The Hygiene Revolution and the Business of Dentistry:

Scrapping the Old Infrastructure and Implementing a New Design

A little over a decade ago, the world watched with fascination as the old Soviet Empire crumbled. We saw Poland's Solidarity movement grow from a dissident fringe to a major political force. Not too long after this, we heard the amazed voices of the three major news anchors announce, "Today, the Hungarian Communist Party voted to dissolve itself."  We saw the Berlin Wall come tumbling down as happy, champagne sipping crowds chipped away pieces of it to take home as souvenirs. Ukraine voted to sever its ties with Russia and become an independent country, and the Yugoslavia that was created by Marshall Tito after World War II splintered into Serbia and Macedonia and some other countries whose names most of us can't even spell.

One of the things that I remember best from this decade of change is something I heard on a television talk show. It was a comment made by a former political dissident of some Eastern European country, a prediction of the region's future prospects. I can't recall his name or his country, but I can recall almost word-for-word his view of what would occur. His major point was that success or failure would depend on economics. Countries that scrapped the old infrastructure and designed a new one would make it; countries that tried to "fix" and "patch" old systems would not. If we look at what is happening in the region today, we can see that he was right on the mark.

So what does this have to do with dentistry? Plenty.

Over the last decade or so, one of the greatest revolutions in dentistry has been the change in perception about the purpose and function of the hygiene department. Where the department was once viewed as a necessary but costly component of every dental practice, the dental establishment now sees hygiene as something much more significant. Once seen as the person who cleaned teeth, the hygienist is now seen as the practitioner's partner in prevention, someone integral to practice commitment to patient oral health and overall health. By now, almost everyone in the dental profession recognizes that what the hygienist contributes is more than a PMV, particularly in light of the Surgeon General's 2000 report on the status of oral health in this country and the vital role hygienists must play in improving that status. And almost everyone has recognized that what goes on in the hygiene operatory has an impact on what happens in the entire practice, especially in light of the correlation between good preventive dentistry and good restorative dentistry.

This said, we find that in too many practices, the old infrastructure remains firmly in place. Instead of creating and implementing a new design, most dentists continue to "fix" and "patch" the old design. This is especially true in terms of economics, the most important aspect of the hygiene department that should be totally overhauled and totally revolutionized.

In some cases, the problem is a philosophical conflict between economics of the practice as a whole and the economics of the hygiene department. Many dentists still view their practices from the traditional perspective that the economics of restorative dentistry are the primary economic factors (and sometimes the only economic factors) that need to be considered.  This often means that their hygiene departments, while given more respect and greater responsibilities, are still operating under the tenets of the old economic infrastructure. It is time for some radical changes.

The first change is the need to recognize that hygiene and the practice must be economically integrated. Everyone needs to be on the same page and everyone needs to have the same economic goals. No one disputes that dentistry is a business. By the same token, everyone should recognize that hygiene is also a business and that the hygiene department is subject to the same principles that make all businesses succeed or fail. A  "revamped" hygiene department that is not economically viable is a hygiene department that needs to be redesigned from the ground up.

The major economic components in the business of dentistry are case acceptance, collection efficiency, scheduling, and marketing. Intertwined with all of these is excellent product quality and excellent customer service. These same components should be seen as the core of the business end of hygiene. Yet in most practices, monitoring the vital economic signs of the whole is standard operating procedure while monitoring the vital economic signs of the hygiene department is seldom, if ever, given the same consideration. This is the most critical symptom of allowing the old infrastructure to remain entrenched.

When you consider that hygiene represents (or should represent) up to 45% of the annual gross production of the practice and that up to 80% of restorative dentistry comes from what is discovered in the hygiene operatory, ignoring the fundamentals of the business design of the hygiene department is unacceptable. When you consider the potential of a perio program, in which 100% of all patients can and should be scheduled for continuing care, 75% of all patients can and should be referred to more frequent recare schedules, and 50% of all patients can and should be referred to more intensive levels of periodontal treatment, paying attention to the economic design of the department becomes even more critical.

What hygiene contributes to the practice as a whole, has made it an economic force that deserves and requires an economic design and infrastructure that is boldly and unabashedly new. Rather than making the business aspect of hygiene a footnote to the business aspect of the practice, practitioners need to recognize that the numbers related to hygiene productivity and profitability merit their own chapter. For this to work, practitioners need to give the department a crash course in the economics of the practice. This includes a road map that provides directions to the desired destination and measuring tools that specify not only what is to be measured, but also the implications of what the measurement reveals.

Among the things that need to be measured are the department's (and individual hygienists') gross production, production per hour, collection percentages, receivables ratio, new patient appointments, average new patient treatment potential, case acceptance ratio, recall rate, and treatment acceptance rate.  And just as no one in the practice would dream of waiting till year's end to see how the practice did, no one in the hygiene department should wait till year's end to see how the hygiene department did. These numbers need to be collected daily, weekly, monthly, and annually. They need to be scrupulously monitored on a regular basis for trends and patterns and warning signs. They need to be analyzed in light of potential as well as achievement, and they need to be used as the baseline for new production goals. Knowing what happened will enable the department to forecast what is likely to happen if things remain the same and what could happen if things change for better or worse.

The department should also be apprised as to how these numbers relate to salary, benefits, bonuses, and expenditures related to continuing education. Those practitioners who are truly ready to implement a radical new design might also wish to incorporate a new component -- commission compensation for hygienists.

It stands to reason that changing the business protocol of the practice and the department means adopting effective measuring instruments and enlisting hygiene department team members as active participants in measurement and implementation of the new protocol. If the protocol and design of the new system are explained well, questions of control and supervision are almost immaterial. The new design, though giving the department a significant level of autonomy, should operate within the parameters of the practice economic design -- without disparity, without conflict, and without confusion. Enlightening everyone on the business and economic goals that you want to achieve for the practice allows the department to tailor its business and economic goals to follow suit.