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Dental Articles by Laurel Grantham

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• 13 "Stress Bombs" that Will Explode Your Day !
• Put It in Writing, Please!

The following article was published in Dental Economics Magazine in the October 1997 issue.

13 "Stress Bombs" that Will Explode Your Day !

Your day is planned, your patients are confirmed and you leave at night knowing that you have filled the appointment book. Unfortunately, your full day turns out to be lots of activity, many emergencies, but no production. Your doctor is frustrated and the entire staff is stressed out. What happened?

Your office has been hit with one or more "stress bombs"! These are the result of poor planning and confused scheduling. If you are aware of certain problem areas, you will be able to develop an action plan that will keep the appointment book stable and the office productive. Listed below are the most common stress bombs and what to do to prevent them from happening. They should be reviewed periodically at staff meetings and corrective action taken, if necessary.

Stress Bomb Number 1. . . .
NOT SCHEDULING EFFICIENTLY AND EFFECTIVELY. If your reception room is crowded and the doctor is continually running late, you may need to take a closer look at your scheduling process. Running through lunch and leaving late each evening are major stress bombs for the entire dental team. This is one of the top reasons for dental burn-out and staff turnover. By using precision scheduling, the appointment coordinator can allow for emergencies and keep the day on schedule. Use the following procedures for non-verbal communication and clarity when scheduling appointments.

• Schedule the next procedure indicated on the Appointment Worksheet in the chart. The next procedure should be indicated by a yellow highlighted line. When the procedure is completed, the doctor or assistant will then draw a pink line over the yellow line which will turn the completed treatment orange. All procedures that have an orange line through them have been completed and charged out. This is a highly efficient procedure for speeding up the check out process at the front desk. The dental assistant does not need to verbally communicate the next visit to the appointment coordinator and the procedure and time needed are highlighted in bright yellow on the sheet. (This is also a fast method to determine unscheduled dental work in the files at chart audit time!)
• Indicate doctor and assistant time by using a dot (•) for the assistant and a slash (/) for the doctor. Each 10 minute unit should have one of these marks to indicate where the doctor is at all times. The procedure times and sequences should be available from the Appointment Worksheet in each patient's chart. By following these scheduling times, you will keep the office productive and efficient. Be sure NOT to schedule two doctor units adjacent to each other!
• Identify appointment book columns by the treatment rooms it represents to create a visual plan. Make sure you are scheduling "actual time", not what the doctor optimistically writes down for the next visit. By timing your procedures for several weeks, you should have a better idea of the accurate time needed for each individual treatment.
• Chain appointments onto each other by overlapping the assistant time in different columns. Begin at the top or bottom of the schedule rather than the middle of the morning or the afternoon.
• Learn communication skills that will help you guide the patient into the correct time slot. Remember, YOU control the book!

Stress Bomb Number 2 . . . .
NOT PRE-BLOCKING THE SCHEDULE. Work smarter, not harder. If you do not pre-block ahead in your appointment book, you are asking for a roller coaster day with lots of activity but very little production.

• Pre-block the doctor's schedule first with primary care procedures (crowns, bridges, root canals, etc.). This accounts for 60-70 % of the production and are the building blocks of your schedule.
• Plan flex time for the doctor to examine hygiene patients. Do not create a solid row of doctor time down the column without time for hygiene exams.
• Pre-block staff meetings, holidays, conventions and meetings, doctor vacation days, etc. one year in advance. Since you will be scheduling hygiene ahead six months, it is crucial to have all days marked out ahead.
• Mark off one day per month in the hygiene schedule (when you schedule 6 months in advance) to save for unexpected time out of the office.
• Ask for feedback from the clinical staff regarding the schedule. They can be a valuable source of help in guiding the appointment coordinator.

Stress Bomb Number 3 . . . .
ASKING THE PATIENT "When would you like to come in?" By asking this question, you have just relinquished your control of the appointment book! The schedule has to be controlled or it will not be productive.

• Offer the patient two choices, one in the morning and one in the afternoon. If the appointment is during school or work hours, explain that the second appointment can be made later in the day, if that is possible.
• Teach your dental team how to use "I" messages and active listening skills in order to effectively communicate with your patients and each other. These skills are powerful in resolving conflicts and maintaining harmony in the office.

Stress Bomb Number 4 . . . .
NOT HAVING COVERAGE FOR ABSENT EMPLOYEES. It is always wise to contact former employees that stay at home or a temporary agency in your area for on-call backup coverage when necessary. The day the office is short-handed is not the time to frantically call around looking for help.

• Be prepared. Have all employees cross-trained and ready to step in if your office has an unexpected need. If you have to re-schedule patients due to lack of personnel, you need to rethink your system.
• Have a notebook with written instructions for all front desk operations. If a temporary appointment coordinator should have to fill in, this can serve as a reference tool that she can use to guide her. This will save time and eliminate the need for the clinical staff to answer questions regarding the front desk.

Stress Bomb Number 5 . . . .
CANCELLATIONS AND CHANGES. These can kill production and cause chaos in the schedule. Take a tactful, firm, professional (yet compassionate), stand about cancellations and changes. Unless the reason is a dire emergency or a serious problem, communicate to the patient the importance of keeping their appointment. Fear of complications as a result of postponing treatment works well when dealing with difficult patients.

• Use prevention. At the initial consult be sure the doctor and the staff emphasize the importance of keeping appointments and your request for a minimum of 24 hours notice for any changes. If the patient is not sure of their schedule, ask if they would like to be put on a short call list.
• Review the patients who cancel. Are there financial problems? Were they kept waiting too long the last time they came in? Has the office rescheduled them several times? (Office rescheduling is sending a message to your patients that it's OK to cancel.) Are they afraid of the dentist? Is there a personality conflict with a staff member? Was the office too forceful in "Selling" treatment rather than guiding the patient to find value? Was this a one-time emergency patient that we talked into an appointment? Were we too rushed, busy or preoccupied when they came in last time?
• All broken, no-show, and late appointments should be documented in red in the patient's chart as well as on the computer. Your office should have a cut-off time after which the operative or hygiene patient will need to reschedule. Usually this is 15 or more minutes into their appointment at which point only minimal treatment can be performed. By seating the late patient and running your schedule overtime, you are conveying a message to the prompt patients that your schedule is flexible. It is not fair to the patients that "play by the rules," that the late patients are seen first.
• If an unreliable patient truly wishes to have their dental work completed, explain the situation and have them pay a deposit on their next visit. This deposit will be credited to their account and if they do not show, it is non-refundable. This is the only fair way to hold time in the schedule and not have the clinical staff be left "empty handed."

Stress Bomb Number 6 . . . .
PATIENTS THAT DO NOT REMEMBER THEIR PRE-MED. Prevention is the key! Patients usually do not remember their pre-medication without a reminder call from the office. A patient who arrives without taking their pre-med kills the schedule for the doctor and the hygienist. Review all charts for the next day and make sure the patient is reminded at the confirmation call. (The word "pre-med" should be printed in red below the patient's name in the appointment book.)

• Give the premed patient a written instruction sheet that explains the medication they are being asked to take and why they cannot be seen if they should forget to take it.
• Under no circumstances should the office skip the pre-medication due to a patient's insistence. No matter how convincing, the doctor must make the patient understand that pre-medication is critical before any dental treatment that may introduce bacteria into their mouth.

Stress Bomb Number 7. . . .
PATIENTS THAT ARE NOT CONFIRMED CORRECTLY. In many offices
the appointment coordinator calls the patients on the next day's schedule, leaves messages on answering machines, and never bothers to try to reach the patient directly. This usually results in miscommunication and broken appointments. These can be avoided by using the following guidelines:

• Confirm all long appointments two days ahead. If the patient decides to change their appointment, the coordinator has an extra day to fill the time. It is very stressful for the front desk to try to fill unexpected open time at the last minute.
• Confirm all appointments early in the morning. Pull charts before calling and make sure you check all pertinent information before talking to the patient. (Do they need to take premed, bring in a co-payment, insurance form, etc.?)
• Ask the patient to return your call when confirming. Merely leaving a recorded message does not mean that they are confirmed. Emphasize that you are waiting for their call-back to make sure the time and date of the appointment is correct.
• Make sure you remind patients that the confirmation call is a "courtesy call," and
  that the patient is ultimately responsible for their own appointment.
• The last thing in the afternoon, call any patient you could not reach in the morning.

Stress Bomb Number 8 . . . .
THE EMERGENCY PATIENT. Emergency patients who are scheduled at a time that can delay the treatment of regular patients or cause an office to reschedule regular patients because of running behind are stress bombs. Emergency patients have a right to receive treatment but not at the inconvenience of regularly scheduled patients. The appointment coordinator and the clinical staff must establish the correct criteria for a pain emergency (i.e. short exam, x-ray and a P.A. film).

• The appointment book needs to be pre-blocked at the morning huddle so that the appointment coordinator can schedule the emergency patient quickly and efficiently.
• Walk-in emergency new patients should be re-appointed later in the day so that they don't spend hours in the reception room. If an emergency patient cannot leave work to be seen, it is not a true emergency.
• Only a patient of record who calls with a severe "pain" emergency should be looked at as soon as possible. Try to work them in without inconveniencing patients waiting in the treatment chairs. If the hygienist has some free time, have her put the emergency patient in her chair and get the x-rays. The patient can then be moved to the first available operative chair and the doctor will have the x-rays available immediately.

Stress Bomb Number 9 . . . .
DOCTOR OR STAFF PHONE CALLS DURING PATIENT CARE TIME. This will not only kill the schedule, but will send a message to your patients that you are not focused and concerned about their treatment. Take messages and let the doctor or staff member call when they have a lunch break or after work. This is the biggest stress bomb in the day and the one that is the hardest to enforce.

• Have a bulletin board put up in the staff lounge or lab and post messages during the day. Unless a staff member is having an emergency, all calls should be returned at lunch or at the end of the day. This also pertains to the business office staff. Due to the easy access of telephones, personal calls may take precedence over their daily duties.

Stress Bomb Number 10 . . . .
NEW PATIENTS THAT ARE NOT SCHEDULED FOR A COMPLETE DOCTOR EXAM. The doctor will run behind when there is not enough time in the hygiene room to do a full treatment plan and financial arrangement. The hygienist runs behind because her room is tied up during the consultation. Result - Stress Bomb!

• The appointment coordinator does not have the advantage of scheduling from a completed treatment plan and financial arrangements cannot be made without a complete treatment plan. This is a primary cause of miscommunication with patients. Do not rush through the new patient process, it will set the tone for the patient's attitude toward your office. Remember, they are interviewing you to see if they will place their trust and confidence (not to mention money), in your practice.
• It is necessary to have a process for entering new patients into your practice. It is for their benefit, the doctor's and the hygienist's. Work with your team to develop a smooth new patient exam. Try role-playing the exam to work out any kinks that might arise.
• Review all materials that are sent or given to the new patient. Is the paperwork neat and professional looking? Do they receive an informative brochure about the office? Are the instructions clear and upbeat? First impressions are critical. How do yours measure up?

Stress Bomb Number 11 . . . .
LOOKING FOR LOST CHARTS. Lost charts will delay treatment, run the schedule behind and irritate everyone. Legally and ethically, your doctor cannot see a patient without a chart. This means a new chart has to be created while everyone waits. It is a human energy waster when the office goes on a chart hunt or a new chart has to be made.

• Make sure all charts are pulled the day before (in the AM), so that a chart can be found if it should get lost. Don't wait to pull the chart as the patient arrives. If a patient chart should be misplaced, just make up a temporary chart for the day. When the original chart is located, transfer the information to the permanent chart. Do not make up a duplicate chart. This leads to confusion and additional work when it is time to do the chart audits.
• Make up the new patient chart while the patient is present....do not delay. Do not make up new patient charts until the patient is in the office. If they should cancel and not reschedule, the chart is now useless.

Stress Bomb Number 12 . . . .
FRONT DESK PERSONNEL THAT ARE INADEQUATELY TRAINED. Unlike dentists, hygienists and certified dental assistants, there is no formal training school for the business office. Since the front desk is the hub around which the office revolves, it is essential to have experienced, well-trained personnel in that area. Since the doctor and the clinical staff are away from the business desk, it is sometimes a sink or swim situation. This is not the place for an untrained or inexperienced person. The doctor must remember that this person is running his business!

• Start the new staff member as an "assistant" to a trained staff member for a period of several weeks. This will give the time needed for the new team member to integrate into the office and become familiar with the guidelines necessary in dealing with patients. If this is not possible, make sure the new front desk person receives adequate direction from the dentist and his staff to make her new job understandable.
• Have a clear "job expectation" list for each position in the office. Review these and update them as needed. Make sure each staff member understands and accepts these expectations as her own. Confused staff members become de-motivated when no one gives them direction or information.
• Have a formal training plan for each new front office person. Make sure they understand dental terminology, insurance procedures and legal collection tactics. Their actions will reflect back on the doctor, he is the one ultimately responsible.
• Make sure all staff members are given a chance to attend continuing education courses to advance their knowledge and capabilities. They will appreciate the training and the doctor will be rewarded with motivated and energized employees.

Stress Bomb Number 13. . . .
MOODY OR DIFFICULT TEAM MEMBERS. Just as there are no perfect patients, there are no perfect staff members, either. Everyone will have a bad day from time to time. The time the office gets hit with a stress bomb is when one team member (doctor included), decides to make the day miserable for everyone. This can be in the form of a gloomy silence, a temper tantrum or snippy remarks.

• Try to remember that everyone has problems, the patients included. No one wants to deal with a sour, grumpy person when they are sitting in a dental chair. The dental team should treat the patients with cheerfulness and conversation, not smart remarks and silence.
• If the doctor is upset with a staff member or members, he should deal with the situation after hours, not during patient care time. There is nothing more negative to a patient than seeing their dentist berate their favorite dental assistant. They certainly will not feel comfortable placing their care in a professional that does not respect his team. Try to temper your reactions and be calm and soothing when patients are present.
• Do not attempt to make collection calls if you are having a “bad day.” The calls will not only be ineffective, but will only add to your discomfort. Wait a day or so, when you can make the calls and be objective and pleasant.

Do any of these 13 Stress Bombs apply to your office? Try to make a list of problem areas that you might add to the 13 already listed. The more you know about potential stressful situations in your particular office, the better prepared you will be to deal with them. The goal is to have a productive, efficient, unstressed, and relaxed atmosphere in which to do quality dentistry on patients that cooperate and appreciate your services.

Laurel Grantham
Grantham Consulting © 1996