Articles By Fred

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.