Articles By Fred

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!