.

Employers are responsible to the employees for enforcing HIPAA regulations, OSHA rules, etc. within the workplace, because the employees are under the dentist’s control. Since contract employees are considered sole proprietors, and therefore their own employees, they are responsible for enforcing these stipulations themselves. This is where it gets tricky in a dental office; the dentist is responsible for the care the staff provides to patients. The dentist must be sure that all the employees are compliant in all aspects of the dental experience. Can a hygienist or any other dental staff member be a true independent contract employee since the dentist oversees/is responsible for the work/care the worker provides? This excludes, of course, another dentist working in the practice as a sole proprietor.

Employers control the work of the employees, not the work of the independent contractors. The IRS manual includes “Following the common law standard, the employment tax regulations provide that an employer-employee relationship exists when the business for which the services are performed has the right to direct and control the worker who performs the services. This control refers not only to the result to be accomplished by the work, but also the means and details by which that result is accomplished.” In other words, the dental office must treat independent contractors like an outside vendor, and avoid the appearance that the contractor is an employee. However, if a dentist must oversee all care within the office, and be accountable for the outcome of care, can a contract worker truly be classified as independent?

This is where the seemingly simple year-end contract question becomes difficult. If the hygienist decides to file a claim for unemployment benefits, the burden of proof to show the employment status of the contract employee to the IRS or state governing boards, is shouldered by the employer. This same scenario can be applied to workman’s compensation due to an injury while on the job or if the dentist decides to employ this person as a full or part-time employee. An IRS audit can be initiated when an out-of-work contractor files for unemployment, files for workman’s compensation/disability claim or decides to change his/her employment status. Once a claim has been filed, the State Department of Employment must determine if the contract worker was actually an employee. Sometimes the determining factor is if the contract worker carried independent unemployment insurance, which because of the expense, few contract workers do. If the State Department of Employment determines that a contract employee was actually an employee, the IRS will be given the heads up that back taxes need to be collected for federal unemployment insurance, and this will lead to an audit of federal and State withholding taxes as well. To prove that a hygienist, dental assistant, office manager, or any other dental employee besides a fellow dentist were contract employees is extremely difficult since the care provided by them was overseen by the dentist.

To sum up, despite having a written or verbal agreement, the dental hygienist can very well collect unemployment benefits, all the while the dentist is suffering through an IRS audit.

Special Note: A world of thanks to Susan Heppner, RN, BSN for the exhaustive research and composition of this article about a confusing subject.

I’ve been working my dental practice for several years now, and I’m just not making the money I would like to make. What should I be looking at in terms of my income and expenses, and how can I trim overhead to take home more money?

To answer this question, let’s turn to some quick and basic fundamentals of good business management and learn how to measure practice profitability. But before we do, a small but direct disclaimer: The author is not an accountant, and is not a tax advisor. This article is not meant to provide tax advice or accounting advice. It is meant to shed light on the concept of identifying cost centers and ways in which a dental practice may improve profit.

Many dentists are not skilled in reading a Profit and Loss Statement, similarly called an Income Statement, because their time and energy is often put forth in learning to become excellent clinicians. This could be construed as a fault of the dental schools, but is it really? Some would argue that dental schools are credentialed to teach dentists in the healing arts, not business management. I concur.

On the other hand, in the real world dentists in the private sector are privy to educational courses beyond dental school in business management, but how many attend? Management consultants, like yours truly, have the information and skills to teach dentists about overhead control and profitability, but how many contact a consultant and make an investment in their business education? This article will help clarify overhead control and profitability, and at least provide help to those who seek answers.

Many dentists use overhead as a measure of proficiency in business. True, low overhead yields good profit, and proficiency in this area is a measurement of business success. But overhead is commonly misconstrued, in that it may not be measured consistently across all practices. Here is a good way to consider measuring office overhead so that the office’s ability to generate profit is enhanced.

The Net Operating Overhead for a practice is derived from the Profit and Loss Statement, or Income Statement, by calculating all operating expenses and dividing it into the practice’s income. The result is in the form of a percentage, usually less than 100%; if it’s more, we need to talk!

The first step is to have an accountant prepare a Profit and Loss Statement, or generate a P&L from an in house accounting program such as Quicken or QuickBooks. Use the feature if it’s available, that calculates expenses as a percentage of income. This will come in very handy later.

The next step is to identify expenses not included in operating overhead. These expenses occur in the P&L but are not part of operating the business, per se. Expenses such as doctor compensation and his or her payroll taxes, interest paid, depreciation, amortization and taxes. In addition, any discretionary expenditures taken on the doctor’s behalf not related to practice operations must be included, such as automobile expense, life insurance premiums paid, medical insurance for the owner, disability insurance premiums, and so on. Again, these expenses are not related to operating the dental practice and are part of the owner’s benefit.

Adding all of the above mentioned expenses would help arrive at a number that represents operating income. The difference between this number and the total collections is the operating overhead. Divide the operating overhead dollar amount into the total income dollar amount of the practice and voila! Overhead Percentage!

Here’s an example. Our fictitious dental practice collects $1,000,000 in our make believe year. Doctor’s compensation and payroll taxes are $230,000, Interest Expense is $25,000, Depreciation is $15,000, Amortization is $10,000, Taxes are $5000, Life Insurance premium is $7500, and Automobile Expenses are $7500. Total non-operating expenses and doctor’s compensation: $300,000. The difference between $300,000 and $1,000,000 is $700,000. $700,000 divided by $1,000,000 is 70%.

Is that good? Bad? Okay? So-So?

Since a large pool of comparable data is not available to measure against the “averages”, it isn’t possible to say 70% is good, bad or otherwise. It’s relative to the income needs and financial plan of the owner.

Clearly, 30% operational profit on $1,000,000 in sales would satisfy a good portion of working dentists in the marketplace. What’s important here is that we now know how to calculate net operating overhead. Take that one step further and begin to study the key cost centers of a dental practice, make budget decisions, and set goals that will decrease overhead and increase profit going forward.

To control overhead and increase profit, I suggest concentrating on four major cost centers of the practice and their target levels to ensure overhead is managed. The percentages are related to income (collections) rather than production. This discussion is focused on general restorative dental practices, not specialty practices such as pediatric dentistry, oral surgery, endodontics, periodontics, prosthodontics, and orthodontics.

Rent/Mortgage: 5-7%; with a target of 5%
The Rent/Mortgage line item in a Profit and Loss Statement is an excellent indication of practice performance against rent expense. If Rent/Mortgage is above the 7% range, the facility is either too large, rent is too expensive, or the office is not generating enough income to support the occupancy payment. The ideal target is 5%. If the rent is below 5%, more often than not this shows an excellent use of facility resources.

In order to reduce this cost center, or reduce the percentage of the cost relative to income, one may have to re-negotiate a lease or improve income. More often than not, leases are locked in for a period and the alternative is to focus on increasing income. To do this, improve communication skills in order to boost case acceptance and increase productivity by having patients better understand their dental conditions and the benefits of proper treatment. Keep in mind, case acceptance is also related to the practice’s ability to help patients understand that the decision to undergo treatment for diagnosed conditions is theirs to make. Ultimately, improved productivity will increase income and bring this line item into a healthy range.

Laboratory: 8-12%; with a target of 10%
On the whole, it is a sign of fiscal success if actual costs are contained below a specific target. This is not true with Laboratory expenses. If this expense item is below the target of 10%, it is an indication that perhaps not enough laboratory related dental services are being delivered. On rare occasion, a low lab expense in a practice that is producing well may indicate a below market fee for lab related work is being paid for good profit.

Increasing this cost center depends on how well the office can increase case acceptance where lab related work is focused. That’s not to say, “Go sell more crowns!” Rather, improve productivity by following the suggestions previously stated.

Dental Supplies: 5-7, with a target of 5%
This expense should not waver. Be sure, however, that the expense entails only disposable dental supplies and materials. Keep equipment purchases separate since they are not usable disposable supplies, per se. Often times, including equipment purchases such as handpieces or other small equipment purchases will boost this category out of the healthy range. Understandably so, a business owner may want to deduct the expense of small equipment expenses during the year purchased, rather than depreciate the expense over several years. Just the same, if the expense is over 5%, it most likely means supply-ordering and inventory systems are inefficient.

If you find your systems are inefficient, integrate a Dental Supply Cost Containment program by setting a budget for dental supply ordering and establish a tracking mechanism to monitor expenditures monthly. Have the person who is responsible for ordering supplies in the office manage ordering so that they do not exceed the budget. For example, in our $1,000,000 practice, if the goal is to keep supplies at 5% of income, then the office would not want to spend more than $50,000 a year in disposable supplies and materials. On a monthly basis, keep track of ordering and attempt not to spend more than $4200 per month for supplies.

Remember not to be penny-wise and pound-foolish. If towards the end of the month materials are needed for scheduled production, such as impression material for a large crown and bridge case, then order what is needed so as not to run out.

Payroll/Staff Salaries: 25%; Employee Benefits: 5%
This line item is critical simply because of the size of the expense item. A quality team can be well compensated. It is not unheard of to pay team members well and maintain the expense in a healthy range.

Administrative and clinical staff may be allocated 12-16%. The remaining 9-13% could be salary for hygiene. Payroll taxes and cash paid benefits, such as bonus and paid time off are included in these numbers.

There is a saying in dentistry: “You’ll never get rich on the money you aren’t paying your team.” But the income of the practice must be able to support a well-paid team of people that produces results and appropriate net income for the doctor.

In some cases, a high salary percentage may be the result of over-staffing in certain departments. For instance, a practice with one doctor may employ two full-time hygienists and not produce enough revenue to offset hygiene salaries. And, a practice may employ extra front office to handle a high traffic of low-revenue insurance patients, there again perhaps not generating enough revenue to offset the cost.

Employee Benefits, such as medical insurance premiums, retirement contribution, profit sharing, continuing education, are separate and could range from 1-3% depending on the practice.

To keep payroll at a healthy level, make sure the team is well-educated in patient services, well paid for their excellent work, and track the income and expense results periodically to be sure revenue is supporting the salaries paid to your great dental staff!

The total of these four cost centers is 43% to 56% (when including employee benefits). Consider that there could be another 25 or so remaining cost centers in a dental practice that will make up anywhere from 10% to 25% of income. These include Advertising, Credit Card Fees, Bank Charges, Professional Development, Dues & Subscriptions, Legal Fees, Accounting, Consulting, Office Supplies, Postage, Repairs & Maintenance, Computer, Internet, Utilities, Meals & Entertainment, Collection Expense, Interest, License & Permits, Printing, Gifts, Medical Waste, and Storage. One can see how confusing this exercise is when each of these expense items is tracked regularly.

It is prudent to establish a budget for each of the rest of the expense categories, but first control the four major areas discussed in this article. Once a practice has the four major areas under control, the rest of the expenses can be evaluated individually to see if work must be addressed in other areas of the practice.

Be Proactive in planning for profit by examining the Profit and Loss Statement for the practice. The end result will be reduced overhead and increase income. Ultimately, this exercise will help create a more profitable and enjoyable practice!

Should I include a confidentiality agreement concerning business systems used in my practice (proprietary forms, special clinical protocols, software, etc.)? If so, what should it state? And on another note, do you have any great suggestions for the New Year?

I’ll tackle the first two questions, then conclude with the third question which I feel is a fun one – there are many wonderful ideas for a New Year; but I will cover one that stands out as the most important and is timeless!

During the course of working in a dental office, employees learn a great deal from their dentist, colleagues, and courses from recognized experts in the field. Most of the internalized information and developed skills are transferable; they can be used from one office to the next. In terms of general information there is a standard set of dental office skills that are used industry wide.

For example, the entire office may attend a continuing education course on treatment planning and case presentations. The lessons that are taught perhaps through lecture or even role-playing to hone verbal skills are not something concrete that can be guarded by an office policy. Transferring these learned skills to another office environment when an employee leaves is difficult to limit. In addition, dental employees from other offices may have attended the same course given by the same instructor; therefore, could those ideas be guarded by an office policy of Proprietary Information? Not likely.

On the other hand, if the team convenes after the seminar and creates original documents, unique case presentation forms, a distinct office greeting, or visual aids that are used in the office for the sole purpose of benefiting the patients of that office, one could argue that these tools are proprietary and could be guarded by office policy.

Another example is a proprietary form prepared by a dentist for special laboratory cases. A long-standing consulting client of mine, and good friend, has created a unique laboratory order form specific for “Smile-Designs” that he uses exclusively for large cases that change people’s smiles. I would argue that this form is solely the property of the office and cannot be taken from the office for other’s personal use.

Be it a form, a system, or idea, a simple paragraph in the Personnel Manual may read something like this:

Proprietary Information:

Although not intended to discourage team creativity, any system, idea or communi­cation developed during your employment here is exclusive property of the practice and remains so even after termination.

Even if it is determined that an office tool is being used in another dentist’s office because a terminated employee introduced the document to the new office, one must consider if it is worth the time to pursue a course of action to make them stop using the form. Does the use of your personalized form in another office affect the performance of yours? Most likely it does not, although it is frustrating to learn that another office is using the fruit of your labor.

Okay, now the fun one: What should you do at the beginning of the New Year?

Well, outside of measuring the past year’s performance against the original goals, re-calibrating goals, and making a new commitment to your business, I have a great idea.

Over many years, I’ve had the pleasure of writing articles that address issues and concerns in dental practice management. The articles have been published in local, regional, and national publications and most recently on the Internet. The articles have essentially been the culmination of many years of experience in dental offices across the country where I have worked as an advisor to dentists and their team. I come away with real and practical solutions to every day problems that face dentists and their employees, fold them into lesson plans, curriculum, and eventually articles for publication.

It is for this reason that I suggest you do what I am doing at the end of this year, and to conclude this article: Giving thanks to a person or people who have helped you to achieve your successes. I would like to give endless thanks to the person who has been helping me put my thoughts, experiences, and lessons into a readable form for many more to benefit. My wife, Susan, has been the “brains behind the scene” as she has been my partner in writing and editing articles, lesson plans, and curriculum for my management company.

Without her, I’m sure my articles would be published. But with her, they have energy, vitality, and foremost make sense! (I’m sure she’ll even edit this part of the article to make sure my emotions don’t get carried away with the real purpose of the message – she helps me a great deal!!!)

As the New Year is now upon us, find the time to go to those people around you in your dental practice, people who affect your career and your life, and let them know how much you appreciate their help, their love, and their support.

I know I can’t make it without them. Thanks Susan for your support and help through the years!

I know I should have an employee manual for my office, but I haven’t the foggiest idea where to start. Should I buy one already written? Is that enough, or should I modify it for my office? Will it solve all of my staff issues?

Personnel Management in dental offices requires specific elements to be effective not the least of which is a manual that clearly spells out the general policies, terms of employment, and compensation & benefits of your office. Included with the manual are forms, worksheets, and employee records for proper information safekeeping. It is not just another “system”, or important legal document.

Ensure the manual works for the practice not against it.

Without this tool and its components, the office policies are ambiguous, and employees are left to guess how they’re supposed to behave in certain situations. Even with this in mind, a manual must not rest alone.

What I will attempt to do in this article is explain essential background information on human resources that must co-exist with a written guidebook on personnel policies. I’ll finish by providing guidance on how to construct and effectively integrate an employee manual into the workplace.

Truth is, in my experience ALL dental offices need an employee manual but only a few have a current working guidebook.

But where does one start?

My suggestion is to obtain an employee manual already prepared for dental offices. There are several on the market that are worthwhile and can be purchased at a fair fee. As a service to each of my consulting clients, I have developed a personnel manual that fits specifically into the dental environment. The manual I have constructed has the capability to be fine-tuned, or individualized for each dental office, due to the unique qualities found in each practice. However, prior to delivering the manual for editing and final production, the dentist and I spend considerable time building an environment that supports fair employment practices. Let’s dive into some of those concepts so that you will have an idea regarding what manual will be a perfect fit for your office.

A cornerstone in business management is providing employees with the reason why things are done a certain way. Acquiring principles that will keep your business running effectively while handling any personnel issues is in line with this concept. Make sure you’ve spent time thinking about how your business will be run, and how decisions will be made. For example, if one declares, “We will always respect other people’s time in our office”, then one tends to focus on staying on time during the course of the day. And, appointments that are scheduled are not moved for the convenience of the office.

In terms of personnel management, consider establishing principles that will help make decisions easier to come by. For instance, “We will strive to be fair to the employee in all aspects of human resources” would be a sensible tenet to adopt. In this way, when a situation arises, fairness would be the prevailing principle ensuring a reasonable outcome.

Another consideration may be to incorporate the “Reasonable Man Theory”; an ancient English common law which states, “In any circumstance, a person is expected to know what is real and/or reasonable and do what is prudent”.

When dealing with personnel management issues, one must ask, “From who’s perspective is it reasonable?” In today’s day and age, the employee’s perspective of reasonable is used. In that case, examine each situation through the eyes of the employee. What one risks is the inherent loss to business through decreased productivity from people who are not treated reasonably and prudently in the work place.

In order to keep morale high, remove hurdles to productivity. Here are some suggestions that can help promote good management of people.

• Create a mission statement – help people understand “why” they are doing what they’re doing.
• Have complete job descriptions - they are the first and last line of defense for personnel management. And, they clarify the employee’s responsibilities, wiping out ambiguity in the workplace.
• Build an office where people know how they’re doing: provide objective feedback on performance.
• Develop tools & reports that employees utilize to make them accountable for their job requirements and work expectations.
• Make all employees feel comfortable and fulfilled in coming to work.
• Ensure a non-hostile work environment exists that is private and safe.

An effective employer shows he/she cares with fair employment policies and parameters for continued employment. Use the above suggestions to add value to any personnel guidebook or manual that is used in the office.

One important aspect in personnel management, in particular our state of Arizona, is the clear establishment of employment “at will”.

In simple, this is employment that lasts as long as both parties will it to last. If one party elects to discontinue the arrangement, then the arrangement is discontinued. Put another way, if the person is employed, the employment lasts as long as both parties agree equally.

Avoid these common errors and maintain employment “at will”. Don’t promise permanent employment; again, employment lasts as long as both parties agree equally. Next, make “at-will” employment very clear by placing it in the personnel manual and on job applications. Also, avoid any “Termination for Cause” statements in the manual or employment documentation, as this will negate the “at-will” status of employment in the office. Finally, don’t neglect to obtain a signed acknowledgement of receipt of the manual!

Time has tested the theory that a fantastic team is built around reliable personnel management systems. Hiring protocols are followed so that people with the right skills and temperament are screened and hired properly. They are employed because they know they can perform the duties described in the job description, and references have provided positive reinforcement of their good work history. From their first day on the job, they know what to expect because they’ve read a manual describing how things work in the office and what is expected of them in return. During their time of service, they know how well they’re performing because a formal review process evaluates their work productivity against the employer’s expectations. Consequently, employees are accountable for the results of their actions – good or bad.

In the final analysis, all involved work in a dental practice should provide for a profitable and gratifying experience. A personnel manual that is customized to fit the particular aspects of your practice is a must, however it should be utilized so that it maximizes employee performance. I'll state the obvious in that just purchasing a manual will not solve personnel issues. Incorporating the manual with good employment policies, intact procedures, sound philosophies, and following through on what is found within the manual will result in excellent human resources.

Denise Rucci, Managing Director of Communications and Marketing at the Arizona Dental Association was recently contacted by a member requesting advice on how to handle this difficult situation:

A dentist placed temporary crowns, and when the permanent crowns came in the staff member called the patient to schedule the appointment. During this conversation the staff member mentioned that the patient had a balance due. The patient became verbally abusive at mention of the balance due and refused to schedule the appointment. Several days later, the patient appeared at the office wearing a large knife outside her clothing, verbally abusing the staff and then walked out. Minutes later the door slammed open, and the patient tossed an envelope of money of the floor and left.

The AZDA member asked:

1. Should I have called the police?
2. The patient was midway through treatment, what are my responsibilities?
3. If this patient appears in our office again, should we attempt to reason with her or simply call the police?

Should the police have been called after the first altercation? Absolutely. Even without knowing the basics of what the patient actually said to cause the staff to label the vocalization verbally abusive (i.e. was there a verbal threat of injury) the fact that the patient showed up with a large knife exposed constitutes a threat. Just think what would have happened if this patient showed up at a courthouse or airport brandishing a knife. The police should be called so that there is a documented record of the threat. Even if the threatening event took place in weeks past, it still would be wise to contact the police to inform them of the situation.

Jeffrey Tonner, an attorney dealing exclusively with dentists, was consulted regarding what course of action should be taken with this patient in the future, since treatment was not completed. Mr. Tonner said that the dentist and staff do not need to continue treatment on a patient who issued threats. The threat has to be legitimate, and the patient’s actions and comments should be documented within the chart with as much objective detail as possible. In this case, the verbiage that was verbally abusive should be included, as well as the knife placement, description of the knife, any actions such as clenched fists, door slamming etc., that are different from the norm, and that the police were contacted and a report was filed.

Assuming the money in the envelope satisfies the balance due, the dentist was paid for services. The remaining issue is whether or not to finish treatment not yet completed. Again, Mr. Tonner states that if the threat is legitimate, then a dentist does not have to complete treatment. The money may then be refunded along with a letter of dismissal sent to the patient, but should not mention specifically why the dentist is no longer going to provide treatment, as this could incite the patient even more. A sample letter of dismissal follows.

Dear Patient:

It has become apparent to me that our professional relationship has deteriorated over the past several {weeks/months}. A healthy dentist-patient association is based upon mutual trust, respect and understanding, which are lacking between us. Without assessing blame to you, my staff, or me it seems now is the appropriate time to terminate our relationship.

If you have an emergency situation within the next thirty (30) days, please contact us and we will do our best to accommodate you. Thereafter, we ask that you seek all dental treatment elsewhere.

You also should select a new dentist soon. Your current condition requires that regular hygiene be performed every {3, 4, 6} months. If you or your new dentist requires copies of your dental records, please send us a written release and we will be happy to forward them to the appropriate person.

My staff and I regret that this situation had to occur. We wish you good luck in the future.

Very truly yours,

{Dentist Name}

If the patient appears at the office again, it would be prudent to call the police immediately. Trying to reason with a patient who has previously exhibited threatening behaviors would only endanger the staff and other patients in the office.

The question has to be asked, “What was the genesis of this event?” It may be difficult to pinpoint how this situation became so intense. No matter how well or how poorly the person was handled before and during the altercation, no one should be subject to this kind of abusive behavior.

In order to better manage this situation and plan for the future, meet as a group. Without being accusatory, ask the following questions:

• Was the patient so frustrated that this was her way of lashing out?
• Were clues left along the way by the patient that were ignored by staff, but if dealt with could have diffused the situation?
• Does the patient have a medical condition that caused the outburst of behavior?
• Why did she become so verbally abusive on the phone when appointing and following up on financial arrangements?
• Was there a prior inkling that this patient exhibited behavior that was unpredictable and explosive?
• Was every step taken by the staff prior to the abuse to appease this patient as a customer that was appreciated?

This kind of situation could happen in any dental office, and this type of scenario must be discussed with everyone working in the practice. Internal protocols should be instituted and followed for the care of every patient, so that a uniform approach is taken for each patient.

There should be a safety system in place so that staff members will know how to handle this situation should the need ever arise. The procedure on how to handle a disruptive, unruly, disgruntled or volatile patient should be included in your office manual. As frightening as this situation is, it is an obvious reminder of how important it is to be Proactive in managing a business. Prepare your practice so that problems like this are handled correctly and safely.

"I'm not really sure patients are brutally honest when asked in the office about their visit and the service they received. Do you know of a good way to get a truly honest response from patients in terms of their satisfaction with a dental practice?"

It is very easy to become complacent in routines. With the day-in, day-out doldrums of work, it is effortless to take things for granted, with the thought that the status quo works.

However, as in any service industry, consumers run dentistry, and oftentimes the consumers see things in a different light compared to the workers. Since patients are out of their element or routine, they become more aware of the environment around them; astute clarity of the goings-on in your office is monitored and internalized.

Hopefully, the environment and service provided leaves a lasting, pleasing effect on the patients. However, when was the last time you stepped back and tried to view the makings of the workplace as a consumer rather than the worker?

Not only should one think about doing a self-performance review, but also think of giving every aspect in the office a "performance" review. After becoming satisfied with any changes or improvements that you could institute, take the performance review one step further, ask the patients.

Most likely, if an appointment was truly unpleasant, for any reason, a patient would be more apt to verbalize a complaint. However, if a patient was asked how a visit went when the appointment was mediocre, do you think an honest response would be given?

Many times, patients could come up with an answer that would benefit the way the office was run, but this opinion is not voiced. The patient may fear retaliation by an employee if a complaint regarding his or her behavior was brought up, the patient may be too shy to be truthful, or the patient would be forthright with critical analysis of a problem, even giving possible solutions, if only given the chance to do so, anonymously.

In order to bridge the communication gap, a lot of weight should be given in building relationships with patients . Care, compassion, and great communication skills more often than not bring out honest dialogue that are able to resolve most issues. Unfortunately, if we’re missing on some of these elements, we could miss out on learning from our patients the very things that will help us solve problems.

The question is always debated, “How do I get a patient (customer) to give me the honest truth about how they feel about our practice (company)?”

In my experiences with dental practices, the way to accomplish this is to combine the compassionate approach with a patient survey. There are a few key elements to the survey that I’d like to elaborate on in this article to be sure it is done correctly.

To begin, write an opening paragraph that is friendly and encourages people to respond openly to the questions. Here’s an example:

• We sincerely hope your experience in our office was exceptional. Because your satisfaction is extremely important, would you assist us in improving our service by taking a moment to evaluate your experience today? Please answer the following survey questions and drop this in the mail. Thank you for your assistance.

Next, develop questions that will address a handful of service matters you wish to evaluate. Following are some examples.

• How would you rate your service overall?
• Are we exceeding, meeting, or not meeting, your expectations?
• When you contact our office, are you treated in a timely, courteous, & professional manner?
• Have you recommended our dental office to anyone?
• If so, thank you! If not, why not?
• If you’d like to comment on a team member, whether satisfied or dissatisfied, please note their name and your opinions here.
• We appreciate and take your advice seriously. What would be your suggestions to help make a patient’s visit more pleasant?

Leave space enough for comments so that people who wish to elaborate can write a few comments.

Construct the survey so that it can be printed on one page, put them in envelopes with a postage stamp attached. Alternatively, you may elect to print these on 4x6 postcards.

The key point to a patient satisfaction survey is to have the responses sent to an independent 3rd party, or alternate address other than the office, if at all possible. Here’s the thought; people are more apt to give an honest response if they believe the surveys are being sent to an objective 3rd party. Response rates for unsolicited customer satisfaction surveys usually range from four to eight percent. In my experience, when patient surveys have been implemented in practices under my guidance, we see anywhere from 75 to 83% response. The reason being, we’re handing them out directly to the patient, encouraging them to respond confidentially, and incorporating the system intelligently.

It is helpful to keep a ledger of all the patients who were in the office and that each of these patients was given a survey. In addition, it would beneficial to always have more than one employee responsible in handing out and double checking that the patient did indeed get a survey. Not only does the survey help to enlighten you as to the patient visit, it also could be a potential spotlight on a specific employee. If there was a conflict with an employee during the patient's visit, and the employee in question felt responsible for poor actions or behaviors, this same employee may be more apt to "forget" to give the patient a survey.

Here are suggestions for how to orchestrate the distribution of surveys in the office. Modify them to suite your practice’s particular style.

Place the surveys in each of the office's operatories and at the front desk. Give one survey to each patient after the office visit. Keep in mind the advantages of the survey when getting ready to release it to the patient: Confidentiality breeds honest response, so stress to the patients that it is being mailed to an independent 3rd party.

Present the patient survey in a positive light:

“We’re always interested in learning if there is any way we can improve the service we provide our patients. Would you please help us by completing this confidential questionnaire? This is returned to an independent 3rd party who will compile all the information for us. It’s more important to us to know what we need to do, rather than who is providing the feedback. Thanks for your help.”

It is best that the surveys are collected off site, by an independent 3rd party, rather than the dentist’s home or an employee's home, and that either the 3rd party or the dentist are the first to see the answers given in the survey. In being the first to review the surveys, all the information can be accounted for. If the dentist chooses to use an employee's home for collection, be sure that the employee hands over the surveys unopened. In this way, there is no shredding of evidence implicating either the employee collecting the information, or the protection of a fellow employee.

The survey results should be tabulated off site, and should never be viewed in the office in front of patients. Any comments that merit immediate discussion or action should be delivered to the office quickly. If any negative patterns are apparent from the survey results, action steps to improve the problem should be implemented as soon as possible. The survey results should be discussed frequently during the morning huddle or at the regularly scheduled office meeting.

More often than not, the surveys reveal what the office is doing right, and also specific employees are positively recognized for actions taken during a visit. Discussing the results, including a specific employee who was listed can boost morale for the entire team, while also improving performance. An employee may go the extra mile hoping that a patient will individually recognize him or her!

The final steps of the management process, when incorporating a patient survey, are to mold the feedback into management action steps and explain to the team how to solve some of the issues presented during a regularly scheduled team/office meeting. Try not to find blame with any one individual, rather find the fault in the practice management system. Fix the system rather than singling out the person. However, if a significant negative incident involving a single employee is brought to light, have a private meeting, one-on-one, with this employee to gather more information regarding the incident.

Here are some examples of what I mean:

A comment by a patient was made that she heard side conversations by the staff about subjects not connected with dentistry, and was offended. Or, a patient commented that he was in the treatment room near the front desk, and overheard the staff discussing how difficult a patient was being on the other end of the phone.

Use this feedback to suggest that these comments are not appropriate and we must be on our best behavior during each moment of the day. Patients can hear more than what we think; it’s important to be aware of how our voices carry. Re-affirm that being patient and respectful to all who come to the office is vital in excelling in patient services.

Another example is a response that indicated a patient waited for some time for a scheduled appointment. In addition, when she arrived at the office, no one acknowledged her. Again, provide feedback to the team and suggest ways to be aware at all times of the schedule and patients in the office. On-time performance is important for people coming to the dental office, as their time is valuable. Know that a reason why patients are late or change their appointments is that we may run late or we may contact the patient to change appointments for some reason. Is turnabout fair play? No. Patients may very well respect your time as much as you respect theirs; but remember, patients are the consumers.

We discuss often in Practice Pointers the importance of patient services. Keeping this portion of the practice operating at peak efficiency is a keystone in practice success. Make sure you know what your patients are really thinking and conduct a survey so that you know for sure. Don’t become complacent in the day-to-day activities of running your business. Be sharp, be aware, and be successful!

“A patient approached me today regarding an article she read in the local newspaper about mercury fillings. Since this is a topical (pardon the pun) subject, how would you suggest I answer?”

Recently it was reported that a federally funded study concluded that dental fillings containing mercury-laden amalgam were unsafe. However, a joint panel of Food and Drug Administration health advisors rejected the findings of this report by a 13 to 7 vote after reviewing 34 recent research studies contained in the federal report. The advisors said that the federal report didn't clearly and objectively present the current state of knowledge about the "silver" fillings. In addition the panel stated that the report's conclusion about safety weren't reasonable, given the quality and quantity of information available. The panelists recommended further study regarding the mercury-based fillings, with emphasis on risk groups such as young children and pregnant women. And so the beat goes on.

The fate regarding the safety of mercury-based amalgam continues, and the debate of these fillings will too. In the meantime there are millions of patients whose mouths are full of “silver” fillings. What is a dentist to do?

Practicing dentists have differing opinions about how mercury based silver fillings affect one’s health and well-being. No matter what side of the track you are on regarding the safety issues of these fillings, you most likely will come across patients with questions. This article is intended not to sway anyone to one side of thinking; rather, it is designed to help the dentist and staff handle these questions or concerns should they come up.

Research and find the facts

Take the time to find pertinent information from reputable sources regarding your position on the matter. Assemble this information in a way that is easy to disseminate to people who may have questions about amalgam. Make legible copies or request reprints from periodicals, newsletters, or internet sites that provide the information.

Educate the team!

In order to make sure that everyone in the practice is on the same page, spend time discussing the issue with the relevant facts. Be open to questions from the team and create an environment that allows people to discuss the topic freely. Make certain that any questions regarding the topic are answered with fact based material, not opinions.

Objective vs. Subjective

Be aware that some may not have the same belief about amalgam restorations. In this case, if the beliefs of a team member don’t mirror that of the doctor, I’d recommend providing the team member enough time to research the subject and allow the person to arrive at an objective conclusion based on the facts, rather than a subjective opinion. If the person’s stance still varies from the doctor’s, then request the team member defer all answers to the doctor and not provide an opinion on the matter.

If there is a team member that has strong convictions and aren’t able to follow these simple instructions, ask the team member to leave the practice and find an office that agrees with his/her philosophy.

Inform before you perform!

One of the most frustrating experiences a patient has is when something happens by surprise. In other aspects of the dental office, “…wow, I didn’t know it would be that much!” happens when we don’t make specific financial arrangements with the patient prior to treatment. In the case relating to restoration materials, make sure the patient is aware of the material used in the restoration prior to starting treatment. That way there won’t be any surprises. Try something like, “Mrs. Smith, we’ll use {name of material of choice} to restore your tooth. In our (doctor, staff) experience, this has served our patients very well.”

If a question arises regarding restoration material, then you’ll have information handy to explain why the practice has selected the material of choice. Further, the entire team will present a united front regarding the issue. Without this approach, patients may become confused as to what may be best for them and won’t be reassured they are receiving the best care.

It is important to be aware that people are receiving information in the public circle and are going to have questions. They may or may not ask them openly in the dental office. When they do, it’s important to be prepared to provide an answer that is consistent across the board – from the doctor to the dental assistant to the hygienist to the front office coordinator. Backing up your position with material from reputable sources makes your position that much more respectable to patients.

The trust and confidence you have with patients goes back to how well you communicate with them. It carries even further when good factual information comes alongside. Be proactive in your approach to this customer/patient relations issue and other sensitive issues to retain patients’ trust.

I’m confused about the term “At-Will” employment. Some have said “You just can’t fire someone without good reason”, yet “At-Will” implies you can. Can you clear up the confusion?

I hear this frequently in my work, almost on a daily basis. Employment law on the local, state, and federal level is confusing to those without formal education and experience. In this article, I’ll do my best to help clear up the ambiguity and provide a few practical steps to solve the issue.

Although many states are “At-Will” states, which is defined as “both the employer and the employee can end the employment relationship at any time for any reason or for no reason without any notice”, you still need to make sure that you are not ending the relationship in violation of any local, state or federal law, act or statute. What dentists, as employers, need to be concerned about is, “How well have employee issues been documented to support personnel management decisions”?

Working with dentists on a daily basis in these matters and as a business management advisor, it is safe for me to say that dentists’ documentation, including misconduct, performance appraisals, attendance and personnel files, is not very good, at best. How do you rate? Check your employee files and ask yourself, “When something goes wrong and I have a discussion with the employee, what do I write down and where do I keep it?” (Sorry, the “It’s too busy, I’ll write it down later; I can remember” card doesn’t work as well as you may think.)

Employers tend to get themselves into trouble by not having proper documentation to support their employment decisions; dentists are not excluded from this group! The biggest reasons I find in my work are fear of confrontation, do not like doing the paperwork, lack of supervisory training and discipline procedures are just too much trouble. Sound familiar in your dental practice?

What’s even worse is that dentists who do an inadequate job of documenting employee conduct or performance are rarely disciplined themselves. Since there is little accountability, why do it? This is what you may be thinking, until a wrongful termination law suite is served and one has to defend one’s termination decision.

Consider these helpful tips to tackle this problem of support personnel management and employment termination decisions.

“If in doubt, write it out”

As the well-known writer on business management, Harvey McKay, says, “Pale ink is better than a short memory”. It is a valuable practice to keep a record of both positive and negative outcomes of employee activity. There will be examples of employee behavior to use in the performance appraisal that will present opportunities to provide positive recognition, which, by the way, is a very popular item on an employee’s “What Gives Me Job Satisfaction” list. Examples also will provide ammunition in disciplinary discussions. Another point: Judges and juries are more likely to believe contemporaneous documents than people.

There should be no surprises when conducting the performance appraisal interview. Many dentists tend to avoid the tedious preparation of a well-orchestrated performance evaluation. Employees want to know why they were rated the way they were and what made the dentist select the rating. This brings home the point of making notes during the time period between appraisals so that ratings have justification – provide examples of instances where the employee shined and did a wonderful job. This can only improve performance, as your people will feel better about themselves being recognized for having done a good job. Just as important is to use examples of when the employee didn’t do so well. When you state specifics about situations that happened, there is little room for discussion. It’s hard to fight facts.

“Three-Strikes, You’re Out!”

Use a three-step method in handling disciplinary issues. Many dentists struggle with handling discipline because it is a distasteful task. No one likes to tell someone that they are doing poorly or violating company policy. The problem however, is that if it is not addressed in a timely and proper manner, it only gets worse.

You know the scene: employee performs poorly, there isn’t time during the day treating patients to pull the employee aside and conduct a quick one-minute reprimand. Time slips away, and before you know it, you never did talk to the employee, they don’t know they did anything wrong, and it is likely they’ll do it again!

First of all, have a discussion with your employee the moment an issue arises. Sure, it’s tough, but find the first available moment to address the issue. Document your discussion. Granted, dentists may talk to their employees, but in most cases, nothing is committed to writing. Do so to avoid problems of recollection and justification later.

A good tip here is to create, on a word-processor, a verbal and written warning guide. This can be a single page that has room for two, three, or four instances, rather than one page for each individual occurrence. Include the following specific points to address. Use the basics of, “Who, What, When, Where, Why, and How” as much as possible; all of them may not apply, but the point is be thorough. In other words, describe who did it, what happened (and what was their reaction to the discussion), when and where did it happen, why did it happen, and how did it happen? Lastly, make notes on what was discussed to prevent it from happening again.

Here is an example; choose the correct way to document employee performance:

“On January 15th, you were 30 minutes late; car trouble. On February 1st, you were 20 minutes late; overslept.”

“You were late three times in the last four weeks.”

Okay, easy one. Sure the first is correct. The second doesn’t provide the specifics necessary to classify as good documentation. Get the idea? Good. Here’s one more, just to drive home the point:

“On December 13th, I heard (employee name) being rude to a caller. Comments such as, “This is our policy; I don’t make the rules; I just follow them.”

“(Employee name) was rude on the phone.”

Did you get them both right? Awesome! Let’s move on.

Have the guide handy so that anytime an issue comes up and you talk to your employee, make a quick dash to the private office, pull the guide from your files, and complete the documentation. Put the filled out guide away under lock and key in the employee’s personnel file.

Okay, that’s strike one. Strike two happens and you find yourself in a position of repeating the discussion. At this point, I suggest a more formal discussion that entails a written warning that the employee will have for himself or herself. Include the date, time of discussion, what was talked about and what the consequences will be if the problem continues this document may be one page for the specific event. Have the employee sign the statement as confirmation of the discussion and that he/she has received a copy of the statement, and most important, that they understand what will happen if it crops up again.

If the problem persists and one of the consequences discussed in the written warning was termination of employment, Strike Three is termination of employment. You now have three pieces of documentation, your notes from the first discussion, the signed statement from the second meeting and the termination notice, which includes a discussion of the verbal and written warnings. This will provide proper backup for most inquiries. You always want to make sure that you have given the employee a reasonable amount of time to improve, that you have spoken with them before about the issue and that the employee has had the opportunity to present his/her side of the story.

In personnel management, as in dentistry, there is no such thing as too much documentation. Train yourself to ALWAYS write it down. This will also provide direction for future situations to ensure that the level of discipline is consistent among employees. Sometimes the things employees do wrong, as standalone items are relatively minor. But when put together, over a period of time, they become your worst nightmare. Document, document, document! It will speed up the process and reduce the chance of litigation.

In conclusion, “At-Will” employment can be confusing. Rather than taking the term literally, be reasonable and prudent when dealing with employee behavior. Prepare documentation regarding employee performance, both good and bad, and use it as a management tool to reprimand poor performance and acknowledge employees for a job well done.

Question: I wish to begin regular documentation of employee performance, both positive and negative. Where do I start and how comprehensive should the documentation be? How do I distinguish between what's inappropriate and what's trivial in terms of behavior?

As an employer, there is no such thing as too much documentation regarding employee behavior. There was a national study conducted by HRhero.com that found that one out of every three employers rated their documentation (for misconduct, attendance, performance appraisals) as "Not Very Good." The reasons for improper documentation vary, but include fear of confrontation, the process is too much trouble, too time consuming, and lack of proper training.

Documenting employee behavior is beneficial for multiple reasons, including performance appraisal reviews, and necessary disciplinary actions. Sometimes when employees do something wrong, as a stand-alone event seem insignificant, but when pieced together with continual infractions show a pattern of behavior that needs to be dealt with.

Although Arizona is an "Employment at Will" state, defined as "both the employer and the employee can end the employment relationship at any time for any reason or for no reason without any notice," it still is prudent to protect oneself through proper documentation of employee behavior. With written documentation, it is easy to produce justification for terminating an employee.

No employee behavior should be considered trivial whether negative or positive. Documentation of behavior should be done as soon as possible, and should be specific as to the details (who, what, when, where, how, time, date). It is not in the employers best interest to have an evaluation form that involves a checklist for an appraisal. Check boxes regarding behavior have been shown to be inconclusive and difficult to determine if a merit raise is warranted or if termination is needed. It is best to use long-hand evaluation forms for specific behaviors to be recognized.

Here are some examples of proper/improper documentation:

Proper: January 9, 2006; 15 minutes late to work, because of "traffic."

January 18, late to work "alarm didn't work".

January 29, 20 minutes late due to "car trouble".

 

Improper: Late to work several times this month.

Proper: August 8, 2006, 2:00pm, front office manager heard rude comments being made to patient E.B. She reported you said "Insurance is your problem, not ours. You should know better since you have been in our office before," using a harsh tone of voice. Office manager then overheard patient telling her spouse that she "felt like she just got yelled at."

 

Improper: August 8, 2006 you were rude to a patient.

 

Proper: August 22, 2006, 11:45 am, Hygienist, S.H. observed you helping out a fellow employee by cleaning her instruments for her because she was running behind.

Note: If the employer does not personally observe a behavior, have the employee that did give a written statement for the file.

When a positive behavior is exhibited, it is best to recognize the employee as soon as possible. Looking for small indicators of good performance and identifying the performance immediately is a successful way of improving future performance, especially when others in your dental team realize that you take note of these actions. Continually writing down and verbally acknowledging good behavior makes the yearly appraisal report much easier to complete and justify.

In regard to negative behavior, once it has been determined that an employee is behaving in a manner not conducive to office policy, disciplinary action must be taken. When to begin the disciplinary action depends upon each employers tolerance, and the extent of the employee's negative behaviors.

The first step in discipline is a verbal warning. An employer should have a face to face conference with the employee and state specifics regarding the behavior that is not tolerated in the office. By giving specifics, there is little wiggle room for the employee. It is difficult to fight when facts are presented. After discussing the negative behavior, set specific expectations for future performance. For example, "It is my policy for an employee to be on time. If you are late again, it will result in a written warning, and the third offense will be termination." Make note in the employee's file that there was a verbal warning regarding ___ behavior on ___date and employee was notified of the disciplinary process.

With another infraction, again have a conference detailing the specific behaviors, this time writing down the specific offense and the expectation of performance regarding the behavior. Have the employee sign this document. Include that further behavior of this kind will result in termination. This document should be dated and kept in the employee's file.

If termination is the final step with a specific employee, the employer can feel confident that the facts were presented, the employee was given a fair chance for improvement and that termination of employment was warranted.

Any given employee can affect an entire team, and your practice. The impact an employee makes, both positive and negative must be recognized and dealt with in an effective manner to keep the dentist, fellow employees and patients happy.

Our operating system crashed and we lost about a third of our patients' radiographs. To make things worse, our backup files were corrupted as well. While we are not planning on ever being faced with a patient complaint and subsequent subpoena by BODEX, we are wondering what would happen in that instance if we were unable to produce an x-ray. Would that be considered non-compliance? What proof would I have that the appropriate x-rays had ever been taken? What are the possible ramifications of having lost these radiographs?

There are two issues involved in these questions. One aspect is the information technology, or computer issues. The other is the compliance issue regarding maintenance of records.

First, let’s discuss the computer issue. Unfortunately, computers are extremely complex machines built by people with engineering and technology related degrees. The majority of employees in the dental work force don’t possess the formal education necessary to understand how they are built or how the machines operate, but they are required to use them in their day-to-day activities.

To battle this dilemma, computer manufacturers and software companies have been successful in constructing a “User Friendly” environment. That is to say, the end user of personal computers doesn’t have to posses an engineering degree or have the technological prowess to operate a computer because of GUI (pronounced, “gooey”), short for Graphical User Interface. This is the mainstay of Apple and Windows based systems that make it simple to orchestrate daily operating tasks with such a complex integration of silicon and metal. I still marvel at how something as simple as using the mouse to move the cursor arrow and double-clicking the 8:30 a.m. appointment slot in the Dentrix Appointment Book pops up a box that helps me schedule an appointment for a patient. What’s going on behind the scenes that make this stuff happen?!

Doesn’t matter, does it? It works! And it makes our jobs easier; we’re more productive; and it looks cool!

Using the computer makes our job easier, until the computer doesn’t respond to the nice commands we’ve become so accustomed to typing, the screen is black, and we realize we are witnessing a disaster in the making…our hard disk is crashing! Now, all of a sudden, our whole attitude and demeanor changes about computers. Four letter words that are outside of dental terminology and completely out of the editorial capacity of this article echo through the confines of the workspace like the roar of an avalanche in the Alps during the dead of winter.

Then, we realize we have a backup. Oh, thank goodness! All is not lost; we’ve been safeguarding our data! As your initial question states, you checked your backup and the data was corrupted. My daughter who is a sophomore in high school would probably respond with, “Bummer”. So would I.

How sad would it be if you reached down to the slot where your tape backup is placed, pull it out, and find that the tape is stuck?! You tug and pull, and it finally releases, only the tape is caught in the drive and the spool of tape is unwinding from the cassette with every inch you pull away from the box.

Okay, all kidding aside, these are big problems. For more on safeguarding computer data and dealing with computer crashes, you can go to my website, www.FredHeppner.com and click on “Articles by Fred Heppner”. Read the one titled, “How Sound Is Your Practice’s Data?”

Now, on to the maintenance of records issue. For this I have contacted known expert on dental law in Arizona, Jeff Tonner. According to Mr. Tonner, recent information from the Arizona State Board of Dental Examiners, or BODEX, indicates a new statute is now in effect, (ARS §32-1264e) that covers Maintenance of Records. Essentially, this statute now states that dental records must be kept for six years from the last date of service for adults; and three years after a juveniles 18th birthday, or six years from the juvenile’s last date of service whichever is later.

When asked about the dilemma regarding losing patient data from a computer crash and the legal issues in our original question, Jeff was very helpful and informative with his responses. Here are answers to the records questions that I trust will be helpful and useful to you.

The Board might find a person in violation if a requested record cannot be reproduced. If one can’t produce the record, x-ray or otherwise, even if the progress notes indicate the record was taken, one may be in violation due to the fact that the record can’t be produced. It’s also a matter of degree. If one can produce most of the records, but can’t produce all of it (request for records), then one may stand a better chance of being exonerated. For example, from a full set of x-rays, one is missing and the missing x-ray is the one needed for the case, then perhaps one may experience some leniency from the licensing board.

Essentially, if everything crashed, and a person had taken proper precautions, and it was a fluke that nothing was recoverable, perhaps there may be some leniency. The more comprehensive the backup plans one has, the better chance one would have to avoid possible legal entanglements if required to produce a record.

Another example would be if the backup routines were sound and reasonable. That is, the routine called for daily backups at the end of the working day, perhaps even at night before the next day, and they were done appropriately. Someone breaks and enters the dental office in the middle of the night and steals the computer and all the data. In this case, the board might be more lenient due to the fact that reasonable precautions were taken and one day’s worth of data was the only information lost.

If one requires proof that an x-ray had ever been taken, then inspect the office for the X-ray itself, a notation made in the progress notes, the ledger for a billing entry charging out for the service, an insurance claim form, or a billing statement.

The ramifications of not being able to produce a record subpoenaed by a licensing board could be Unprofessional Conduct: Failure to Maintain Records. Or, one may be in violation when the patient requests the records and one is unable to produce them. Again, the board may find that person in violation.

Another event that happens occasionally is a patient arrives at an office and brings their own records, in particular their own x-rays. When the patient leaves and requests their original x-rays, oftentimes the office gives them back to the patient without obtaining a copy of the records for their files. True, the patient owns records brought by the patient. But without records, the office may put themselves in an embarrassing situation in the future, or in a legal entanglement if a complaint is filed. To guard against this, make a duplicate immediately, and make a note in the record: “Patient brought full mouth series from Dr. Simpleton on 10/10/06. Copy made for our records”. If a copy was not made, Dr. Simpleton’s records could be subpoenaed and therefore could help in supporting the diagnosis.

It’s a tragedy when hard work is lost when a computer crashes. The uneasiness that comes along when the records are required for potential legal entanglements compounds the frustration. Be Proactive and safeguard your data, and work hard to maintain your records so that you will be prepared, just in case something happens.

Author’s Note: Last month, we handled most of the following question:

“We have a patient who sometimes ‘misbehaves’ during visits by either playing practical jokes on the staff or making inappropriate sexual and politically incorrect comments. What are the steps we should take up to and including dismissal?”

As promised, this article will suggest ways to appropriately handle how to dismiss patients.

In time, every dentist will come across a patient that causes a cringe when stepping foot in the practice. This problem patient could be a nuisance for any number of reasons, such as chronic no-shows, failing to pay bills yet expecting continued service, or even disruptive behavior toward staff.

Can a patient be terminated for any reason? Generally, yes. A dentist needs no reason to terminate the professional relationship, however one should not discriminate against race, creed, gender, age, or disability. By following the parameters in this article, a patient can be dismissed from the practice with the proper notice.

Dentists often tell me that 5% of the patients cause 95% of the problems. Despite this prominent disparity, many dentists feel compelled to retain and treat troublesome individuals indefinitely, most likely due to their caring, compassionate manner, which includes a sense of duty and responsibility toward the healing arts. With careful analysis, a dentist must ask him/herself; "Am I truly serving this patient to the best of my abilities, or have I become biased and would the patient be better off being serviced by another?"

A patient may be safely dismissed from a practice as long as s/he is not "abandoned". A general definition of Legal Abandonment is as follows:

"…the doctor-patient relationship existed, the situation required continued dental care, and the dentist, without giving the patient reasonable notice to enable him to secure proper treatment elsewhere, abandoned the patient when he knew or ought to have known, in the excise of reasonable care, of this need for continued care."

In other words, there are several aspects to consider.

1. Is there any pending dental treatment?

A patient cannot be discharged in the middle of on-going treatment. As a rule of thumb, if you start a procedure, it must be completed before the patient can be discharged. Better yet, ask yourself, “Did God create the problem or did the Dentist?” This does not mean completing an entire treatment plan, but relates to interim conditions created by the dentist and not conditions brought about from ongoing dental disease, injury, and/or neglect.

To give an example, prosthetics provides a simple illustration. If a dentist prepares a tooth for full coverage and places a temporary, s/he must continue to see the patient until the final crown is seated. Prudence also would dictate that at least one adjustment or follow-up visit be allowed. If the dentist refuses to complete the treatment sequence, then the patient would be left with a temporary dentist-created situation where breakdown is both inevitable and foreseeable. The net result would be a dental state that could be worse than the originally diagnosed condition.

A more complicated scenario arises in orthodontics. What happens when a patient discontinues payment in the midst of lengthy treatment? If the dentist initially extracted teeth, thus creating a permanent situation, then treatment should be completed. The dentist can follow practical collection methods in order to collect the fee. On the other hand, it may be permissible to remove the brackets and allow the teeth to resort to the pre-treatment position if no permanent harm will develop.

2. How are emergency treatment situations covered?

The dentist-patient relationship contemplates full care, thus, emergency coverage is expected. Without advance notice of termination, an "active" patient naturally assumes that treatment will be available for any crisis situation. With prior notice of dismissal, the patient has been given the opportunity to find a new dentist and maintain the continuum of care. Thirty days is a reasonable time period in most cases.

The process of dismissing a patient is not difficult, but a dentist must take the following precautions to protect him/herself from abandonment. Once treatment that is started has been completed, written correspondence should be sent to the patient informing of the discharge notice. While the discharge notice in writing is not required for it to be legally binding, it is prudent for a dentist to have written documentation regarding the event. In addition, written correspondence does not need to be sent by certified mail, but it is beneficial to prove receipt.

Following is an example of a discharge notice that I encourage my dental clients to use. Feel free to use this information in your practice.

Dear Patient:

It has become apparent to me that our professional relationship has deteriorated over the past several {weeks/months}. A healthy dentist-patient association is based upon mutual trust, respect and understanding, which are lacking between us. Without assessing blame to you, my team, or me, it seems now is the appropriate time to end our relationship.

You should know several things about your oral condition. There presently is no dental work pending. If you have an emergency situation within the next thirty (30) days, please contact us and we will do our best to accommodate you. Thereafter, we ask that you seek all dental treatment elsewhere.

You also should select a new dentist soon. One potential source is the {State/County} Dental Association referral program at {Telephone Number}. Your condition requires that regular hygiene be performed every {3, 4, 6} months. If you or your new dentist requires copies of your dental records, please send us a written release and we will be happy to forward them to the appropriate person.

My team and I regret that this situation had to occur. We wish you good health in the future.

Very truly yours,
{Dentist Name}

Dismissing a patient may seem like an inordinate challenge and one may reason, “I can handle this block of treatment time”. But as a practitioner, ask yourself, “Am I willing to deal with the mountain of repercussions that may follow?”

Since a small number of people cause a majority of problems in an office, the stress and frustration of having to deal with these people is not worth the angst. Dismiss troublesome patients from your practice sensibly and professionally.

“One of my employees sells cosmetics in her spare time, one hosts cookware demonstrations and one has a child who is forever soliciting us to buy cookies or raffle tickets. I applaud my employees for their energy and drive but feel their business should be conducted on their time, away from the office. Can I implement a policy prohibiting employees from bringing other business into the office and if so, what’s the best way to handle it professionally with the staff?”

Wow, I’ll bet this takes us baby-boomers back to the days when multi-level marketing hit the scenes with product being sold to friends and family at home. But Amway and Shaklee buyers take note, now there are jewelry makers, purse, lingerie and Botox parties, just to mention a few. Amway, long considered one of the most successful company’s in America, grew from people selling products part-time in the home direct to the customer rather than through retail establishments. These part-time jobs for some turned into multi-million dollar distribution networks yielding huge dollars for the ambitious. Naturally, building a multi-level marketing enterprise at times found their way into the workforce and sales strategies were tried on co-workers to find even more customers. It wasn’t unusual that employees at the job received unwanted solicitations from motivated entrepreneurs wanting simply to build a future for them. Unfortunately, some were doing it on someone else’s clock.

Many times there is a sense of pressure with these types of secondary businesses. People will buy the product (cosmetics, cookies, cookware) not because they really want these items, but because they don’t want to hurt the other person’s feelings or feel the pressure of being the only one not to but the mother-load of products. There is a sense of obligation since the people who are selling the items are personal friends. This ultimately can create animosity between fellow employees not only within the working environment but after hours as well. For example, one employee neither sells items on the side nor asks for employees to contribute to school fund drives, whereas another employee constantly solicits her/his wares. After awhile, constantly being harassed for purchases will get old. Problems will percolate and tempers may boil over. Add to this the encounters with patients in the office who are asked to buy something or overhear employees discussing the secondary businesses. An action of success, monetary value and happiness with even your most valued employee could become a lesson of disaster that may backfire and cause the business harm.

It would be very wise to implement a policy prohibiting employees from soliciting secondary businesses within the office. This should apply not only with patients but also among employees. During working hours, the main task at hand should be focused on dental matters. As an employer, you should expect your employees are getting paid to do their specific jobs, not discussing, thinking about, and conducting secondary businesses on the side.

It is difficult to prohibit solicitations during breaks when employees are off the clock such as lunch, but even then selling should be discouraged.

The question that comes up for me as an Advisor for dentists: “Are employees putting forth the same effort encouraging patients to pursue necessary dental services as they are Tupperware?”

To this, it is sensible to consider placing the person selling the most product that has nothing to do with dentistry, and has no obvious problem with time management, away from direct patient contact and place her/him in the treatment coordinator position responsible for gaining case acceptance to necessary treatment from patients!

Of course, I’m using humor to make a point. Consider for a moment that a great dental team, as in any successful business or even major sports franchise, plays to its strengths. Sure, establish a policy that prohibits solicitation of outside businesses within the office to both employees and patients but consider the talent used to sell cosmetics, kitchenware, or even laundry soap can be parlayed into case presentations and ultimately help grow the business (dental office, of course!) in the same way a successful sports team puts their key players in a position to best utilize their skills.

To sum up, if the Personnel Manual in the office does not make clear that solicitation is not allowed, included it in an addendum or revision. Here’s a sample:

“Time spent on solicitation during work hours (exclusive of time spent off the clock) by either the soliciting or solicited employee is prohibited. Distribution or posting of literature on office property requires special permission.”

It would be wise to make clear that unprofessional conduct not allowed by the office is better defined. Consider, “Unauthorized solicitation or attending to personal affairs during work hours”.

And finally, build your team around their strengths! Make your dental practice a successful business by placing your employees in positions that will utilize their skills and help patients become well. Watch the byproduct come about in a full schedule, happy patients, and empowered employees!

My staff would prefer to have compensatory time off instead of overtime pay. Would doing so be in compliance with Arizona employment law?

Ever wonder how the overtime pay rule got started? Some time ago, so did I. Here’s a history lesson to provide a bit of background for the answer to your question.

During the time when our country was just recovering from the Great Depression, people were willing to do anything for menial wages and employers took advantage of this situation. Businesses known as “sweat shops” made workers toil incredibly long hours while paying very little for their time. Congress believed that imposing an overtime penalty on employers would induce shorter working hours and help the nation solve its economic problems by spreading work around. In 1938, the Fair Labor Standards Act, or FLSA, was enacted to require employers to pay nonexempt workers at least one and one-half times their regular rates of pay for all hours worked in excess of 40 per week. The premium overtime rule may have outlived its original purpose, but the law is still on the books. The law still needs to be in place to protect employees from unscrupulous company’s who would take advantage of workers by requiring them to work long hours without overtime pay. Employers are challenged in some cases with a changed work ethic among employees where unemployment is significantly lower than seventy years ago. The job at hand today is to inspire employees to do the job right, efficiently and effectively.

The FLSA doesn’t require an employer to pay a worker for overtime simply because he or she worked more than eight hours in a day. Generally, the law mandates that hours are calculated by the week and pay is provided accordingly. There is flexibility as to when the workweek can start; it can begin on any day and any hour the employer establishes. Regardless, each workweek stands alone; one can’t average two or more workweeks, and one can’t manipulate the start of the workweek merely to avoid paying overtime.

People often times are confused about who is exempt from being paid overtime.

Most workers who are not required to be paid overtime pay fall into one of five categories:

1. Executive employees – manages two or more employees, can hire, fire and promote employee.
2. Administrative Employees – performs specialized or technical work related to management or general business operations
3. Professional employees – performs original and creative work or work requiring advanced knowledge normally acquired through specialized study
4. Outside salespeople
5. People in certain computer-related occupations

Executive, administrative, and professional employees generally are paid a minimum weekly salary and spend at least 80% of the workday performing duties that require a measure of discretion and independent judgment.

In dentistry, the Professional employee is the closest example of what might constitute an exempt worker; perhaps even an Administrative employee. However, a test for these types of employees helps determine their exempt and non-exempt status:

• Person must earn at least $250 per week in salary
• The employee’s work requires advanced knowledge and education
• The employee must customarily and regularly exercise discretion and independent judgment
• The employee’s work requires invention, imagination or talent in a recognized artistic field, or
• The employee works as a teacher.

As one can determine from this quick test, dental personnel are typically not exempt from overtime pay.

So, with that bit of history and education, I’ll address the question regarding “Compensatory Time”. The practice of granting hour-for-hour compensatory time, for example, giving a worker time off for overtime hours worked the previous week, isn’t usually allowed for private sector employees covered by the FLSA. Employers and employees are often puzzled when they learn that comp time isn’t permitted in the private sector, because it seems like a sensible and mutually beneficial way to handle overtime in many situations.

One has a few options for avoiding premium overtime pay by giving a worker time off instead of money. One option is to rearrange an employee’s work schedule during a workweek. For instance, Kathy, a dental assistant, normally works nine-hour days, four days a week, and four hours on Friday. On Wednesday afternoon, a patient in the practice commits to a treatment plan for full upper and lower veneers. The patient wishes to have them done right away. The doctor asks Kathy if she would agree to work an extra four hours that evening, Kathy agrees. The patient agrees to pay in full, funds are verified and the treatment begins.

Kathy worked an extra four hours that day, and rather than shouldering the business with overtime responsibilities, the doctor grants Kathy the day off on Friday. Kathy is paid for her normal working hours that week, 40, and receives compensatory time off on Friday, but no overtime pay. This is legal because Kathy hasn’t worked any overtime as defined by the FLSA; only the hours over 40 hours a week counts as overtime hours.

The key here is to provide the compensatory time during the 40-hour workweek; not for another period of time to be determined later, for example.

It’s also permissible to reduce the worker’s hours in another week so that the amount of the employee’s paycheck remains constant. This comes in handy when an employee works more than 40 hours in one week. In essence, the time off is given within the same pay period as the overtime work, and the employee is given an hour and one-half of time off for each hour of overtime worked.

For example, Sara is a front office employee and gets paid $1500 at the close of every two-week pay period. Because the doctor she works for has started a promotion for Invisalign and anticipates a great demand for services, the doctor wants Sara to work longer hours that week. However, the doctor doesn’t want to increase Sara’s paycheck. He asks Sara to work 50 hours during the promotion week and gives her 15 hours off the next week. Since Sara is paid every two weeks, the office may properly reduce Sara’s hours the second week to keep her paycheck at the $1500 level.

Private deals can be risky. It’s unlikely that a federal or state labor investigator will look into ones’ comp time arrangements unless an employee files a complaint. Knowing this, it may be tempting to work out comp time deals with employees to meet the needs of the business and worker. This can be dangerous. One can never know when a friendly, loyal employee may turn sour and look for some legal technicalities to use against an employer.

Because employers and employees alike feel that the current rules on comp time are too rigid, relief may be on the way. Congress is working on changes. One plan being considered would allow a person to offer employees a choice between receiving overtime pay or one and one-half hours of comp time for each hour of overtime worked.

One final note, the Industrial Commission of Arizona, our State Labor Department regulating wage and pay, indicates that Arizona does not have an overtime law. Therefore, federal laws apply, as discussed in this article.

To sum up, be careful about offering employees compensatory time off in lieu of overtime pay. It can be done, but know that special deals can be risky, and the FLSA is very specific about paying overtime. Be proactive: work your schedule to avoid the issues and complications overtime presents.

Dentists have long wrestled with balancing the duties of a clinician with those of a manager. And as a dental practice grows, so do the tasks and responsibilities needed to sustain growth in such a competitive profession. Effective delegation can dramatically improve the efficiency of a practice by helping to build teamwork within the staff. And cooperation and teamwork can contribute to helping staff members to reach their full potential.

One of the reasons why people hesitate to delegate is that they believe they can do things better themselves. However, market forces such as managing the financial aspects of a dental practice, dealing with managed care, ensuring compliance with governmental infection control standards, leading a team of workers, and sustaining growth in a competitive environment take dentists away from productive treatment time. These factors necessitate the proper distribution of responsibility in such a way that it is embraced and accepted by the staff.

Here are some tips on distributing responsibility effectively:

1. Remember that the ultimate goal of delegation is not just to get rid of the work; nor is it just to keep employees busy. The ultimate goal is to increase the output of the team and the practice.

2. Don't delegate the method, delegate the task. Let the person you delegate to determine the method.

3. Ensure that the person delegated to "buys in" to the task, agrees to the time frame, and accepts the responsibility. If one is unwilling to delegate the responsibility, one shouldn't bother delegating the task.

4. Define measurable goals, ensuring that the person delegated to has input into what constitutes accomplishment.

But don't confuse delegating with dumping. If an employee feels he or she is being dumped on, then that is probably because a task has been delegated without adequate authority to carry it out. It's all in the way one delegates. Yes, there's an element of risk in delegating authority. But if one doesn't feel comfortable with that risk, it probably means that the task is being delegated to the wrong person. And if the right person to delegate to doesn't exist, it's time to hire better people.

5. Once the task is assigned, keep your distance. It's okay to ask for updates, but don't snoop or pry. If you feel you must, you've delegated to the wrong person.

6. Require reporting, but not excessive reporting.

7. Follow up only on target dates, or when the project is finished, or when it should be finished.

8. Make sure the person delegated to is accountable for his or her success or failure. Applaud and reward success, discuss and document failure. If necessary, develop a plan together to improve performance.

9. Beware of over delegation to superstars. If one employee is relied upon too heavily, then there is a superstar shortage. And there may be a bigger superstar shortage if the overloaded superstar's workload is not balanced.

10. Finally, do not confuse the "delegatee" with the "gofer". Gofers "go fer" because they have to. Delegatees "go fer" because they want to.

In summary, the basis of effective delegation is trust. If one doesn't trust, then one can't delegate. Prepare a plan to carry out the work, implement the plan, and measure progress. Effective distribution of responsibility will yield leverage by allowing the dentist to become more productive with their time. Enjoy distributing responsibilities effectively and witness increased staff productivity, enhanced practice performance and increased profit.

Appearing in the July 2002 issues of "Inscriptions", the journal of the Arizona Dental Association:

What has changed in the dental industry since September 11th?

My advantage is that I was able to witness the effect 9/11 and the downturn in the economy had on the 35 practices I have worked with from September 2001 through the end of May 2002. Each experienced some repercussion from the events of last fall. Granted, my world is small in comparison to the total number of dentists in Arizona; but it is large enough to gather some generalities.

What changed was the realization that regardless of how great each dental practice operated, nothing could be taken for granted any longer. Whatever level of patient services a practice strived to achieve prior to September 11th, 2001, those levels are being tested. Practices realized they needed to put forth even more of an effort to secure the trust and confidence patients had in them.

In the practices I worked with, new patient volume dropped a bit. Some patients weren't readily accepting recommended treatment as witnessed by a decline in case acceptance. The occurrence of failed and broken appointments rose a bit. These factors were present in all offices, although some felt the effect more than others.

What was different in the offices that witnessed less of a change than those that experienced more?

I observed that the offices which encountered less of an impact, had previously worked hard on customer service and building relationships with their patients. The trust and confidence of the patients was well established through exceptional service by the doctor and staff. This resulted in steady case acceptance and kept appointment rates. The offices that took their success and patients for granted productivity slip. These consequences forced them to re-focus on what is important in sustaining patient relationships.

What is important in surviving downturns in the economy?

In my experience, it's relationships. And in order to ensure one has loyal patients in a practice, it is vital to have a solid foundation of fundamentals in dental practice management: A well thought out business plan, a fantastic staff, effective marketing, and superior patient services. I've seen predictable and measurable growth and prosperity in dental offices after 9/11 when attention is focused on the details surrounding the entire patient process. Each step of the process must be perfected so that patients comply with treatment recommendations, keep their appointments, pay for services, and are so happy with the office that they refer friends and family to the practice. Walt Disney said, "Do what you do so well so that people cannot resist telling others about you."

These details are difficult to master; it takes hard work. Education is a large part of the process. One has to realize that learning is ongoing. Not only the doctor but also the entire staff must consider the value of reading books on how to deal with people, attend courses on negotiation, sales, and/or interpersonal skills. More importantly, consider talking about these issues as a team and discuss how to handle them in the practice on a day-to-day basis.

Speaking of staff, were there any issues regarding staff that jumped out, and what were they?

During the morning of September 11th, the entire staff of a client of mine was so distracted from the television coverage that patients were being seated late for their appointment, and staff was not focusing on the treatment. He immediately assembled the team in the staff lounge and acknowledged that a catastrophic event was unfolding and as horrible as it was they had an obligation to serve the patient. He encouraged the team to focus on the task at hand: take care of patients! One slip during a procedure because of inattention in the operatory could cause irreparable consequences for the patient and the practice.

Unfortunately, I discovered staff didn't fully comprehend the impact 9/11 had on the dental industry right away. By and large, they didn't perceive that people had changed. The staff realized how serious the impact of 9/11 was when a number of patients called canceling their appointments because they were second-guessing if their jobs were stable, if they would still have dental insurance, and if they would have enough discretionary income for dental care. Initially, some patients kept appointments because they were being laid off and they wanted to complete recommended treatment in time to use up their insurance and while they still had the money. But after that, reality set in and patients no longer were scheduling at dismissal because of all the uncertainty about employment and finances.

Overall, there was not a sense of urgency to raise the standards of how we served the patient.

How does a practice guard against future downturns in their productivity?

The first step is to employ a great staff made up of people who have the following characteristics: honesty, autonomy, integrity, responsibility, self-discipline, enthusiasm, strong work ethic, and accountability. Next, lead them in using principles that are well grounded in ethics and doing what's professionally and morally right. Finally, train them to do the job so well that the patient receives the highest level of patient service and professional dental care. The end result is a strong relationship of trust and confidence that patients have in the doctor, the staff, and the entire practice. There's an old adage that I truly enjoy, "Ideas are a dime a dozen. People who put them into action are priceless."

Due to the downturn in the economy, are people more hesitant to comply with treatment recommendations?

To some degree, my answer goes back to the previous discussion on how well the office built relationships, and how people were faced with a high degree of uncertainty. What I found in the practices I work with is that we saw a slight decline in case acceptance. Once we acknowledged that patient's had changed, we moved quickly into corrective action. We went back to fundamentals and reviewed what we were doing, and more importantly WHY we were doing it. Why were we talking so much about diagnosis, treatment, etc., when we could be asking questions and listening carefully to the patient to learn about their desires, motivations, and possible resistance to treatment recommendations? Why weren't we embracing change and raising the standards on how we take care of people? Sometimes it takes a wake-up call like 9/11 to help us realize that nothing can be taken for granted, and it's up to us to improve ourselves and make even more of a commitment to a higher standard of patient service. Raise the bar on all that you do. Make a contribution. Make a difference.

As dentists view their practices more as a business, the question arises, "How do I know if my practice is really financially healthy?"

To know this, consider the following standards that are being used by dental offices in Arizona and across the country to measure their proficiency in this area. And, be sure that these criteria are met simultaneously; it's not enough to achieve one or two and slip on another.As dentists view their practices more as a business, the question arises, "How do I know if my practice is really financially healthy?"

1. Collect 99% or better of Net Production, after adjustments that is. Divide net collections by net production to find out this percentage. Because of the up and down nature of cash flow in the traditional dental office, this number should be tracked over a rolling 12 months, if at all possible.
2. Accounts Receivable Ratio at 1 to 1¼ . Compare the total accounts receivable, including insurance receivables, to a rolling four month average of net production. That is, divide total accounts receivable by the last four months average monthly production.
3. No more than 20% of total accounts receivable should be aged more than 60 days from date of last payment. Run the aged accounts receivable report that shows the date of last payment. Total the over 60 day aged accounts that have not made a payment in 60 days. Divide this number by the total of all accounts receivable for this statistic.

Compose a quick report for the practice that shows the levels of performance in all three of these areas simultaneously. If one or more of the areas are not within the recommended range, there may be a fault in the payment systems that may need attention. If the report shows a financially health practice, carry on!

Reprinted with permission from the AzDA Journal Inscriptions, volume 11, number 2, August 1997

Dental patients across the country are becoming more service savvy. They want to be sure their investment in healthcare provides them with the benefits of good oral health: looking good, feeling good, having strong teeth and gums, and enjoying their natural teeth for a lifetime.

To meet these demands, practitioners continue to educate themselves on the new techniques which are constantly becoming available in modern dentistry, and which enable them to deliver the highest quality of care to their patients. Often overlooked, however, is the need to keep up with the changing marketplace regarding payment.

Managed care plans are available but should be analyzed thoroughly regarding the financial impact and practice characteristics they represent. Yet, according to the Health Care Finance Administration, dental consumers continue to pay for approximately one half of all dental treatment out of their own pockets.

Three simple ground rules will help your practice cope with these changing times. Follow these rules diligently; make them the foundation upon which you build your payment systems. In this way, you can experience payment success in your practice.

Ground Rule #1: "We will inform before we perform. " Patients should be informed of all fees, and specific arrangements should be made for payment before any treatment begins.
Ground Rule #2: "Our dental office will not loan money." When patients are allowed to pay for their care over an extended period of time, you are actually loaning them money!
Ground Rule #3: "We will provide flexible-but firm-payment options. " It is a reality that, while people generally want the best possible care, they often need some form of financing. The best way to solve this problem, without breaking Ground Rule #2, is to provide a variety of payment options for your patients.

What kinds of firm yet flexible payment methods are available? Here are some suggestions. Offer a cash discount (or as I would prefer to say, a cash courtesy) for treatment paid for in advance. This is a great way for patients to save money, and a way for the practice to secure payment. An added benefit to the practice is patients tend to keep appointments for which they have already paid!

Make better use of major credit cards as a payment option. One approach which could be used more is the process of spreading payments out over time using signature on file for credit cards. There are forms available which provide structure to this system. In all cases, it is important to make sure your patients know you accept payment by credit card. Display signs at the front desk, include a notice on your billing statement that you accept payment by credit card, and tell each and every patient, "We have made arrangements to accept payment by credit card, would you like to use VISA or MasterCard?"

Use a dedicated healthcare credit card for patients in need of financing. Here, you receive payment up front, and the patient can make low monthly payments. A definite win-win for the patient and the practice.

But what if patients are not able to pay for services using the previously mentioned payment options? Most dental offices offer a "payment plan" that usually results in the patient paying whatever they want, whenever they want. There is, however, a fourth payment option that is more firm, yet still provides flexibility for patients. It is called Pre-Authorized Checking. Here, the financial coordinator and patient arrange to deduct payments directly from the patient's checking account. This payment option is a great way to make structured financing available to patients who don't qualify for the ideal payment methods mentioned above.

Although the principle objective is to be paid without loaning money, be aware of indications from the patient that they may need financing. At that point, use a simple, straightforward, one page written financial policy which explains the various payment methods you have elected to accept in the practice. With this tool, move through the various payment methods, making sure you establish well structured financial arrangements. In other words, don't leave the payment schedule up to the patient.

Use these recommendations to build payment systems which work for your patients. In the final analysis, patients deserve the very best care you can deliver, and you deserve to be paid!

In business management, dentists seem to have a commonality; they are reactive in their management style. This reactive approach occurs because dentists must focus the majority of their energy on treating patients rather than concentrating on running a business.

While consulting with and lecturing to countless dental offices across the United States since 1983, I have found a similarity between all; dentists tend to be reactive in their management style.

For instance, if the checkbook is low on funds, dentists wonder why collections haven't been keeping up with production. The battle cry then becomes: "Susan, why aren't you collecting more money?!? Get after those patients and make them pay their bills!" Or, "Why didn't the parent pay for their child's emergency treatment?!?", "How long have we been waiting for them to pay? That long? Send 'em to collections!"

If there are few patients scheduled in the appointment book, panic sets in. Followed by the edict: "I wonder why parents aren't scheduling their children for treatment? We send a pre-determination to the insurance company so treatment coverage is known. Why aren't they interested when we call five weeks later? Maybe the solution is to get a bigger ad in the Yellow Pages. I'd rather pay more for an ad than to take a cut in my fee by joining a reduced-fee insurance program, just to get new patients."

More often than not, the supposition to why people don't pursue treatment is that they can't afford it. Typically, parents indicate to the dental team in some way that they don't have the money to move ahead with treatment. Unfortunately, the reactive approach is, "We need the production; let's just do the treatment now, we'll worry about the money later!"

Another catalyst for reactive behavior in a dentist occurs when employees of the office cause stress in the workplace. Imagine the perception given to the other team members when the marching order from the dentist is: "I won't put up with this. You're Fired!"

Rather than having to deal with the events described here, dentists and their team can prevent negative occurrences from happening by developing systems and coaching employees to create a more proactive approach to dental practice management. The results are worthwhile!

There are many different ways to accomplish proactive approaches to dental office issues, and in the following paragraphs, I will entertain a few ideas on how business systems can be restructured. The end result will ward off problems before they occur.

The first example is handling patients who are in need of emergency treatment. In my experience, dentists create accounts receivable problems in these instances because they begin treatment before a discussion about finances occurs. According to popular rationale, payment arrangements are best created in a private place away from the front desk and the operatory. But in this situation, an exception to the rule by asking for payment during the treatment process would be in the best interest of the patient and the practice.

Here's one solution that works very well. Once the dentist has exercised pain control and the patient is now comfortable, call a brief "time out" and have a key member of the staff present the fee for treatment and make payment arrangements before any long lasting treatment is rendered.

This proactive solution makes sense because patients are informed and have agreed to how they will handle payment before treatment begins. The end result is that patients follow through on their payment arrangements because the expectation for payment was created from the beginning.

The second example entails how to deal with sustaining practice growth by attracting an appropriate number of new patients. Through continuing education and practice, dentists become knowledgeable and skilled in the healing arts, but dedicate much less time to learn how to market their services. Without a well thought out and executed marketing plan, new patient flow is unpredictable and may be too low to sustain practice growth.

In order to create a consistent flow of new patients, proactively market the practice by following these simple guidelines:

1. Set Goals. Clearly define the number of new patients you wish to acquire each month. Dental practices across the country lose 20% of their patient base annually. Patients move, change jobs, pass on, or elect to seek services from another dentist. Set your practice goals first to replace the 20% attrition, and decide how much of an increase in the patient base you desire. As an example, if the practice has 2000 active patients and seeks to grow 10%, it must acquire 600 new patients. Mathematically: 2000 multiplied by 20% equals 400 (for attrition), plus 2000 multiplied by 10% equals 200 (for growth).
2. Create a Mission or Vision statement. Articulate the direction of the practice in a few sentences. Utilize the office's team members' input to create a sense of unity.
3. Create a Budget. Practices which desire accelerated growth may wish to designate 5% of the previous year's revenue to marketing; mature practices who wish to only maintain current patient flow may allocate up to 2% of the previous year's revenue.
4. Decide on Methodology. Determine what appropriate marketing tactics will be used that fall in line with the practice's vision statement. Internal and external means of marketing may provide a suitable mix. Ensure these methods are within the budget and can be measured.
5. Delineate Limitations. Some dentists are steadfastly opposed to certain forms of marketing. This element of the plan entails deciding what the practice will not do to market.
6. Implement Tracking Mechanisms. Make sure you follow the business axiom, "When performance is measured, performance improves. When performance is reported back, the rate of improvement accelerates." Track the results of the program and meet regularly to discuss your findings.

The third and final example deals with the attitude children today have towards orthodontics. In contrast, a generation ago children with braces were viewed as anomalies; labeled as "tin-grin", they were routinely made fun of by their classmates for reflecting brightly from the flash bulb in the class picture. Not to mention the headgear worn by some that seemed so foreign, it was easy to tease.

As with eyeglasses, orthodontics seem to be an easier sell to kids lately compared to twenty-five years ago. Kids these days seem to have everything. For instance, they have a plastic bin full of Matchbox cars instead of a collection of ten to twenty. Instead of one Barbie and one Ken, the playroom is now a small city of dolls. The mentality of children today is that they want everything, including "the cool things" others in their age group have today: braces. It's not uncommon for kids to even play guessing games via e-mail for what color braces they will choose, "Wait until you see me tomorrow."

And, as precocious as some children are today, they will notice adults with crooked teeth. They are becoming more and more exposed to and aware of advertisements and television shows with people (models, actors) who exhibit beautiful white, healthy smiles. They observe adults' teeth that aren't straight, almost in horror and may not even fear to comment, "How come you never got braces before?"

The continued challenge, it seems, is to be proactive and sell the parents.

In order to address this element of business management, offices must remain keen to what drives the family's desires and strive to connect it with the quality of services offices deliver.

Certainly people today are more educated about health and well-being, but the fact remains that dental offices today must hone communication skills so that parents are provided information on services in such a way that they choose what is right for themselves and their children.

And, lest we forget, financial obstacles exist today in some parents' minds because of the fee for orthodontics. Parents may not be aware of the variety of payment methods available to them. Offering discounts for payment in advance, budgeted payment arrangements locked into a contract over time, and outside financing are part and parcel of a great payment system that won't get in the way of case acceptance, and won't cause the practice financial problems down the road due to non-payment.

Bear in mind, these are just three examples of issues confronting dental offices today, and ways in which to become proactive in their approach to achieving a practice's goals. Each system within a dental practice can be refined in order to ward off problems before they occur. A proactively managed practice will deliver many benefits to patients and the community will be well served. Dentists, and their team members, will be rewarded with a more profitable and gratifying workplace.

In the spring of 1996, I presented a seminar on practice management to members of the Florida Academy of General Dentistry. At that meeting, Dr. James McIlwain and I first met and had an enjoyable conversation about the dental profession. Shortly thereafter, Dr. McIlwain contacted me and asked me to visit his practice and provide my professional assessment of his operation. The engagement was mutually beneficial, especially for me in that I witnessed a first-class operation and came to know an outstanding individual in Jim McIlwain.

Last August, Dr. McIlwain and asked me to contribute articles to this publication in hopes that my experiences would benefit pediatric dentists in the region. I was appreciative, honored, and immediately accepted.

Over the past 20 years I have been serving dentists in the capacity of a business management advisor, assisting them in developing plans, integrating systems, and providing coaching to help enhance their practices. My experiences have educated me in the real world of how dental offices face day-to-day challenges serving patients and the community in which they live and work. I hope my literary contributions will shed some light on solutions to various topics readers of this publication may encounter in their own office.

Over the past few years, recent economic conditions and world affairs confirmed to me that our world changes and challenges us daily. The resulting effects on the business of dentistry can take us by surprise if we're not prepared. In my years of service to the dental industry working with hundreds of dental offices nationwide, I have discovered that plans can be made to prevent business decline in these changing times.

I have been able to witness the effects a downturn in the economy has on practices. Each office I have worked in within the past year has experienced some impact. Granted, my world is small in comparison to the total number of dentists in the country, but it is large enough to gather some generalities.

What was clearly evident is the realization that regardless of how great each dental practice operates, nothing could be taken for granted any longer. Whatever level of patient services a practice strives to achieve, the levels are being tested daily. Doctors and their staff realize they need to put forth even more of an effort to ensure patients and their families understand and embrace the value of excellent dental care.

Many practices have had a drop in new patient volume. Some patients and families aren't readily accepting recommended treatment as witnessed by a decline in case acceptance. The occurrence of failed and broken appointments has risen a bit. These factors are present in all offices; although some are feeling the effect more than others.

I have observed that offices which encountered less of an impact had previously worked hard on customer service and built trustworthy relationships with patients and their families. The trust and confidence of the patients was well established through exceptional service by the doctors and staff. This resulted in steady case acceptance and kept appointment rates. Productivity slipped in offices that took their success for granted. These consequences have forced them to re-focus on what is needed in sustaining patient and family relationships.In my experience, the most important factor in surviving downturns in the economy is relationships.

In order to ensure one has loyal patients in a practice, it is vital to have a solid foundation of fundamentals in dental practice management; a well thought out business plan, a fantastic staff, effective marketing, and superior patient services. I've seen predictable, measurable growth and prosperity in some dental offices during this economic downturn. These offices have prospered because attention is focused on the details surrounding the entire patient process. Each step of the process must be perfected so that treatment recommendations are followed, appointments are kept,services are paid for, and families are so happy with the office that they refer other people to the practice. Walt Disney said, "Do what you do so well so that people cannot resist telling others about you."

These details are difficult to master; it takes hard work and dedication. Education is a large part of the process. One has to realize that learning is ongoing. Not only the doctor but also the entire staff must consider the value of reading books on how to deal with people, and attending courses on negotiation, sales, and/or interpersonal skills. The knowledge gained must be shared with the entire staff, and incorporated into the practice on a day-to-day basis. Without question, these skills must compliment the high level of professional dental care offered in the practice through continuing clinical education.

Unfortunately, I discovered staff in many offices didn't fully comprehend the impact 9/11 and the downturn in the economy had on the dental industry right away. By and large, they didn't perceive that people had changed. The staff began to realize how serious the impact of world events was only after they started seeing the effect on their patients, the schedule, and the slowdown in business operations. For example, a good number of people called canceling their appointments because they were second-guessing if their jobs were stable, if they would still have dental insurance, and if they would have enough discretionary income for dental care. Initially, some patients kept appointments because they were being laid off and they wanted to complete recommended treatment for themselves or their family in time to use up their insurance and while they still had the money. But after that, reality set in and people no longer were scheduling at dismissal because of all the uncertainty about employment and finances.

Overall, there was not a sense of urgency in the minds of many staff members to raise the standards of how they served the patient.

With all this, how does a practice guard against future downturns in their productivity?
The first step is to employ a great staff made up of people who have the following characteristics: honesty, autonomy, integrity, responsibility, self-discipline, enthusiasm, strong work ethic, and accountability. Next, lead them by using principles that are well grounded in moral values and doing what's professionally right. For example,

"The office is great because employees are empowered, motivated, and happy."
"As an employee, I will continually educate myself so that I am able to reach and even exceed my potential as a quality healthcare provider and team member."
"As a dentist, I will continually educate myself so that I am able to reach and even exceed my potential as a clinician and leader."

Finally, train staff to do the job so well that the patient experiences the highest level of patient service and professional dental care. The end result is a strong relationship of trust and confidence that patients have in the doctor, the staff, and the entire practice. There's an old adage that I truly enjoy, "Ideas are a dime a dozen. People who put them into action are priceless."

Sometimes it takes a wake-up call like a catastrophic world event to help us realize that nothing can be taken for granted. It's up to us to improve ourselves and make even more of a commitment to a higher standard of patient care. Raise the bar on all that you do.

Working to help dentists automate business systems through computer applications, I have come across an unfortunate occurrence that is not only devastating, it is happening far more often than imaginable:

COMPUTER HARD DRIVES CAN CRASH!

When a crash occurs, all the data stored on the computer could be lost. Imagine for a moment, walking into your office tomorrow, turning on your computer and nothing will get your computer working. When you describe what the computer is doing, (or isn't doing), to your hardware technician, the answer returned is enough to make you shudder; "I'm afraid something has gone terribly wrong. Your hard drive has failed. When was your last backup?" Unless you can reply with 100%certainty that your most recent backup was done correctly, your entire practice's data could be gone…forever!

There are actions to take in your backup protocol to assure sound data recovery. The first step in the backup routine is to have a system in place that is carried out on a daily basis, and known by more than one of your team members. Your backup routine needs to be done on a daily basis, regardless how redundant it seems. It is a good idea to have your data backup protocol printed out and kept in your office manual, for the employees responsible for the backup duty to reference.

For years there was only one option for data backup, this involved manually backing up data 'in house' using several different means, such as tape drives, external hard drives or internal hard drives. Now, dental offices have another option, backing up electronically. Whether using a manual system, electronic, or both systems, a visual verification of correct data backup is needed.

When performing manual tape backups, a person needs to be certain the tape is in the correct drive, and the tape is not malfunctioning. The safest way to protect data is to use one tape for each workday, and performing a month end backup, using two tapes for the month end backup, rotating these tapes so that the office data is never more than thirty days out. One must be certain that the correct files are selected, for example; not just the Registry. If the backup does not include all the valid data, the backup may be for naught.

A process that is performed by some offices is a "test data restore". This can verify if the data was backed up. However, using the verification process in your backup software may be a waste of computer time, because of the immense nature of the files being verified. It can be quite time consuming, since the files are verified one at a time, in reverse. It is better to visually inspect the Report Log text daily to be certain of what exactly was backed up. The backup report will inform that the following files were not backed up or the files were busy. Busy files do not get backed up. Most times backing up the busy file is easily rectified by making sure all programs are closed before beginning the backup process. However, sometimes the report will show busy files with all programs closed. This is why it is prudent to have a competent computer hardware technician to rely on for problem solving discrepancies.

Speaking with computer technicians recently, I have learned that even the popular backup program, written by the well-regarded "Veritas," may have a flaw. Veritas may indicate a successful, 100% backup, even though this is not the case. A complete backup should mean that every selected item was copied. However, some files may not have been included in the backup routine. Again, one must check the Report Log that the backup program provides and read the status of the backup routine to determine if any files were not included. If errors were reported, contact your computer hardware technician and describe your findings to determine if there is cause for concern.

When data is assuredly backed up manually, there is another safeguard to consider; keeping the backup tapes, (or internal/external hard drives), secure. The data can still be lost from a variety of other causes, such as damage to the facility where they are stored, theft, vandalism, or viruses that attack your computer. It is best to keep tapes in multiple areas, being certain that HIPAA regulations are followed, and use antiviral software.

Electronically backing up data is a newer option, which could be used as a primary means of backing up data, or as a secondary assurance. A high-speed Internet connection is necessary to transmit the data to an off-site computer storage facility. The high-speed connection is preferable because backups by dial-up modems could tie up phone lines for hours. If using this option, be certain that the information stored is in an encrypted format, and that the company you choose is in compliance with HIPAA security. Transmitting data will be automated and scheduled in the time period you choose. The monthly rate for electronic storage depends on the amount of data you are storing. Typically it costs twelve dollars per gigabyte of data, per month. Most online services offer data compression and filtering. If this option is chosen, one must be certain that the company chosen is reputable, has recourse for lost data, and that all data can be retrieved if the company goes out of business. It is best to ask your computer hardware technician for assistance in choosing an online program.

As much as we rely on computers, they are susceptible to failure and can ultimately ruin what would otherwise be an anticipated day of bliss at the office.

Remember, computers use superb technology, developed and run by humans. Taking charge and being proactive about backing up your invaluable data will save time, money, and help avoid the stress and aggravation aligned with a computer breakdown.

In today's age of modern dental practice management, fundamental interpersonal relationship skills are necessary to help patients and parents achieve the level of health they desire. But it seems that the knowledge of asking questions correctly, listening carefully to the reply, building the person's knowledge through education, presenting treatment options that make sense, and making good financial arrangements may not be enough to gain acceptance to treatment. A key ingredient that may be missing in helping dental offices achieve accelerated practice growth today is PASSION; a passion for dentistry that links all of these skills together into one seamless engagement that helps patients and their parents become as healthy as they desire. A passion that comes from being excited about all the options available with modern dentistry, including esthetics!

What often is an obstacle in the process of gaining acceptance to treatment is the perception by some who work in the practice that they are going above the accepted norm, or that they are pushing unnecessary treatment. Comments from team members that come to mind are, "I don't like to sell", or "I don't want to sound like a used car salesman."

Perhaps dentists have thought of these questions over time:

• What is the reason why staff feels uncomfortable with "selling" treatment that is prescribed by the dentist?
• Why does staff feel "pushy" when they are asked to discuss treatment options and reinforce dental care that the practitioner feels is important for optimal dental health?
• Do staff members have preconceived notions of what would be the proper care?

In order to overcome the "sales" barrier, empower staff with the knowledge to educate parents about all the available options for their children's care. That may include helping the parent become aware of and excited about treatment that yields a more pleasing esthetic result, even though it may be more expensive. Some team members may have a mental block created from their own personal circumstances that may lead them away from discussing esthetic treatment because of cost. Avoid this by encouraging team members to allow parents to make decisions for themselves based on the knowledge provided during their visit.

The patient process requires determined steps to help patients and parents arrive at the logical and sensible conclusion of accepted treatment. These steps include asking questions that help determine a need or want, educating them to help the person become more familiar with their options, and using communication skills to lead them to the decision that makes sense for them. Injecting passion into this process requires a true belief that the options are exciting and will create an end result that helps address the particular desires of the parent and child.

Getting caught up in the skills of day-to-day operations, such as cleaning and polishing teeth, restoring teeth that are decayed, promoting good oral hygiene at home, can lead our minds away from the real reason why people will pursue treatment recommendations. That is, people who accept and pursue treatment are excited about the outcome because the doctor and staff created a passion about the end result.

In this day and age, people are very conscious of the way they look. We are bombarded with images of beautiful airbrushed models looking perfect. Adults as well as children strive to look their best to fit in to the social norm. Parents may not feel esthetics are as important for the child based on cost versus teeth that will eventually be replaced by permanent teeth or that are hidden from view when the child is smiling.

This summer, my nine-year-old niece was very upset because a boy in her class brought attention to her teeth appearing yellow. After many days of the nine-year-old crying and pouting, her mother responded by buying her whitening strips from the local drugstore. My niece proceeded to covet and show off her new beauty treatment to cousins and neighbors. This started a chain reaction, and now all six other children present, ages five through twelve, feel the need to use the whitening strips to have model perfect teeth. This is the thought pattern of many children, as well as their parents, today. Children have always felt the need to fit in, not to be deviant from the norm, and parents are more willing to give in to the child's perceived needs.

Esthetics in dentistry for children, now more than ever, is necessary to help a child's self esteem, especially when one thinks of actors in movies today. In order to portray a villain or a character lacking intelligence, the actor's teeth are crooked, missing, or chipped. When portraying someone with low self-esteem, the teeth are yellow, gray, or dingy because of poor hygiene. Children internalize this and feel that they are lacking in potential too, regardless of their true appearance.

Dental team members need to be cognizant of how these factors affect children and communicate this to parents. Specifically, they must explain all of the provided options, teach the benefits of treatment, and be aware of how dental treatments will benefit a child not only physically, but psychologically as well.

A practitioner should continually build on staff's knowledge base as to why esthetics is necessary and beneficial to children. As staff becomes more familiar with treatment options, they in turn can more easily explain to patients and parents why choosing more than just the most basic and perhaps less expensive option may not be in the best interest for the child. In essence, the staff member will arrive to the level of getting excited about not only the physical but the psychological impact on the child, as well.

The staff needs to understand that they are not selling treatment to a parent/patient, but providing parent/patient with a solid knowledge base so that the parent/patient can be well informed when making the final decision regarding dental care.
The end result will then most certainly be that the parents and patient have been involved in a process in which they feel educated, comfortable with, and excited about the treatment outcome. They will be convinced that the payment they are making is valuable and worthwhile. They will share the passion for dentistry!

On many occasions, I have come to know practices that are operating extremely well, are profitable, and employ a stable staff. All until…something happens: a spouse is transferred, pregnancy, or a move to (allegedly) greener pastures. What was once a well-run machine now has a wrench thrown in the works. Successful management of this type of event will depend largely on the strength of the practices' personnel management and the leadership abilities of the doctor.

Whenever a new employee is acquired and introduced into the practice at any position, careful thought and consideration must be given to the person's skills, ability to meet the qualifications of the job, and personality traits. After checking the new hire's references and verifying skill level, what may be most difficult to ascertain during the interview process is the candidate's personality style.

There are four distinct personality traits. Learning these traits, understanding them, and embracing the fact that everyone is different is the first step towards blending people together as a team. A combination of these traits among the members of the team will help your office relate to a broader spectrum of people who frequent your practice.

Controller or Director
These people must be in charge. They are strong willed, decisive, direct in their approach, and tend to be domineering. They make quick decisions based on what is best for them. They care little how decisions affect others. They are interested in results, not emotions. They are willing risk-takers. They are always in a hurry. They want the straight facts and will quickly decide on a course of action.

Analyzers or Engineers
They must have all the facts before reaching a decision. They will desire every bit of information you have available concerning the job, and they often request more. If you try to rush them into a decision, they will become frustrated. They are unemotional, detail-oriented, and proceed with decisions slowly and methodically. They are definitely not risk-takers.

Promoters or Cheerleaders
They look at the big picture and don't sweat the details. They are fun-loving folks, often storytellers. They make decisions quickly, frequently without benefit of the facts. They tend to be self-centered, to live for the moment, and are enjoyable to be around. They are often most concerned with appearance, and they are definitely risk-takers. They have little interest in the details of the task and will be turned off by such information.

Supporters or Helpers
They are reluctant to make decisions. They work well with people, having tremendous concern for the feelings of others. They are very anxious about how their actions affect others and are intensely uncomfortable with conflict. They go along with other people's decisions easily and are excellent workers. They will also take on more work to ease someone else's job; but in the end may not be able to complete the additional work; they have difficulty in delegating to others.

These personality traits exist today in every dental office among all team members. Despite pre-conceived notions, there's no specific personality trait for each position. Not all excellent administrative or front office workers are "Controllers or Directors"; not all great dental assistants are "Promoters or Cheerleaders".

Consider your own personality. A dentist could have any one of these personality traits and find harmony as well as conflict with other traits. This is true for the rest of your team. And keep in mind; this is true of your patients and their families who frequent your practice.

Blending these personality traits brings into focus the big picture. As a team, you will be better able to relate to a wide variety of people in ways that make them feel comfortable. You will in turn build trust and confidence in their minds for your ability to care for them.

Here are some down-to-earth approaches that you and your team can undertake that will help make use of workplace styles and personalities. Consider first the application among yourselves, then apply them where appropriate to patient services:

1. Understand your differences: Pay attention to feedback, assimilate it and apply it to solving issues or praising for a job well done.
2. Keep lines of communication open: Address any concerns immediately before they snowball.
3. Be Proactive: Develop a knack for thinking ahead.
4. Keep everyone in the loop: People don't like surprises or embarrassment. When things are going well, a short message or conversation, would suffice. When a problem arises, don't hide it; explain and offer solutions.
5. Be a rock: Show up early, meet deadlines and volunteer to help others when you have free time.
6. Don't take criticism personally: Keep an open mind, control your emotions and stand up for yourself, politely, but firmly.
7. Don't play games: Never criticize or gossip about people, and mind your own business.
8. Know people's quirks and accommodate them: Does he/she prefer notes, formal memos, or communication face-to-face?
9. Pitch ideas: Make sure they're reasoned, solution-oriented and will benefit the function of the practice, not just to make your own workload easier.
10. Speak clearly: Collect your thoughts, write down what is needed or be concise when verbalizing your needs.
11. Stay Cool: Avoid losing your temper. Don't be defensive. Control emotions and hold back negativity in self and among the team. Be positive and sensible in dealing with workplace conflict.

Building great relationships with people at every turn is key to good management, and ever more important in today's changing times. A sluggish economy has forced layoffs and other cutbacks in businesses of any size, resulting in high stress, low moral, and concerns about job security. People have fewer options in terms of walking away, and keeping a job has more to do with demonstrating both technical and interpersonal skills. During the late 1990's, dentistry was experiencing widespread growth and prosperity. In comparison, it's more difficult to sustain growth and profit today.

No matter how experienced a person is, it is inevitable that conflict within the work place will arise. It's inevitable because its human nature. Handling conflict in such a way that it creates an alliance, rather than an obstacle, is the result of successful management of people.

Small businesses such as dental offices rely on outstanding people performance. Managing people and personalities are the foundation for retaining patients, keeping an excellent team of people, and sustaining profits.

As a small business owner, a dentist has many responsibilities to keep the business running smoothly; employing staff, maintaining the office equipment, marketing for patient flow to name a few. However, with all the careful planning and attention to detail, there is one aspect that the majority of dentists don't plan for, which is how to keep the business viable if the dentist is unable to practice. Every year a fellow practitioner may unexpectedly lose the ability to practice due to an unexpected injury or illness. Weeks or months of lost practice time will affect patients, staff and cash flow. Moreover, disability insurance has a waiting period before benefits will be paid, typically three months. In this article, I wish to share events that I have witnessed and ways in which they were handled in hopes that others may benefit through proper planning and organization.

Since 1983 when I first became involved in dentistry, I have worked in nine major metropolitan cities and served clients in countless others. During that time, numerous events occurred that were both sad and frustrating. Dental offices were left stranded without a practitioner for a variety of reasons including: a dentist needing time off for recuperation after emergency surgery, dentists with broken arms or hands, and unexpected death.
In these cases, the dentist wasn't able to treat patients, the employees in place didn't know what to do, and the spouse often did not have the business acumen to carry forth the business operations and therefore the business faltered. In the event of death, a practice's productivity would plummet until a potential buyer arrived with an offer far less than the previously thriving business was worth. Sad, but true, the estate of the deceased dentist may be left with little if any proceeds from the sale of an asset.

Most dentists carry disability insurance, but again the period of time until benefits begin may be far too long to wait for much needed funds. This can destroy a fine dental practice. An option to managing operating expenses when little income is being generated is to carry office overhead insurance. This policy protects the short-term financial needs of a practice with payments until the disabled dentist returns to work.

But even overhead insurance has limitations; will the proceeds from insurance enable the office to remain viable, keep the patient base intact, and continue to employ staff until the dentist is able to work again or the practice is sold? Most likely the answers to these posed questions are NO.
Rather than risking harm to a most valuable asset, dentists may consider becoming involved with a group of conscientious dentists in their community who would help preserve a practice if something unexpected happened to one in the group.

I have designed a successful program to help a 'fallen' dentist's practice remain viable. It is based on a simple premise, that the dental community is a caring one, willing to volunteer services for fellow comrades. The program is termed "Inter-Practice Protection", and it has worked successfully in Arizona since developed in 1997. The concept is straightforward: form groups of like dentists who agree to volunteer coverage for each other in times of illness, short-term disability, trauma, or death. This is not an insurance policy; rather, it is assurance that a practice, the team of employees, and patients will continue to be served. Inter-Practice Protection provides coverage for the practice during a dentist's absence to ensure that it does not lose production, the team continues to work, and patients continue to receive care.

Since its inception, nearly one hundred dentists in the greater Phoenix Metropolitan Area have formed six separate groups to cover for their practices should an untimely and unexpected mishap occur. These groups are well-structured and organized associations of private practicing dentists who have committed to volunteering a day of their time if a colleague within the group is unable to practice.

Members of the group operate their own private practices and collectively volunteer their time to care for patients and keep the fallen dentist's office functioning while the doctor rehabilitates, or until the practice is sold. Patient payments for treatment provided by the covering doctors are made to the practice being covered.

After activating groups for a variety of reasons, such as cardiac surgery, a broken arm, a broken hand, and even an untimely fatal heart attack, the coverage specifics have been fine-tuned, with the participating dentists input. In addition, the groups' dynamics have become stronger with each passing year. Following are guidelines for effective operation of the coverage groups.

• The groups are comprised of about 17 dentists.
• A Chairperson and Vice-Chairperson are elected by the group to function as administrators of group communications, manage annual meetings, and coordinate activation for a doctor needing coverage when necessary.
• The group provides coverage if a member is not capable of providing usual dental services due to non-intentional mishaps, illness, disability, or death. Normal maternity, without complications, substance abuse, and alcoholism shall not be considered a disability or illness.
• Upon the event of a disability, the member or family member promptly contacts the Chairperson to advise coverage is needed. The Chairperson then calls an activation meeting to be held at the disabled member's office within 24 hours and creates a coverage schedule with the members of the group.
• Coverage begins no later than 15 days after the date of disability, and continues for a maximum of 12 weeks. Coverage will cease when the disabled member returns to practice, or upon death when the practice is sold.
• Members covering a practice are not responsible for managing, administering, or directing the business of the disabled member's practice. A personal representative, family member, or other representative of the practice is responsible. Members may assist without any obligation to do so, but are not liable for any damages.
• The dental team should notify patients of the disability and make known the name of the covering dentist prior to the patient's appointment. The team will maintain all normal business operations, cooperate and assist the member who is providing coverage, and ensure there are adequate supplies and personnel for the practice of dentistry.
• Members are not obligated to cover more than their allotted number of days. After the entire roster of the group is contacted for coverage, any more additional days of coverage by a member is voluntary.
• Contact your malpractice insurance company and ask them specifically: "In the event of my untimely death, will my policy allow for patients to be treated in my office by my staff under the supervision of a dentist volunteering his time and still provide malpractice coverage?"
• Each member must review their personal information to be sure that the Power of Attorney is delegated to a significant other so that payments for accounts payable and payroll may be made without delay.
• If a member is contracted with an insurance company as a preferred provider, then the member must find out guidelines for each particular plan in the event another doctor, who may or may not be contracted with that insurance company in his or her own practice, treats patients during a covered period. This will ensure payments for treatment rendered to patients are made to the doctor's office receiving coverage.
• Members of the group agree that if a patient of the doctor who is receiving coverage wishes to pursue care from the volunteering dentist, the volunteering dentist will decline to accept the patient in his or her practice until a waiting period has passed. In the event of a disability or illness, one hundred and eighty (180) days shall pass. In the event of death, ninety (90) days shall pass.
• Attendance to an annual or biannual meeting is urged to reunite with fellow members, review past year's events, and demonstrate commitment to the group.
• Prior to covering at another practice, a schedule may be faxed so that the covering doctor may review the patient load and treatment mix. At that time, the covering doctor may consider bringing some of his or her own instruments.

Through careful planning and preparation, the groups here in Phoenix were well organized and ready to step in under any circumstances.

On the evening of July 31st, 2003 around 7 p.m., I received a call from a periodontist who is a member of the "Concerned Periodontists", an Inter-Practice protection group in Phoenix. He informed me that a fellow periodontist had passed away suddenly and unexpectedly of a heart attack at the age of 41 at his home that morning. By 7:30 a.m. the next day, the coverage group was activated and within a few hours a schedule was created in which eighteen periodontists had volunteered their time over the next sixty days to cover the practice.

I arrived at the deceased periodontist's practice at 10:30 a.m. and was met with an enormous amount of gratitude and appreciation by the team. To know that the doctor had thought ahead and aligned himself with a conscientious group of practitioners was such a relief to his staff, and to know the practice would be covered in this difficult time lifted a huge weight of concern off their shoulders. In the following weeks, patients were treated, the staff continued to work, and the business continued to operate while the surviving estate planned for the practice's sale.

No one really knows what tomorrow brings. We plan for our practices to grow, we plan to maintain a happy and productive team of employees, we plan for retirement, and we hope to have enough insurance coverage to provide financial help in catastrophic situations. Be prepared and have a plan in place so that your practice will continue to be productive when you're not there.

Question: One of my employees broke her ankle during a weekend skiing trip. She has a note from her physician excusing her from work for the next 10 weeks. Am I required by law to hold her job open?

The answer to this question, for most dental offices in Arizona, is no. Since Arizona is an "at will employment state," there are no rules governing job security regarding an injury that occurs away from the workplace. That being said, if your dental office employs more than 50 people then the employer may be required to follow Federal Mandates under the Family Medical Leave Act, or FMLA. Here, an employer may be required to give an employee, who has worked for the employer for at least 12 months or 1250 hours during the 12 months before the leave, up to 12 weeks of unpaid leave for certain family and medical reasons. The employee would return to the same or a similar position when the leave is over.

Although not required to hold a position for an employee, it may be prudent for an employer to do so anyway. The question that should immediately pop into an employer's mind in this situation is, "Is the injured employee worth holding open the position?"

An employer should immediately evaluate the injured employee's worth to the practice. Is the employee a star performer who will be difficult to replace? Is he or she the "model" employee who receives well deserved, excellent job reviews every year? Does he or she have such rapport with the patient base that a permanent absence will affect the practice? How will the rest of the dental team work without this person?

Most employers have a pretty good idea regarding the performance of each team member. There are some that are so well suited for their office that they cannot imagine working without them. There are other employees that do not seem to meld, may be inept in various situations, and the employer spends many hours thinking that it would be nice if a more competent worker could only replace them.

For the employee who is competent, and would be sorely missed, hold open the position until he or she is well enough to work again. For the employee who is not up to par, replace him or her.

In addition, because Arizona is an "at will employment state," it is possible for an employer to retain one employee and not another. Following the rules in Arizona, it does not matter if a precedent has been set within an office. For example, regarding the original question, two employees could have been on the same skiing excursion, both equally injured, but the employer has the option of retaining only one employee. However, managing this scenario in your office, is not recommended.

When an employee must take an unpaid Leave of Absence, whether it be for a broken ankle, maternity, or caring for a seriously sick child/family member, there are ways to diminish the financial hardship to your employee. Earned but unused paid time off in the form of sick pay and/or vacation pay should be used first. Some employers feel compelled to grant unearned, future vacation pay to an employee who is in good standing with the office (tenured, trustworthy) however this is not recommended. Not only may the employee never return to work and therefore the money is not "recouped", burn-out is high without some vacation/time away from the work environment if the employee does return to work.

In the event of an injury, one may consider asking for certification from the physician that details the date when the health condition started, the length of time the condition is likely to last, diagnosis of the condition, treatment prescribed, and whether inpatient treatment is required. You are free to decide when to ask for a certificate, but maintain a uniform policy; don't be selective concerning the event or the person, it may lead to discrimination issues later. Since most people are honest, the simplest and legally safest policy is an honor system in which you accept employee's statements at face value. Finally, ask for a final written statement from the physician that the employee is cleared for work and if there are any restrictions prior to commencing employment.

With this issue and others that may occur in the practice, double check the practice's Personnel Policy Manual and be sure a fair and sensible policy for a leave of absence is in place. Accidents happen, and we must be proactive in warding off problems that may result from such events.

Can I implement a personal cell phone use policy stating phones are to be shut off during business hours? If so, should that policy stipulate the use of personal cell phones is permitted only during break and lunch periods?

How in the world did we ever live without cell phones? How did we have the patience to sit by a land-line phone waiting for a call? How did we track down a friend at the stadium, or our teenager in the mall? How many of us remember trying desperately to find a pay phone, and then realizing we didn't have a dime or correct change to make a call?

Cell phones have become an important, beneficial part of society, I suppose it could be said that they are a necessity. As valuable as cell phones are in this day and age, they also have become an intrusive part of society. Twenty years ago, we weren't reminded to turn off our cell phones prior to a movie or performance. Twenty years ago we didn't take a phone call in the middle of a restaurant, and we weren't subjected to listening to one-sided conversations in most every environment.

Cell phones have their purpose, but also can be a bane to mankind. It is increasingly difficult for people to disconnect from their own personal worlds with its distractions and live in the here and now. For example; "I am glad I am enjoying an intimate luncheon date with you my friend, but please excuse me if I need to take an important business call."
Although cell phones can be considered a valued asset in some circumstances, they are not ALWAYS a necessity. In answer to the original question; yes by all means a dentist should have a policy requiring cell phones be turned off during the working day. Not only should cell phones be off, but also cell phones should be kept in the employee's purse or locker so as not to become a distraction such as in cases of text messaging or retrieving voicemail, both of which can be done silently. Even with the extenuating circumstance of an emergency, family members can always call the dentist's main office line to relay any concerns or urgent need to contact an employee. An employee should only have the benefit of cell phone use during lunch or break periods. The final judgment as to whether or not a call is an emergency lies with the dentist or employer.

If you do not have a policy in the manual regarding cell phones, I suggest you implement one immediately by issuing an addendum to your manual, educating all the employees regarding the new policy, having each employee sign the policy, and put this signed copy in their employee files as part of their permanent record. At this time it would also be prudent to make sure all your employees have read your office manual, and each employee has a signed statement in their file that they have read and understand the office policies and procedures. This is a safeguard not only for the employees, in that they understand what is expected of them, but also for the employer, in that expectations have been made known and adherence to policy is expected.

Say "goodbye" to unwanted interruptions during the work day. And Say "hello" to a higher level of patient services, where patients in your office leave after a positive experience, without a cell phone ringing!

What are we allowed to say when a prospective employer calls our office for a reference for one of our ex-employees who was dismissed or resigned?

This question certainly raises a dilemma, and in today's litigious society, one to carefully think through. According to the Arizona Industrial Commission and Labor Board, no laws govern this issue in our state. Following basic guidelines will help one decide how to disclose information about former employees and avoid litigation.

An employer may fear that if any negative statements are made one could be sued for libel (written) or slander (spoken). It is best to stick with the facts and lay aside personal feelings. Basic information that may be disclosed would be dates of employment, job title and description, rates of pay both at the beginning and end of employment, and if the employee resigned or was terminated.

In order to avoid defamation, a former employee must prove that information given out was false and that the information harmed his or her reputation. Proving the information given was true dismisses these types of lawsuits. For example, disclosing disciplinary action taken during the employment period is justified provided that documentation signed by the ex-employee is on record. Make sure personnel files reflect fairness, objectivity and honesty; free of unproven gossip.

My recommendation is to speak only to the doctor, or the owner of the practice. Ultimately, these people are responsible for hiring, training, reviewing performance, and dismissing employees.

It also pays to be discrete while attending informal gatherings. Don't speak freely at a meeting or other functions where social and/or business chatter may take place. Among colleagues and employees, disclose the reasons for firing strictly on a need-to-know basis. Limit the announcements to, "Sally has left the practice and we're seeking a replacement." Either 'speak well of the dead', or say nothing at all. For example, if one believes nothing positive can be said of a former employee, simply state that it is the policy of the practice not to comment on former employees with prospective employers. Airing grievances about someone will likely spread, potentially causing legal complications.

The "Crown Jewel" of all questions that will tell a person most all they need to know about a former or prospective employee is, "Given the opportunity, would you hire the employee again?" A "yes" or "no" answer speaks volumes. Take it from there.

What are the best ways to deal with chronically late and repeat no-show patients?

Knee jerk reaction: Dismiss them from the practice.
Long answer: Read on...

In my experience, 23 years this summer, I can't recall having worked in an office where patients are NEVER late, or NEVER miss their appointments. It's foolish to think that ALL people are conscientious and keep their appointments; events happen in people's lives that prevent them from following through on their commitments.
For instance, haven't we heard of the patient who is scheduled, and confirmed, for an appointment that doesn't show up? The nerve… Only to find out that they were detained unavoidably at work for a meeting that may have more severe consequences than a tooth going south; like losing their job. Something may have occurred that we didn't hear about. Let's take a listen…

Patient's Boss: "Mary, we have an emergency meeting this afternoon, it starts in five minutes; grab your things, let's go."
Patient: "Gee, boss, I have a dental appointment, and it's real important that I go, I promised; and they already confirmed my appointment yesterday."
Patient's Boss: "Mary, what part of "emergency meeting which starts in five minutes; grab your things, let's go" did you not understand? I'll make it real simple, you choose: Meeting - keep job, Dental appointment - lose job."

Okay, all kidding aside, there are things we can control in this process, and things we cannot. When offices focus on the things they can control, kept appointment rates increase, failed appointments decrease, and patients by and large will arrive on time; sure, not always, but improvement is the idea here.

Before I lunge into providing some quick and useful ideas for integration into existing systems to improve kept appointment rates, here is another quick case study as an example of what not to do. During the first few weeks of a consulting engagement in an office I worked with a few years ago, the team showed me the following letter, received recently in the mail:

"I am sending this letter expressing my disagreement with your current policy of charging $45 for a patient that has missed an appointment.
On several occasions my daughter waited past the originated appointment time to receive your services. Additionally, we have never been past due on an account for your services.
Enclosed is the payment that you have requested. However, you are at a great loss, for my daughter will never return for your services nor will we recommend your services simply because I feel you have little value for a good customer.
Recently, my family moved to a new home. Apparently, the original appointment card was lost in the move. However, this letter is not intended to make excuses. It is simply to voice my opinion on your policy and my perception of your lack of appreciation for a good customer."

The team asked me what they should do in response to this letter from a patient of record. We pulled the chart to look into past events and discovered the mother and daughter had been patients for around 19 months. During the first six months, a chart entry indicated that they failed an appointment without notice. An entry on a later date indicated the mother called apologizing for not keeping the appointment due to car trouble. Okay, apology accepted, onward to better health.

A year passes with multiple entries indicating treatment for the daughter and mother; kept appointments; low or no balance due on the account. A chart entry was made about a month prior to receiving the above letter, about 18 months from the date of their first appointment. The entry indicated: "Failed appointment without notice - second occurrence, failed appointment charge issued, $45."

It gets better. When I asked if the reference in the letter about running late was true, the team members acknowledged they run late, constantly. Even though the reminder card was lost in the move, the family had mentioned that buying a better car was secondary to their children's dental health.

Uh, oh.

Seemed to me the office violated one of the fundamental principles of good appointment scheduling: Respect other people's time before you expect them to respect yours.
So, lesson number one: Be on time; don't make people wait. Also, avoid, as much as humanly possible, changing an appointment to make the day better for the office.
Gone are the days, I certainly hope, where we try to move people around because of holes in the schedule, due to cancelled appointments on short notice, or try to move patients up in the day so that we can leave early! This may backfire. There's nothing wrong with trying to make the most of your day and be as productive as possible, but when one takes the point of view of the patients, it may be an inconvenience to them to change the day or time of their appointment; we're all busy!

Okay. Let's be proactive and manage this situation so that we reduce the number of people that are chronically late and those that fail their appointments.

1. Respect other people's time. Stay on schedule, and make every effort to run the office in an orderly, professional manner so that appointment times are in line with the clinical treatment and skills of the providers.
2. Be polite and flexible, but firm and businesslike. Patients learn quickly if a receptionist handles the issue with tact and diplomacy. Example, "We missed you at your appointment, but it's good to know you'd like to make another appointment and complete your treatment. Let's find a date and time that you know won't conflict with anything else and that you'll be able to keep."
3. Listen to the patient's side of the story. There may be a very good reason why the patient didn't attend the appointment; hear it out. Then, decide based on your philosophy and what you've decided as an office if the reason is acceptable. If it is, move forward and re-appoint; properly. If it isn't, make the decision to dismiss the patient instead of facing the inevitable - chronic no-shows and cancellations!
4. Be nice. Patients may feel uncomfortable canceling during the confirmation call to avoid confrontation with an abrupt receptionist. Result: No Show.
5. Treat each case individually. Is there a clear-cut answer? No, but you can work within guidelines. Establish a foundation of good patient services and communication skills.

Dealing with patients who are late for their appointment:
When someone comes in late, have a conversation to let them know:
Team: "Mr. Herbert, hello, how are you?"
Wait for a response, knowing that they may provide you with all the ammunition you need.
Patient: "I'm fine, thanks."
No admission of guilt, even though they're 20 minutes late!
Team: "I noticed your appointment time was at 2:00, was that the time you had?"
Stop and wait for a response.
Patient: "Yeah, I got caught in traffic."
Team: "Boy that can happen around here, that's for sure. Let me see if we still have time to complete your treatment."
Leave the front; walk away. Check and see if in fact there is time to complete the treatment without inconveniencing the patients already scheduled.
Team: "We can still see you; but we'd like to stay on time as a courtesy to the patients later today. We may not be able to complete everything we had planned. In the future, if you'd be so kind as to do what you can to be here on time, we'd appreciate it very much."

Handle this professionally; but be direct. Let the patient know it's not okay for him/her to be late and try not to chastise or belittle him/her. If the patient could care less, and doesn't respect your time or other people's time, consider dismissing him/her as a patient. Standing firm on this is tough, but in my experience, there's a difference between letting patients run the office and you running the office.

Oh yes, and let's remember that delays happen, emergency appointments occur, and treatments may take longer than anticipated. Tips on putting out the fire when we may run behind:

When delays happen, talk to patients. Explain the delay, don't ignore it and behave as though it is a usual occurrence. Consider something like this.

"I'm sorry we're running late for your appointment. When our patients have a problem that needs immediate attention, we do our best to see them right away; hopefully without inconveniencing other patients. If the same thing were to happen to you, we'd do our best to see you immediately. Thanks for your patience."

A few final thoughts: Don't dismiss arbitrarily. Avoid patient abandonment issues by following this simple rule: do not dismiss a patient who has started but not yet completed treatment. In simple, what the dentist created must be completed. On the other hand, one may dismiss a patient who has a condition that must be treated, but has not started treatment. What nature created, you don't have to finish. You don't have to treat everyone.

Finally, be proactive. Work with the entire team to raise the bar on being on time, excelling in patient services, and enhancing communication skills. Put it all together to improve practice performance and rid the practice of patients who fail or are chronically late for their appointments.

I'm considering implementing an incentive bonus program.
Where do I start? Are bonus programs effective? What are the pitfalls?

Incentive bonus programs serve a valuable purpose for rewarding a team based on exceptional performance rather than just required duties. This sharing in the extra profit from successful operations is a generous gesture from the doctor towards the team, and adds energy to the business. Earning extra income for performance beyond normal expectations is an incentive for employees to contribute extra effort. However, there are pitfalls; but if constructed with careful calculations and good intentions, an incentive bonus may work very well.

When constructing an incentive bonus program, establish a Baseline level for calculating a bonus that must be met before a bonus can be paid. This number must be based on collections, or payments, after any refunds. Do not use production. Funding a bonus program must be done through actual money collected.

Since the bonus will be paid from income beyond normal expectations, the team needs to pull together as a unit to produce more. It has worked well to set a Baseline at the number that relates to how much the team is paid for expected productivity. Therefore, calculate the total gross wages paid, including pay for time off, such as vacation, and include payroll taxes. Exclude any wages and payroll taxes paid to the doctor. Make these calculations over a reasonable period of time, preferably six months.

Practices that control overhead typically hold salaries and/or wages, including payroll taxes to less than 25% of income, or collections. In this case, multiply total monthly salaries by four to arrive at a reasonable Baseline of collections for the bonus. Example: Total wages, salaries, and payroll taxes may come out to be $12,500 per month. A reasonable Baseline is then $50,000, because salaries would be held to 25% of income. Anything over the $50,000 may be considered available for bonus.

Pay an incentive bonus on 25% of any amount over the Baseline. A key point here is that controlling employee costs though the incentive program happens by only paying out 25% of any collected revenue over the Baseline. And, going forward, include any bonus paid when re-calculating the Baseline for future bonuses.

Since some months are longer than others due to the number of working days and vacations or time off for continuing education, a provision must be in place to even the playing field. Otherwise, the practice will pay out huge bonuses during big collection months, and suffer through reduced profit in lower collection months. To balance this, consider a rolling three-month average. Calculate total collections less any patient refunds for the previous three months and divide by three. This is your current total collections. Compare this number to the Baseline, and pay out accordingly if the total exceeds the Baseline. For the next month, conduct the same calculation for the most recent three months.

The abovementioned steps have worked well across most all practices when putting together an incentive program. Each practice is different in how much revenue is collected and operating costs. Following are some pitfalls and how to avoid them.

1. Employee turnover: Salary calculations may not represent the current salary level for calculating the Baseline; make adjustments to the bonus when employees are added or released since salaries will change as a result.
2. Fringe Benefits: Some employers offer extensive benefits beyond regular pay. If the practice pays for health insurance, vacation, holiday, sick days, disability, retirement contribution, etc., it may not be financially feasible to offer an incentive bonus in addition to the extra benefits.
3. Keep bonus pay at 25% of Baseline to control costs: To illustrate, when bonuses are kept at or below the 25% range, mathematically the total of salaries including bonus going forward will remain below 25% of total collections.
4. Cap on the pay out: A good rule of thumb is to limit the pay out of the bonus to a dollar amount; say $500 per employee, if on a monthly bonus. Reason being, the employees are given added income for their performance, and the practice can re-invest extra earnings into operations to retire debt, purchase more equipment, continue a successful marketing campaign, etc.
5. Provisions for slower collection months: There must be an "equalizer" for those months that the office may not collect enough revenue to meet general operating costs. A rolling three-month average is a sensible solution.
6. Quarterly Baseline Revisions: Keep an eye on payroll, bonuses paid, payroll taxes, wages and salaries quarterly. Make minor adjustments if these numbers begin to fall out of the healthy ratio of 25%. Again, exceeding the Baseline in collections, paying only 25% of collections over the Baseline, and capping the pay out will prevent the numbers from jumping out of the healthy range.
7. Qualifications: Consider placing qualifications on the incentive program. Here are a few:
   - 90 days must pass before new team members are eligible for the bonus system to calibrate their contribution and their part of payroll
   - Employees must be active employed members of the practice at the time of the pay out
   - Termination, either voluntary or involuntary, negates participation in the program immediately
   - Any manipulation of the appointment book or payments to influence the bonus will cause the bonus program to terminate immediately
   - Any material change in personnel (adding or reducing staff) may cause the program parameters to change
   - Pay out of the incentive bonus will be done at the next pay period following the end of the month

In conclusion, an incentive bonus program is only as good as the team and systems in place. Great communication skills, outstanding patient services, and a team working cohesively will lead to more income, profit, and will ultimately make the bonus program work.

"How do I handle a situation with an employee who's gone way over our quota of sick days as outlined in our employee manual?"

This question provides insight to the management style of the specific dentist or office manager who submitted the question. The fact that the office manual was referred to in order to handle this problem shows an office that is trying to follow policy, yet has a compassion factor in that the employee has been allowed to go over the sick day quota and is still employed. Compassion is a beautiful thing, but too much compassion may backfire.
Once a standard has been set, by deviating from the employee manual and allowing an employee to take additional sick days, it is difficult to return to a sense of normalcy. How fair is it to allow one employee to behave as he/she wants without letting other employees do the same?
At the end of this article I have included examples of how a sick day policy may be written. It details creative ways that an employer can help out the employee who truly needs time off because of illness. It is inevitable that employees will need time off due to the flu or to care for a sick child or family member. The general rule is be consistent with the written policy regarding sick leave and the number of paid and unpaid sick days allowed per employee.
The employee may need time off for an extended illness or injury, in which case a leave of absence may be more appropriate. Make sure the employee manual details a leave of absence policy for such occasions. Please note that the Family and Medical Leave Act will affect companies of 50 or more employees. The Act protects employment rights of individuals who are facing certain family situations requiring absence from work, such as childbirth or adoption, care of a seriously ill parent, child or spouse or their own serious illnesses. For companies with fewer than 50 employees, a fair and sensible policy is in line with good management.
The dental office relies on each team member to be present in order to function effectively. The office may no longer function as a well-oiled machine when a team member is absent or ill. Unfortunately, patient services may suffer as a result. Additionally, there is an added cost in finding a replacement on short notice; another little something that employers detest.
If an employee abuses the sick day policy, this can be considered misconduct and the dentist or office manager has a valid reason for disciplinary action. Oftentimes, in this day and age, discipline comes across as a negative action. Disciplinary measures should be instead thought of as a tool for learning and improving job performance. Without evaluating and providing feedback to employees, mistakes or poor work would never be addressed. Discipline should not be considered punishment, but rather guidance. The main goal is to guide the employee to satisfactory, and eventually excellent, job performance.
Employee discipline should be carried out as soon as possible, never put it off or hope that the problem was an isolated incident. If there is a significant time lapse between the misconduct and discipline, either the employee or employer may forget the specifics of the incident, or a message will be silently sent that the problem wasn't that serious. That being said, if one honestly feels that the misconduct was truly an isolated incident, out of character for the specific employee who normally performs well, the disciplinary action should be less severe than with an employee who has a track record of poor performance and misconduct.
Disciplinary actions should begin as verbal counseling. Direct communication regarding the office policies and how the employee is not meeting the expected standards should be a first. The initial verbal counseling does not have to come in the form of a warning, but rather to try and establish why the employee is behaving in a manner that is not acceptable. When situations like this arise, ask, "Why"; as in, "Why the behavior?"
After establishing with the employee that a change in his/her actions is needed, document the initial verbal counseling in his/her employee file specifying the topic and date. If the misconduct continues, more severe disciplinary action should be taken in the form of a written document listing the misconduct, actions that will be taken for improvement of the problem, consequences if the misconduct continues (termination) and concluding with the signatures of both the employee and the dentist. Part of the action phase should be an evaluation within a set time period for discussion between the employee and dentist regarding how improvement has taken place; make sure you follow-up! It is best to create an open dialogue regarding performance rather than slapping the employee with termination if the problem has not been resolved.
Effective employee managers catch and improve employee problems or shortcomings before they escalate into serious misconduct issues. It is always best to prevent the problem from snowballing. Be proactive!

Template for establishing Sick Days as an employee benefit:
A new employee must work for months before being eligible for paid sick leave. Prior to this period, an employee will not be paid for any time off work for illness.

Employees of more than months will be entitled to days off for illness per calendar year with pay. After an employee becomes eligible, a prorated amount of days is given until the beginning of the next calendar year.

Sick time will be cumulative up to a total of days. The {office manager/doctor} keeps records of sick leave. Unused sick days are not cumulative; they do not rollover or add onto the next years sick days. Unused sick days are not payable days upon termination from the company.

{OPTION}
Unused sick days {are/are not} payable at the end of the practice's fiscal year.

Days off for illness exceeding the number of paid sick days may be taken from vacation time, if any days remain. After those paid-leave days are gone, no compensation will be received. Persons ill for a period of time may take a leave of absence for up to days upon the approval of the Employer.

Dentist, doctor or other medical appointments which require an employee to come in late or leave early for a particular day will not count towards sick leave if scheduled and approved in advance. However, an employee must be at work at least hours during the day. The employee must present a written document from the attending doctor's office upon request. We encourage employees to schedule these types of personal appointments on days they are not scheduled to work, if at all possible.

When can we throw records away, and how long are we required to keep patient records? Also, should we charge patients for copying records? If so, what's appropriate?

For the answer to these questions, I contacted respected attorney Jeff Tonner. Mr. Tonner has extensive experience with dental law in Arizona, and is a wealth of information on this subject.
According to Mr. Tonner, nothing in the statutes tells us how long an office must keep records. Each year, he interviews insurance companies he works with and asks them, "Have you ever had a claim come up that is longer than ten years between the work being done and the claim being made?" Invariably, the answer is no.
So, ten years is a good rule of thumb. The ten years begins after the patient was last treated. If the patient were to return after ten years or so, the records would be so old that it would be advisable, and sensible, to start fresh with new records. For all intents and purposes, one really couldn't rely on material that dated. After ten years, one would probably be safe in destroying the records. However, keep in mind that for minors, the statute of limitations doesn't begin until two years after the minor becomes an adult, age 18.
Mr. Tonner also relayed an interesting story regarding the only instance where a dentist was asked to produce records more than ten years old. The case involved an orthodontist who treated the patient as a minor. Some issues came up relating to Temporomandibular Joint Dysfunction when the patient was in his 30's. When asked to produce the records, the dentist went up in his attic, and lo and behold, actually found the records! And, he also had the right stuff written down to help solve the case in his favor!

Records Request:
In my experience, many offices handle the question regarding how to handle requests for records incorrectly. There is a correct way, and the answer is here!
Follow these guidelines when you are asked to duplicate records, or when you are requesting records yourself:

• Make sure the request is not ignored. Ethically, an oral demand should not be ignored; legally, an oral demand may be ignored.
• When requesting records, prepare a short and simple form stating that a request is being made, and the name and address of the intended designee.
• Even though some states do not require written authorization, with the initiation of HIPAA, written authorization is advisable. Allow for a signature line on the office's records request/release form.
• NEVER GIVE UP ORIGINAL RECORDS. Mr. Tonner clearly states, "The dentist owns the chart, but the patient controls access to it."
• "Records" may include many items, including the entire record. Always designate what records are being requested. For example when a person asks for their records, try to clarify: "By 'Records', do you mean your current x-rays?" If the answer is, "Yes", then copy only the x-rays. If a person requests the entire record, then the entire record must be duplicated. In addition, if a person asks for multiple copies of the entire record, then the request must be fulfilled, and one may charge an appropriate fee for each copy made.
• How much is "reasonable charge"? A good guideline is to consider the hourly cost in wages of the individual's time plus the hard costs (paper, x-ray film, etc.) to duplicate radiographs and any other records; say $20. It is not recommended to withhold records due to an unpaid balance or for payment to duplicate records. This may promote a board complaint.
• When may one charge for duplicating records? In Arizona, the Dental Practice Act states a charge can be assessed; but it does not clearly state that payment must be made in advance {A.R.S. § 32-1264}. On the other hand, the Medical Records Act {A.R.S. § 12-2291} states a charge cannot be levied against a patient when a healthcare provider requests records on behalf of the patient from another healthcare provider. This is the basis of the majority of the confusion in the dental field. When a patient requests his/her records be copied and transferred then yes, a charge may be assessed; not when another healthcare provider makes the request.
• Essentially, there is a conflict with the Dental Practice Act that says you can charge; it just doesn't specify when. The Medical Records Act says you can charge in advance. To be safe, inform the patient who is asking for their records that there is a charge, you will prepare a statement for the duplication costs, and duplicate their records per their request. But remember, if another healthcare provider requests records on behalf of the patient, then a charge cannot be assessed to the patient or the party requesting records.
• An event that happens often is when a patient changes doctors, and asks the new office to request records from the previous office. The new office contacts the previous office, asks for records on behalf of the new patient. The previous office cannot charge for duplicating records, and must honor the request for records to be duplicated and transferred to the new office. Another event that occurs is when a patient calls their current office, states they are changing doctors, for whatever reason, and would like their records transferred to their new office. At this time, a fee may be charged to duplicate records and made available to the new doctor or to the patient to take to their new office.

Following is an example of the kind of text to use on a form to request records from another office on the patient's behalf:
"We have been asked by {Patient Name} to contact you and formally request his/her records sent to our office. Below you will find his/her signature authorizing the duplication and release of his/her records.
Please honor this request at your earliest convenience."

Here is an example of what to send to a patient who requests records from their current office:
"Please make copies of my original records and have them delivered directly to me at the following address."
or,
"…send them to {Dr.'s Name/Practice Name} at the following address.
Enclosed is my payment of $20.
Thank you"

Handle the duplication of patient records intelligently by knowing the rules and regulations. In addition, be sensible with this issue; patients ask for records for a variety of different reasons. It may be that someday, circumstances may change, and they may feel the need to change dentists again. The way in which this issue is handled will either remain a positive experience in their mind, or a thorn in their side. You choose.

For more information on this issue, reference the Dental Practice Act {A.R.S. § 32-1264}, the Medical Records Act {A.R.S. § 12-2291, 2295}, and attorney Jeffrey J. Tonner at 602-266-6060. The Arizona State Board of Dental Examiner's (BODEX) website provides information online at www.azdentalboard.org.

What are "the rules" for paying my staff while we're traveling for continuing education, including my hygienist?

The issue regarding pay and travel for continuing education comes up quite a bit, and since there is no "rule" or industry standard, a dentist or employer should consider an approach based on what the business can afford financially, while being reasonable. Once a protocol or policy is formed, commit it to paper, have each member of the staff acknowledge and sign off on the policy. Finally, include it as part of the office's personnel policy manual.
A general "rule of thumb" to follow is if one requires an employee to attend a lecture, meeting or training seminar then expect to pay for that employee's time. Situations in which paying for the employee's time would be an option are if:

• The employee attends the event outside of his or her regular working hours.
• Attendance is voluntary.
• The instruction session isn't directly related to the employee's job.
• The employee doesn't perform any productive work during the instruction session.

With this background information, here are a few recommendations.
Continuing Education Rate of Pay
When the team is required to participate in continuing education during normal working hours or outside the normal schedule and they are not directly applying their skills, compensate employees at a Continuing Education, or CE, rate of 50% of their regular pay. Each employee will be responsible to note on his or her time log the hours that are accumulated for CE, and travel time if away from the office. This applies to all personnel except registered dental hygienists and employee dentists.
For hygienists, I suggest offering to help pay for courses they need to complete their requirements, but not compensate them for time worked while at the course. Require pre-approval of the course, and offer full tuition reimbursement of up to $200 annually. Here, one is assisting them with CE and licensure compliance, their responsibility, and in turn they accept the day off without pay.
Continuing Education Away from Home
For continuing education courses where travel outside of the immediate metropolitan area is necessary, and the course takes place outside the normal business schedule, consider these guidelines:
The employer will pay course tuition, travel expenses including airfare, ground transportation to and from the hotel, lodging, any meals sponsored by the employer, and a $40 per day allowance for incidental expenses to each employee, including hygienists. Transportation from home to and from the airport will be the responsibility of the employee. If group shuttle arrangements are more reasonable and accommodating, then the employer may elect to arrange and pay for group transportation. Under these circumstances, wages for hours worked will not be paid.
When a significant investment in continuing education and travel is made on the employee's behalf, I suggest considering a policy where the employee agrees to remain employed with the office for a period of one full year after the course is completed. If the employer terminates the employee because of a violation of company policy, or the employee resigns, then the employer may, at his or her sole discretion, require the employee to reimburse the cost of tuition, lodging, and airfare.
It is highly recommended that team members are aware that continuing education is an important part of career and practice development. State this in the personnel manual and make sure employees sign an acknowledgement form that they understand one aspect of their job will be time spent learning how to improve their own performance along with the entire team.
In summary, make sure employees understand the basis of the recommendations for this policy:
· The employee is engaging in a group session to educate the team on enhancing people and practice performance.
· They are not performing productive work during the session.
· It is an integral part of the businesses plan to support an educated and organized team.
· A significant investment has been made on their behalf to advance their knowledge and skills.

Continuing education is necessary in today's changing environment. Enhancing people and practice performance leads to enhanced patient services, and as a result, improved productivity and profit. Provide employees with a reasonable package for continuing education and travel so that the team is encouraged to advance their skills and to put forth their improved expertise.

Should I Conduct Background Checks For Potential Hires?
More often than not, I run across dentists complaining about their new hires' performance. When asked how the reference checks went prior to offering the new employees jobs, the dentist will respond sheepishly that this was not done. The reasons that reference checks were not done run the gamut of "the office was too busy and I needed someone immediately" to "the person seemed so sincere and trustworthy."
Reference checks should always be done on each applicant that one is considering hiring. With that said, we get to the more detailed investigation, that of background checks.
There will always be some dishonest people seeking employment. The job of the employer is to discover false or incomplete information given on the job application so that the dishonest person is not offered employment. The first step in securing a worthy employee is to have a thorough, well written job application. This application form can be useful not only in finding out the applicant's past experience, but can also serve as an informational tool that allows the applicant to understand the basic terms and conditions of the job he/she is seeking. The job application can also serve as a consent form in order to obtain reference checks and background information. When giving the person your application form, impress upon him/her the importance of being as accurate and truthful as possible. Application fraud, or resume fraud, is a serious offense, and dishonesty is justification for firing. In other words, discovering after the fact that a false application was submitted is cause for dismissal.
The need to investigate a potential hire is legitimate, but the employer must be careful not to infringe on the applicants legal right to privacy. The best way to circumvent privacy issues is to only pursue background information that is directly related to the person's job. Inform the applicant, within the job application, that part of the hiring process is to request information from a variety of sources that could include schools, former employers, credit reporting agencies and law enforcement agencies. Have the applicant sign a consent form as part of the hiring process. The consent form can be a part of the application or a separate form.
There is a federal law called the Fair Credit Reporting Act or FCRA that imposes strict rules on the use of "consumer reports" which includes background checks. The FCRA stipulates that in order to use a report, it must be prepared by a consumer reporting agency; meaning a business that assembles reports for other businesses.
For example, when hiring an office manager with fiduciary responsibilities, it may be prudent to perform a credit check. If the dentist uses a credit bureau to obtain the applicant's credit payment record, this would be covered under the FCRA. One might think that credit history is not relevant to employment, but when dealing with an employee who will be responsible for managing the dental office's finances, hiring an employee that has difficulty keeping personal finances in the black may not be the best choice for the job. Also, if a person is in debt, they may be more prone to skim money from the dental coffers. Embezzlement is an unfortunate, but fairly common problem that occurs in dental offices. I personally have known three dentists that unknowingly employed an embezzler.
Another background check that may be performed is the inquiry regarding criminal history. Be mindful that asking about an arrest record is a subtle form of discrimination since oftentimes arrest charges are found to be without merit and dropped. Conviction records however can be used to rule out applicants as long as the conviction has a correlation with the job being sought.
As said earlier, include written information with the application that notifies the potential hire of consumer report inquiries for employment purposes. Written permission is a requirement in obtaining consumer reports. Any agency that prepares a report for the employer will require that the dentist certifies that he/she is complying with the federal law and that the information received will not be used in violation of state and federal equal employment opportunity laws.
Upon receipt of the report, particular rules apply if the dentist decides not to hire the employee based on the report results. Before informing the employee that he/she will not be hired, a dentist must give disclosure regarding his/her decision. The disclosure should include a copy of the consumer report and a copy of "A Summary of Your Rights Under the Fair Credit Reporting Act." This is a publication written by the Federal Trade Commission (FTC). The dentist can obtain a copy of this publication either by visiting the FTC's website at www.ftc.gov/os/statutes/2summary.htm or by asking the business who prepared the consumer report to send a copy. Once both reports are given to the potential hire, or even an existing employee, the dentist can notify the person that he/she will not be hiring the applicant (or firing an existing employee). The notification can be written, verbal, or even by e-mail.
Also note, when informing the person that you will not be employing him/her, or terminating a current employee, a dentist must inform the person of the credit reporting agency (CRA), including name, address and phone number of the agency and also state that the CRA did not have any decision making abilities regarding the employee's hiring outcome as well as the CRA is unable to give specific reasons for the dentist's decision. The applicant, or employee, has the right to disagree with the accuracy of the report prepared by the CRA and an additional copy may be obtained from the CRA, at no additional charge within 60 days.
The employer must perform the above steps in order to avoid legal trouble.
This seems like a lot of work. And, as I've written in other articles, when the work performed up front during the hiring process is thorough, problem are few later. Performing a background check, although laborious, is an important, albeit optional, tool that protects the dental office from future problems with a dishonest person seeking employment.

I suspect one of my employees has a substance abuse problem. What are my options?

Each employer has the right to insist on a drug-free workplace. There are no laws preventing one from combating the use of drugs and alcohol in the workplace. There are, however, some limits on your ability to test employees for drug usage. Legally, you're free to prohibit the use of drugs and alcohol in the workplace, require that an employee not come to work or return from meals and/or breaks under the influence of alcohol or drugs, and require that all employees meet the same performance standards.
Employers needn't tolerate absenteeism, tardiness, poor job performance or accidents caused by alcohol or illegal drug use. Guard against these events with a good policy that is fair and within your legal rights.
One obstacle that gets in the way of drug testing is with workers' rights to privacy. Laws on drug testing vary widely from state to state, and legislators and judges struggle to strike a balance between workers' rights and the legitimate needs of businesses.
In our state, the Arizona Revised Statutes § 23-493 explains our limitations and legal parameters. Here is a summary to start things off.
· Employers with one or more full-time employees must abide by the statute.
· Employers must inform prospective hires that they will undergo drug testing as a condition of employment.
· Employees are subject to random and scheduled tests for any job-related purpose, to maintain productivity and safety, and upon reasonable suspicion.
· The drug-testing policy must inform employees of their right to explain positive results.
· Before conducting tests, the employer must give employees a copy of the written policy. The policy must state the consequences of a positive test or refusal to submit to testing.
So, in direct response to the question heading this article, "Reasonable Suspicion" is your key. However, be careful.
There's nothing wrong with firing an employee or rejecting an applicant who uses, possesses or distributes drugs illegally. This includes the use of illegal drugs and the illegal use of prescription drugs that are deemed controlled substances under federal drug laws.
Example, Quite Bright Smile Centers, a fictitious dental office, fires Hilda after determining that she takes amphetamines without a doctor's prescription. Amphetamines can be legally prescribed, but are classified as "controlled substances" because of their potential for abuse. If a doctor didn't prescribe amphetamines for Hilda, Quite Bright Smile Centers would be justified in firing her for illegal use of drugs.
How did Quite Bright Smile Centers know Hilda was using drugs? The most reliable way to determine that an employee is using drugs illegally is through a drug test.
Most businesses have a policy prohibiting employees' use of alcohol or illegal drugs in the workplace. In addition, some businesses offer employees help in dealing with abuse of these substances, often through an employee assistance program in which the business pays for professional counseling. In my personal experience, dental offices rarely have a written policy on drug testing. And, dental offices may not be prepared to handle the cost of providing help in this regard.
Once an applicant becomes an employee, drug testing gets stickier. Testing is usually permitted when employees have been in an accident or you've seen them bring illegal drugs to work. Your legal right to test at random without a solid written policy signed off by each and every employee is unclear, and questionable.
Recovering addicts are protected within the Americans with Disabilities Act. The Act prohibits you from discriminating against people because of past drug problems. This includes people who no longer use drugs illegally and those who are receiving treatment for drug addiction or who have been rehabilitated successfully.
Pre-employment testing is the safest type of testing from a legal standpoint. After an employee is hired, federal and state laws as well as court decisions control testing. If you decide to test, your primary motive should be to ensure the safety of workers, patients/customers, and members of the general public who frequent your office.

You're most likely to withstand a legal challenge if you limit testing of employees to three situations.
1. Safety and Security. Because a dental office provides hands on health care that carries a risk to the public's safety, you can require periodic testing of your employees.
2. Accidents. You can require testing of an employee who's been involved in an accident. For instance, an employee who accidentally causes injury to a patient or themselves.
3. Retesting. You can require periodic retesting of an employee who is currently in or has completed a drug rehabilitation program, or an employee to whom you've given a second chance. Example: one who tested positive for drugs after a personal injury accident, but was kept on the job anyway.
Even though you have a right in these situations to require a drug test as a condition of continued employment, you can't force an employee to submit to a test against his or her will. You can, however, fire an employee who refuses to be tested if it is in your written policy as a consequence of declining a test.
In general, avoid a policy of testing all employees. Not all of them will be in a position to cause harm through drug usage. Similarly, avoid a program of random drug testing. If you test all employees, test them randomly or test without a good reason, you may get sued for invasion of privacy or infliction of emotional harm.
To keep your drug testing program on a solid legal footing, use a test lab that's certified by the U.S. Department of Health and Human Services or accredited by the College of American Pathologists, keep the results of the drug test confidential, and be consistent in dealing with those who test positive. Also, keep good records documenting why and how tests are administered. Require employees to acknowledge in writing that he or she has been given a copy of the drug and alcohol policy, or include the policy in your employee handbook and obtain a written acknowledgement that the employee has read the handbook.
Alcoholism is treated somewhat differently. A person disabled by alcoholism is entitled to the same protection from job discrimination as any other person with a disability. But, you're not required to overlook the effects that this disability can have on job performance. Under the Americans with Disabilities Act (ADA), you can discipline, discharge or deny employment to an alcoholic if the person's job performance or conduct is so badly affected by alcohol usage that he or she isn't qualified to do the job.
Example: Quite Bright Smile Centers employs Gertrude who often is late for work and sometimes is unable to perform her job up to standards. The employer disciplines her because of her tardiness and poor performance. The company holds Gertrude to the same standards as its other employees and disciplines her in a like way. This doesn't violate the ADA.
Neither the ADA nor its regulations define alcoholic or alcoholism. The lack of definitions may have little practical effect, however, since the ADA allows you to judge the employee by his or her ability to do the job. People who have an alcohol problem aren't legally entitled to any special consideration.
Be proactive in handling the sensitive issue. My "Practice Pointer" today is to establish a written drug-testing policy and have each employee sign off on the written document. Provide this to each applicant so that they too are aware of your position. Follow the guidelines in this article so as to be fair and prudent within your practice.
Here's an example of what I would recommend:

Drug Testing

The aim of random and scheduled drug testing is to ensure a safe and drug-free workplace. The practice will treat all team members consistently and not single out any one person or group.

Prospective employees and team members currently employed may undergo random and scheduled drug testing as a condition of employment. These tests will be conducted for any job-related purpose, to maintain productivity and safety, and upon reasonable suspicion of substance abuse.

Employees have the right to explain positive results. And, before conducting tests, the employees will be given a copy of this written policy, along with the consequences of a positive test or refusal to submit to testing:
· Results of a positive test may lead to termination.
· Refusal to submit to a random or scheduled drug test will be grounds for immediate termination.

I understand the policy stated above, and the consequences of a positive test result and refusal to submit to a random or scheduled drug test.
{Provide lines for employee and employer signature dates of their signatures}

Federal laws on drug testing by and large cover employees who hold jobs in which drug abuse can affect public safety. For instance, the Drug-Free Workplace Act of 1998 requires all contractors with the federal government to certify that they will provide a drug-free workplace. However, the Act doesn't require employers to test employees.
For more information, contact the Center for Substance Abuse Prevention Workplace Helpline at
800-967-5752 during business hours 9 am to 5:30 pm weekdays. Or, go to their website at www.drugfreeworkplace.gov.

Also, for information specific to Arizona law, contact the Industrial Commission at the Arizona Department of Labor in Phoenix at 602-542-4411, or www.ica.state.az.us.

What is the General Trend With Regard to Policies on Office Romances?The general trend, in the past five to ten years, is for large companies to view office romances with a more lenient eye. The Employers Council reports that only 25% of companies nationwide have some sort of policy regarding workplace "relationships."

And, let's face it…having a policy prohibiting office romances won't stop love. Also, if a dentist did choose to initiate a policy prohibiting office romances, how is this relationship defined? Outside of the office, how reasonable is it to assume that this could even possibly be monitored and followed up on? The ideal office setting is one where everyone is amicable, willing to go above and beyond to lend assistance where needed.

This friendship may continue outside the office setting. Often, colleagues get together for social time outside the office, and this is considered friendship. Where does a boss draw the line on friendly gatherings versus dating? The ramifications of the inquiry could easily bring on a sexual harassment lawsuit…
"So, you spent the night at {you-know-who's} house?" (This line of questioning could be interpreted as a probing question regarding intimate relations and breach of privacy). "Yes, {you-know-who} was the designated driver, and I slept on the couch. What are you implying?"

Office romances are inevitable. It is easy to understand how such relationships develop; people spend a majority of their waking hours during the week at their job working side-by-side with others. Not only is there a common background and interest (workplace and skill sets), there is a lot of time spent getting to know each other in a non-threatening environment. The interested party has an idea of what the person is like after spending so many hours together. It is a wonderful feeling to find a soul mate so conveniently, no more searching. No more bar hopping or church single-socials, no more expensive dating services or Internet chat rooms. Ahh, bliss. As the saying goes, love can be blind. And blind it is in that there is much more involved regarding the work environment. It would be a wonderful thing if an office relationship came without hitches, but the hitches are aplenty, and they are called: additional fellow office workers; career advancements; job reviews; job requirements; terminations; rivalry; competition; jealousy; favoritism…to name a few.

Whenever advancement occurs, co-workers of equal status will try to determine why; "Why him/her and not me?" If there is a known "relationship" in the office, career advancement is even more carefully scrutinized. If the significant other was promoted, there is the risk of blame, "We know how he/she got that job!" The fallout from these thoughts and emotions causes less respect toward the person in the new job, as well as jealousy and resentment. It will be more difficult for the significant other to fulfill this new role to its full potential.

On the other hand, if a colleague of equal status was promoted, and not the significant other, jealousy and resentment may also arise. There will always be the internal office struggle regarding ulterior motives. Was an advancement based on a relationship, was the advancement of a colleague based on merit, or even, was the advancement of a co-worker based instead of the significant other due to a love squabble outside the office? In any of these scenarios, resentment and jealousy can easily arise within the office, and these emotions can easily be transferred into a case of sexual harassment/sexual discrimination.

Since office romances do occur, the best option for a dentist is to have an understanding of how people work together and how human emotions and relationships develop when people work in close proximity. It is also advisable to have a strong, enforceable policy prohibiting sexual harassment/sexual discrimination. This policy should be contained in the office's Policy Manual. And, as we all know, a signed acknowledgement form stating the employee has read and understands the office's policies should be included in each employee's personnel file. The policy should be explicit regarding what is considered sexual harassment/discrimination, and the ramifications of violating the policy; the employee is subject to disciplinary action including termination.

Below is a copy of the sexual harassment section that is included in the office manual of dentists that I provide consulting services for. It would be wise to check your policy for completeness, and have your employees sign the policy immediately if they haven't already done so.

Sexual Harassment
The employer is committed to providing a work environment free of discrimination. In keeping with this commitment, the employer maintains a strict policy prohibiting sexual harassment. This policy applies to all employer agents and employees, including management. Sexual harassment includes: flirtations, touching, propositions, verbal abuse of a sexual nature, graphic or suggestive comments about an individual's dress or body or actual or perceived sexual orientation, the display of sexually suggestive objects or pictures, including nude photographs.

Sexual harassment also includes, but is not limited to unwanted sexual advances and requests for sexual favors where either (1) submission to such conduct is made an explicit or implicit term or condition of employment; (2) submission to or rejection of such conduct by an individual is used as the basis for employment decisions affecting such individual; or (3) such conduct has the purpose or effect of substantially interfering with an individual's work performance or creating an intimidating, hostile, or offensive working environment. Employees who violate this policy are subject to disciplinary action, including dismissal.

Any incident of harassment, including work-related harassment between employees, patients, or any other persons, should be reported immediately to the employer and/or to the designated individual. Employees will be given the name and or title of the individual so selected. A prompt investigation will be conducted as discreetly as possible. Obviously, no employee reporting any such harassment will be subject to any sort of retaliatory action. Any employee accused of prohibited conduct will have the opportunity to explain the conduct in question. In the case of our employees, if harassment is proven, the offender will be disciplined, up to and including termination. It is the responsibility of every employee to conscientiously follow this policy.

Conclusion
Romances between co-workers, employers & workers, vendors, and customers/patients may happen. Discuss with your team how you will handle this issue. Establish a policy that is professional, sensible, and in line with your dental practice's fundamental principles. Regardless of inter-office relationships, your team must know the expectations for job performance and behave in a responsible, professional manner within the work environment.