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The Self-Managed Hygiene Department”
With special guest – Rachel Wall, RDH, BS

Welcome to the Madow Brother audio series with Rich and Dave Madow!

Madow: Hi, and welcome to the Madow Brothers audio series. This is Dr. Richard Madow, and our guest today is Rachel Wall. How are you today, Rachel?

Wall: I’m doing super, Rich. Thank you so much for having me on. I really appreciate the opportunity.

Madow: It is great to have you on and actually we are having you on again. You were on the series a few years ago and your interview was very well received and you are back with some brand new stuff today, so we are really excited to have you back.

Wall: Thank you, happy to be back.

Madow: Oh, it’s always good to be back. Maybe those listeners who don’t remember from a few years ago or maybe some of our newer listeners aren’t familiar with Rachel, although it seems like we see your name everywhere these days, but just in case, I’ll give you a quick intro. You are the founder and owner of Inspired Hygiene, and feel free to correct me if I’m wrong, but you are helping dentists and dental practices all over the world, or mostly in the U.S. I would imagine, really get more from their hygiene department. I think maybe your theory is there is so much untapped potential in the hygiene department and you are there to bring it out and enliven it and make the hygiene department more robust, more meaningful, more profitable, and all those great things. So you’ve been doing this for over 20 years. Here’s the funny thing; I’m reading your bio actually off your website and I’m looking at your picture and that just doesn’t go with over 20 years.

Wall: Yeah, so I graduated hygiene school in 1991and worked as a full-time hygienist for years and years and years, and then started in consulting about 10 years ago, and this is really the 10-year anniversary of Inspired Hygiene, and it’s pretty exciting, so yes, the time has flown. It’s been a great gig and I am so blessed to be in dentistry, and it kind of happened by accident. As you know, Rich, we just have such great people in the industry and we have such a good time together when we collaborate and we see each other at meetings and we get to work with our clients, and I think we all feel really lucky to be in dental.

Madow: It’s a lot of fun. Just a couple highlights that we will give: you’ve spoken at many meetings including RDH Under One Roof, which I would imagine is the premier event for hygienists in the world these days; that’s a great event. You’ve been to the AACD annual session; that’s a top-notch, high-end group for sure. You’ve had lots of articles published; you’ve been in Dentistry Today, Progressive Dentist, RDH, Hygienetown, and you received the 2012 Dental Excellence Award from DrBicuspid.com for the “Most Effective Dental Hygienist Educator,” and a ton more things, so congratulations on your accomplishments and your success.

Wall: Thank you.

Madow: Well deserved. So the topic we are tackling today is what you call the “self-managed hygiene department” and we will get into that in a minute but I think maybe we will open up with a broad question that will probably open the door to what you mean by a “self-managed hygiene department.” Again, you are out there, you are speaking, you are writing, you are on DrBicuspid, you are all over the web; it seems like people probably call you for help all the time, and when dentists call you and say, “Hey, I want to get involved with Inspired Hygiene” what are some of the things that they really need the most? What do they ask you about the most when they call you to talk about hygiene coaching?

Wall: I’ll say it’s probably three things. They want to get their team calibrated, not just the hygienist but really have the entire team on the same page is what we hear all the time with regards to their perio protocol, or helping enroll restorative, or just really getting everyone in sync with the preventive piece of their practice. A lot of times the numbers are what got their attention. Either they were reviewing their numbers with their CPA or they sat down and looked at the P&L and said, “You know what, over the years hygiene has kind of gotten stagnant.” Maybe the production isn’t increasing and it hasn’t grown when the rest of the practice has, and that got their attention so then they start looking and realizing, one of the things that happen a lot is the doctors that we work with are so great at continually learning and taking CE and going to all these postgraduate courses, and sometimes they are really busy implementing all of that, that hygiene kind of gets left behind, and then they realize one day, “Gosh, I’m practicing in 2014 and my hygienist is still back in 1994.” Then they call us and say, “We need to be trained, we need to get up to speed, we need everybody to be calibrated,” and as a result we know that that is going to have an impact on the bottom line of the practice. The other interesting thing that we hear a lot is that “I would like to have a hygiene department that runs itself. One that I don’t have to micromanage and I don’t have to wonder if they’re saying the right thing or if it’s producing what it should be, it’s one that manages itself,” and so that’s where the concept of the “self-managed hygiene department” came in, and so I thought, well, if dentists are asking about this, they probably like to hear a little bit about how to do it, so that’s how this program kind of came about, and so this interview is a building block to delivering this content as a speaking program and also as part of our coaching program.

Madow: Wow, fantastic! What do you actually mean when you say “self-managed hygiene department”? Does that mean the hygiene department is like an island in the office and nobody’s allowed to enter that bubble? What’s the deal with that self-managed hygiene department?

Wall: Great question, and so that is something that happens. It happens sometimes with the hygiene department. It can happen with each department in a practice becoming an island. Really, the best results have been when we all work together. Really, what this looks like, and it can be a little bit different for every practice, but they have really specific, clear goals that are written and that they are tracking and measuring against. Here is the ironic thing; one of the most common obstacles to creating a self-managed hygiene department is poor doctor leadership. When we say “self-managed,” it’s not a removal of leadership by that owner/doctor. It may be a dramatic reduction in the time that is spent managing that department, and obviously that can translate into multiple departments. There still needs to be leadership from the doctor, the vision and the goal. We all have to be on the same page knowing what you are here to achieve and what are our specific measurable goals and then how do we track against that, how do we get to that, and if we are not hitting those goals, what are we missing? So, we need to be measured to know that the expectations are met. Very clear vision, very clear expectations from the doctor, and then really tracking and making sure that they are being met, and hygienists making some decisions on their own within boundaries that have been set by the leaders. For instance, instead of having to come to the doctor every time you need a new ultrasonic inserts, it’s more of a concept of “Here is a budget, a monthly budget of $300 for instruments,” and if you have measured the instruments and you know you are at 50% effectiveness based on the measuring tool that you have, then make your decision and just know that you have this budget to work with and that you may need to order some this month and next month, so that is just a specific example. Being proactive and being able to back up those decisions with facts and recognizing when those key performance indicators aren’t being met and what training or tools need to be in place to get the results that you’re looking for, and always being responsible for their own self-improvement and not waiting for that one time of year when they come to TBSE, and that they are taking CE all along the way and having departmental meetings and saying, “Okay, we don’t like this material that we’re using; what are we going to go about it? We’re going to test two or three others and we are going to bring that to the doctor and say, look, we have tried these and this is the one that we feel like works the best and takes the least time, and one that does the best work in the most efficient way.” These meetings are set up and run by the hygienists. I was talking to a client yesterday and that one, that was one of his goals, and said he wanted to make sure the hygiene department had regular meetings and that he doesn’t have to run it. The doctor can be present, certainly, and give input, but it’s not up to the doctor to say, “Okay, we’re having a hygiene team meeting and it’s going to be next Thursday,” and everyone is like, “Oh great, here we go again.” This is a chance for us to just continue to get better and calibrate and there are some things that need to be in place to make that picture happen.

Madow: I have a couple asides for you; all these thoughts are going through my head. First of all, can you have an office that has one hygienist and still have a self-managed hygiene department?

Wall: Yeah. I certainly think so. You know, before the hygienist or hygienists can make decisions or have conversations just as the doctor would, they have to know how the doctor thinks, so whether it’s a team of hygienists or whether it’s one, really that one-on-one time with the doctor sharing treatment philosophy, and I say one-on-one, but again, I think it is important to remember that this can translate to the entire team. The hygiene meeting may not be a meeting of one but it could be the hygienist meeting with the doctor once a month and saying the same conversation about the material, “Here is what I have requested from our rep, and I’ve tried these three and here is what I think is the best.” So yes, it can still work.

Madow: Got you. It’s funny; we’ve been in so many practices and of course hear from so many more electronically, e-letters, whatever. One of the biggest complaints, and it seems so petty because it’s not clinical, it’s not financial, but one of the biggest complaints ever, and I imagine you probably hear this too, the old “the front doesn’t get along with the back,” and you are almost making another segment of the practice when you isolate the hygiene department. Is that a problem that has to be looked at?

Wall: That’s a great question. I think the way that you can avoid that is (a) and we will talk about compensation in a moment because that is part of the motivation around some of this, but we always tell our clients, if you are going to implement some type of commission or incentive type compensation model, you still need to have some type of full team incentive in place. So it can’t be that hygiene is the only part of the team that has an incentive. There still has to be a reason to have teamwork, and I think that these concepts can translate to the admin team and to the operative team so that each team feels like “You know what, I’m empowered and I have some autonomy here. I don’t have to be micromanaged. Once the expectations are set, then I either meet them or I don’t” so I think that the key to not creating even more division is to have it translate to multiple departments. You will still have your full team meetings, so we are not removing hygiene from the team; it’s just an additional layer, and since hygiene is our niche, this is kind of where we start, but I think it can certainly translate across all departments.

Madow: Definitely, and even make all departments stronger, so that’s a great piece of advice. So that might be seen as one obstacle but I would imagine you see some other common obstacles when you create the self-managed hygiene department.

Wall: I think not having the right tools in place and so that brings us to what does it take to make this happen, and one of the things is having the right tools, and tools can be literally tools and equipment and technology, but it also can be what tools do we have to keep the hygiene schedule full? Are we using electronic patient reminders? Are we doing a consistent reactivation effort? What are our systems? One example is making sure that the notes get put in, and again, this translates across all departments. One of the things, we had a client that was very frustrated because one of their hygienists who was paid, all of their hygienists were paid 100% in commission, and depending on how you feel about that, that’s not the point. The point is that there is one hygienist in the practice that would go days and there would be no treatment notes, and part of it was because she was so concerned about packing her schedule full that she didn’t allow time in her appointments to do the notes or she didn’t take time at the end of the day to stay and do the notes. When it was done, she was done and she was out. They had to really put some parameters in and say, “Look, in order to qualify for the team bonus, you have to make sure your notes are done and all these notes have to be done,” and the expectation for everybody was that all treatment notes need to be completed before you leave for that day. Having a really clear parameter around it and also an easy way to get notes done is to have a notes template, and so the obstacle is not having any of those systems and just having to recreate the wheel, or also not knowing what your expectations are or what the goals and benchmarks are that you need to meet, and so there is no way to measure whether or not this is working.

Madow: Interesting. So it sounds like most practices probably have, from a technological standpoint at least, are probably using the things they need to have the self-managed hygiene department. Is there anything that you say, “If you don’t have this, then you can’t do it. You are at a huge disadvantage.” Any kind of must-haves that need to be in place?

Wall: Well, I think that obviously the proper tools have to be in place. There has to be the willingness to make sure that the instruments are up to a standard that’s going to allow the hygienist to work in a timely manner. They are going to have the tools that are working for them and not against them, for instance, a dull instrument or an ultrasonic tip that’s really badly worn, which we see a lot in practices; it’s actually going to work to the detriment of the patient and the hygienist, and also things like the intraoral camera. If the doctor wants to empower the hygiene department to help enroll restorative, then they have to make sure they have the tools to do that, and that’s not the intraoral camera that’s in the cabinet, in the storage room down the hall next to the fifth operatory. It needs to be right there where it can be used.

Madow: With six inches of dust on it.

Wall: Right. It just is, that’s just the truth about technology. If it’s not accessible, it’s just not going to get used, and so then you won’t see your return on investment. I think there are a lot of options in that area, certainly. I worked in a practice for years where instead of intraoral cameras we had extraoral cameras, and they were available and there are mirrors in every room and we had a neat little card reader system, so it’s very accessible, and it doesn’t have to be that one thing, but there has to be a tool in place to get that result that’s desired.

Madow: I think you briefly mentioned electronic communication systems. Do you find things like Demandforce, Smile Reminder, Patient Activator to be a huge help in implementing a self-managed hygiene department?

Wall: Yeah, we do because there are things that can be automated and at the same time we can’t set it and forget it. That’s kind of what sometimes we think when we get these automated systems, that it’s a set-it-and-forget-it system, and it’s really not; there’s still people involved, and so it still involves you seeing, “Okay, so who did confirm the email; all right, those people are good to go, but how about these other folks?” So I do and I think that it can also help in generating internal marketing opportunities that obviously help hygiene and the rest of the practice hit the goals through newsletters and things like that.

Madow: Right, cool. How about training? Any kind of training we should be concerned about? We are assuming our hygienists are well trained clinically but is there something they need to take them to the level of being able to maintain their own hygiene department?

Wall: I think the first step in deciding what type of training that you need is to do the analysis of what’s going well and what’s missing. It’s kind of doing that gap analysis and focusing on and using benchmarks to focus on where are we hitting these and where are we missing the mark, and so if the doctor would like more support in restorative codiagnosis and pre-enrollment, then let’s do case review. Let’s sit down with a few cases and have doctor really go through his or her treatment philosophy and really start sharing, “Okay, here is where I’m going to recommend a crown. When I see a premolar that already has an MOD and there is decay around one of the edges, then I just know that the longest, strongest, best investment for this patient is going to be full coverage,” and so having some specific conversations like that that are going to increase the team’s confidence in pre-enrolling that type of treatment and it’s also going to increase their ability to say what the doctor would say. So part of this is, when we talk about the hygiene department running on its own, and it’s also from an efficiency standpoint, so the doctor is feeling like he or she can go in and everything is prepped and prepared for the diagnosis, and all he or she has to do is to just give the blessing and make that final diagnosis. One of the things that frustrate dentists and hygienists both is the time that’s spent during the hygiene exam, and is it efficient, and so many times I hear hygienists say, “I went through the whole explanation with them about Six Months Smiles and the doctor came in and did the whole thing again and meanwhile he’s stressed out because he needs to get back to his patient and I’m stressed out because my next patient is waiting.” It’s just incredibly inefficient, so identifying where are the things that we need to improve on and then figuring out if it is a matter of “Here is how I say it,” and “Here is how I say it,” and now just trust that this is happening. It depends on where the gaps are, Rich, so for example, one of the benchmarks that we set is that your perio percentage, and so that’s the percentage of perio procedures compared to prophies, is at 25% or higher, and we have a tool on our website that folks can use, but let’s say that you run that tool and your perio percentage is 10%, so now you know this is an area where you have some potential, and so you can do some training. You can go to a CE, you can have Inspired Hygiene come in and do some intensive training on putting together a perio system and really getting the whole team on the same page with this and getting everybody excited about delivering that next level of care. I think to get the best result and to get the best return on the training, is finding out what’s most urgent, what’s our biggest gap and starting out there.

Madow: It’s really interesting; you mentioned the term “calibrate” a few times and it’s so important, I think, if you are going to have a self-managed hygiene department it’s even more important because for those of you who maybe don’t know what we are talking about or maybe our definitions are even slightly different but to me it means everybody has to get together and decide what the standards are for the practice; when does a tooth need a crown, when does a patient need scaling and root planing? How do you answer a question like, “Why doesn’t my insurance cover this?” or “Why does it hurt after you do the restoration when it never hurt before?” and everybody has to believe in the answers and have the same answers in their own voice and in their own words of course, but the same thing, and just picturing you just trying to have a self-managed hygiene department without that, and the department is running a little bit more dependently than in the past and the office isn’t calibrated, that could be a problem because people are hearing different things at different times and just get totally confused.

Wall: Yes, and that’s one of the reasons when our team goes in to do training with our clients, the workshop day is a whole team experience so that you don’t have hygienist Rachel coming up to treatment coordinator Kim and saying, “This patient needs four areas of periodontal therapy, with local antibiotic, and then she is going to be on periodontal maintenance,” and Kim is thinking, “She came in for a prophy.” If Kim hasn’t been educated as to why this is in the patient’s best interest and what the new standards of care and the threshold for needing additional treatment are, then she is going to be questioning it; the patient is going to be confused. Kim as the treatment coordinator will not be able to present as confidently because she is not sure if this is necessary or not. You are dead on and that’s why when we teach new things, the whole team has to be involved and then everybody says, “Yes, this is what we need to do.” Now when hygienist Rachel brings the patient to the treatment coordinator Kim, Kim says, “Absolutely. I see exactly why Kim recommended this and I know Dr. Madow is totally on board, and so the good news is we can get you in quickly and take care of this.” Now it’s seamless and so calibration has to happen across the board within the practice and that’s what I was saying; doctors are always calling and saying, “We need to get everybody on the same page.” That’s what they are asking for, the calibration, and that can apply to as detailed as how you are angling the probe and how you are reading the probe to get the right measurement to what do you say when someone picks up the phone and the patient says, “My tooth hurts and it didn’t hurt before.”

Madow: You mentioned another interesting scenario where the hygienist gives a beautiful description and recommendation of Six Months Smiles and then the dentist comes in and repeats the whole thing. It’s a waste of everybody’s time, and the patient is bored. Is there a way to avoid that? Does the hygienist just simply say, “We already talked to Rachel about Six Month Smiles.” How do you do it?

Wall: That really comes into the area of trust, so a big part of creating the self-managed hygiene department is the dentist being able to trust that the hygienist is going to do what he or she would do, and so there are cues that the hygienist can give to the doctor when she walks in to do the exam and can say, “You know, we discussed Six Month Smiles and I even talked with John about this open contact here that he really is catching food and how the Six Month Smiles is going to address that. I gave him a realistic expectation of six to eight months is our typical case.” Whatever the doctor says here are the absolute musts; this patient needs to know when they are presented with it, then the hygienist needs to be presenting the same thing, and there are key words or cues that they can give to the doctor and then the doctor says, “Okay, cool. They got it, the hygienist said exactly what I would have said,” and then all they need to do is to build up that hygienist and say, “You know what, that’s exactly what I would have recommended. She is so good; it’s just like we work from the same brain. She knows exactly what I would recommend and that is right on.” How beautiful is that? It doesn’t happen overnight but it can absolutely happen. There just need to be some little key words or cues. One of the things that we use a lot, with perio for example, and one of the things that we train on quite a bit is visual cues too. So when the hygienist walks in the room and if the doctor has recommend perio therapy, then she is going to immediately hand the doctor the printed out colored perio chart and hand it to the doctor. That is a visual cue that we are having a perio conversation today and then the hygienist does the hand-off and says, “Miss Jones is ready to move forward” so now the doctor doesn’t need to stand twenty minutes talking. Miss Jones is ready; all the doctor needs to do is bless it and say, “I completely agree with what Rachel has recommended and it’s really important that the infection is eliminated and that you get started quickly.” Or the hygienist says, “Miss Jones has some more questions for you.” Now the doctor can get comfortable and recognize that I have to really listen and participate and I need to do a little bit more enrollment here. This patient needs a little more information to feel comfortable moving forward.

Madow: So many great verbal cues you gave in that little dialogue. That was just fantastic. You know, it’s funny, and you mention the word “trust” so many times; do you ever, I’m sure you have come up against this, but a doctor who is just such a micromanager and just has to be on top of everything and be the ending authority on everything. I don’t think this could work with a doctor like that; they’ve gotta loosen up.

Wall: Yeah, and, you know, that’s really stressful too because I’m sure the doctors feel like, I can’t keep up with everything, and so I think that there needs to be some conversations about what would need to happen, what would you need to hear, what would you need to do, doctor, for you to feel comfortable letting us take this on? Whether it’s a marketing project or whether it’s a reactivation campaign or whether it is every time you come in to do the exam you are saying the same thing that I’m saying, so what happens is the team quit saying it so then they say, “Well, doctor is going to repeat it so I’m going to quit saying it,” and the doctors are saying, “Gosh, I have to go in there and have to start this whole conversation from scratch.” So I think it is let us help you, what would we need to say to you for you to know that we have already had that conversation; we said everything that you would say and what do you need? So sometimes it’s just, I just need you to say, I told them about the potential need to come back for a bite adjustment; I told them about this, and then as that happens, then that trust develops. Trust doesn’t come overnight.

Madow: But then, dentists, don’t set this system up and then sabotage it. Don’t do it.

Wall: Right. You have got to trust the system, but you have got to have some confirmation that it’s working and that it’s being implemented, so sometimes those verbal cues work, and then the other thing is tracking, so if you set up the perio system and then you are tracking and you are tracking and you are not seeing any improvement, then something is not working. There is an obstacle in there somewhere and that’s like opening a whole other can of worms or can of information. There are some real physical obstacles that come into play, like schedule. Let’s say one of the systems and the pieces of training you’ve identified as your perio system, and so you got some training and you went to a CE course but you didn’t identify the fact that there is nowhere to put those patients on the schedule and we haven’t held any time aside for them; you are not going to see the results because it’s going to be months before they can even get in and you can see the results showing up on the track. That’s one of the things we help teams do too, is look at, before you implement something, what are the things that we need to help you do for you to see success, and sometimes it’s just real specific things like creating room on the schedule so you can get these patients in.

Madow: That’s certainly a must. We will get to tracking in a second but just thinking about having the right hygienist to even be a part of the self-managed hygiene department. What do you look for if you're hiring a hygienist? How can you tell that they would be the right fit for the self- managed hygiene department?

Wall: Yeah. What do they say hire for attitude and train on skills? I have to say that I have seen that ring true multiple times, and so if you're looking at the resume and there is things on there other than “Worked with Doctor Madow from 1995 to 2000,” and “I’m CE certified,” those are just, you're a hygienist or you are an assistant, so yeah, we expect that you had other positions and you’re doing the things that are required to fulfill your license renewals, but what else is there? Does it say increased perio production by 20%, implemented a budget for instruments, created a recare system? I mean, those are just tools for someone that has some entrepreneurial characteristics and that’s really what you're looking for, right? You're looking for someone who’s going to care about business the way you do and that’s going to come up with ideas to make it better. Aside from all of those kinds of management type things that we talked about before, what does it mean to have a self -managed hygiene department, a big piece of it is ideas. What could we do to be better? That might mean we need to quit doing things the way we have always done them, the comfortable way, and we need to do something different. We need to change the product or we need to start using the fluoride varnish instead of the foam, or you know, whatever it might be, just coming up with ideas, and if you see points like that on the resume, that’s a good sign, and then, when you're interviewing, ask more about that. “So tell me, how did you do this? How did you increase hygiene production by 20%?” You will hear, “Well, we decided to add a patient a day,” which may not always be the right way to increase production, or maybe “We implemented things that our patient needed anyway that we weren’t offering, and so all of a sudden we were delivering higher level care, and by the way, we increased production.” Those are the things that you want to look out for, and someone who is going to be open to being in this type of role.

Madow: I would imagine there are hygienists listening to this interview right now that have done some things like that and would never even think to put that on their resume because we are so used to the standard resume being training, experience, but these things are so important; brag about them.

Wall: They are important, and sometimes a lot of those hygienists that do those things, they are just second nature and they think that, yeah, isn’t that what everybody does, and the answer is no, so sometimes it’s really good to sit with a colleague or someone you trust and say, “I want to just tell you about my experience at this office,” and they will say, “Oh my gosh, so you got more patients to come into the office, so I think you should put that on your resume.” Even if it’s someone who is not dental, sometimes it’s good just to bounce ideas off of somebody else.

Madow: Definitely. Anybody who has like a sales career will certainly put if they increased the sales of their company by 23%; that would be on their resume, but in dentistry we never think of doing that kind of stuff.

Wall: I know.

Madow: How about the current hygienist, let’s say you are working with a hygienist and he or she is great but you want to take the next step in getting them to take over managing the hygiene department. How do you do it? How do you get them excited about it? Let’s face it, a lot if hygienists are very comfortable in their positions and may be resistant to change.

Wall: I think that there are a lot of hygienists out there too who want more fulfillment in their career and they are just not quite sure how to get it. So a lot of times we look outside of dentistry to what is the next thing when we might not be able to see the opportunities that are there, so what we tell a lot of our clients is that the things that the dentist is frustrated with about the hygiene department, a lot of times the hygienist is just as frustrated. They just don’t know how to verbalize it or don’t know that there is anything that can be done about it, so sometimes they just settle in and just kind of accept things the way they are. I would say from a doctor’s perspective, bring it up and say, “Hey, I would love for you guys to take more of a leadership role in running this department and give you some autonomy in making decisions about things like products and how the hygiene appointment goes and what we can do to improve the department, and obviously there would be some parameters that have to fit into the budget but I would love for you guys to bring me the ideas,” and part of motivating that is having a favorable compensation structure that’s a win-win for both the practice and for the individual. I will say that we have clients that pay on every different, we’ve seen every different kind of compensation structure that you can think of from hourly and that’s it, to all the way up to where multiple hygienists in a practice and they actually make a commission on the pooled production. They all make the same commission based on the total production of the hygiene department, so there are a lot of different ways that it can be structured. What we’ve seen that seems to be a good hybrid, a good brand is an hourly or salary that is a little bit less than the market value. However, then having a commission once a certain goal was made. One of the benchmarks for any hygiene department and this is pretty standard for the industry, is that hygiene should be producing a minimum three times the salary and benefits, and so if the salary and benefits add up to three hundred dollars a day, then hygiene should be producing at a minimum of nine hundred dollars a day. How this would look is, let’s say you have a base of two hundred dollars a day, I’m just throwing that out there as an example, and then the minimum goal is six hundred, and then the hygienist makes a percentage of whatever is produced over that six hundred. That way profit is going into the practice for new equipment, for CE trips, for improvement and other incentives like a team bonus, and yet the hygienist has some motivation and some skin in the game when there is improvement, and doctors like to see that. They like to see someone else helping share the load and helping grow the practice. Hygienists and other team members for that matter can get a little resentful when they are working so hard and implementing new things and doing new stuff and they are not seeing any changes in their compensation or no other types of acknowledgement. Not everybody is motivated by money, but everybody needs money to make a living, and so that is one of the tools that we see that can contribute to that self-managed hygiene model. I’m trying to go back to your original question and how I tied compensation into that, but I think that it encourages a high level of care and it encourages that entrepreneurial attitude. Here is the thing, I’m reading this book that a good friend of mine, Tanya Lantier, introduced me to called Ownership Thinking; it’s by Brad Hams and it’s really great. I haven’t gotten all the way through it but the first third of the book is so applicable to any industry and particularly dentistry, and it just talks about how to end entitlement, create a culture of accountability, purpose, and profit, and how people prefer accountability, and I will tell you that we see that in our surveys, so before we ever go in to do any coaching, we do some team surveys just to hear what everybody has to say of the whole team, and we see it over and over that they are asking for accountability from the leaders. People want to have accountability but then they want to be able to see some direct results for their work. Activity and results are not the same, so if we think about someone in an office job; answering emails, reading memos, and going to meetings, that’s a lot of activity, and that’s not the same thing as getting results, and so the way that translates to the hygiene department is showing up and just kind of working the schedule and not really doing anything more; that’s the minimum, that’s the minimum effort. The results really come when we step out above that, and by the way, there are not just financial results, there are also better results for the patient. Better tissue response, better health, better enrollment to getting the care that they need.

Madow: It’s so funny; we will just use soft tissue management as a generic term. I know it’s kind of old, maybe even a generic term. When you talk to dentists and hygienists about how having a great soft tissue management program increases production, it’s also the best thing for the patient, and people can be so resistant, but don’t you want to give your patients the best treatment that you can possibly give? I don’t know why people are resisting. Hey, what’s the name of that book again? I want to get it.

Wall: Ownership Thinking, and the author is Brad Hams. To go back to what you said, Rich, you are right, and so this whole concept can’t be about production and anything new that we implement can’t just be about production. You get that, and that’s where you are coming from, right? You are coming from a place that is in the patient’s best interest, and so one of the things that we do with teams when we go in to do training is we spend a lot of time developing the “why,” so that goes into the training piece of developing the self-managed hygiene department. There has to be a why that is about more than production so the team as a whole has to see that the value of the treatment that they are providing far outweighs the cost. So the value has to far outweigh the cost. If you can identify and if you can believe that treating active perio infection reduces the patient’s risk for cardiovascular disease or makes it easy for a patient to manage their diabetes. Don’t you think the value of that and all the other implications financial and otherwise are worth so much more than the cost of the therapy? When you can get a team to say yes, we believe that then you know you have got into their heart and that it has to be the head and the heart. They have to believe it, they have to believe it or else it just is another sales tactic.

Madow: You know, it’s funny, an exercise that I used to use to tackle that, I used to use it more about a crown or something like that, but we can do it with perio. Sometimes a hygienist would say, “I have so much trouble telling a patient who thinks they came in for a cleaning, they are going to wind up spending two thousand dollars to get their gums in good shape” and I say, “Well, if I paid you two thousand dollars, how much would you pay to have your gums be in horrible shape that would eventually lead to you losing your teeth? If I gave you twenty thousand dollars and infected you with perio disease, would that be a good deal for you?” Everybody says “No! No! No! I would never do that.” We are talking about so much less money than that. It’s just hard for people to conceive.

Wall: Yeah, yeah, yeah! That’s great because it kind of turns it around. Yeah, I love that.

Madow: Well, feel free to use it.

Wall: Thank you. What we’ve kind of touched on are the four T’s.

  1. Tools: So there have to be really clear tools in place for this self-managed hygiene department to happen. Technology tools, compensation structure, the tools that help to motivate team members to take their efforts to the next level and really get results, systems, checklists, hygiene team meetings are a tool.

  2. Training: So advanced skills for hygienists, how do they enroll perio, how do they enroll restorative, even advanced skills like lasers. What are they adding to the service mix and adding to the overall perception of your practice?

  3. And then the tracking.

  4. And the last thing is the trust.

They have to be working at the same time, so the example that I came up with is if you are only doing the tracking, if you are only tracking as benchmarks and “Are we hitting our goal, are we hitting our goal?” and nothing else, then it becomes really frustrating because if these tools and these other things aren’t in place, it’s going to be hard to meet the goal, and everyone gets really down and really frustrated, so all these things really need to be working in combination.

Madow: Absolutely. You can’t have one piece or it just doesn’t work. You can’t have two pieces or it doesn’t work. I want to get to the trust in a couple of seconds, and it’s probably a good way to kind of wind down our interview too; you have given some great information. Tracking, you have talked about benchmarks and I’m sorry if I missed this but is production or financial the easiest way to track and to set your benchmarks? Is that really the way you do it? I know you mentioned 25% should be perio treatment over just prophies. Are those the main benchmarks?

Wall: Obviously there are some benchmarks that are not as tangible, right? Like personality, like one who helps create trust from the patient, someone who is out in your community as a good representative of your practice. Those are some of the things that are a little bit more intangible. Some of the real specific benchmarks that you can track are your perio percentage, and you can go onto our website, you can go onto inspiredhygiene.com/periotool and you can get a really simple little spreadsheet, and you can print a “procedures by provider” report for a year, and you can plug in all the quads of scaling and root planing that you did, all the perio maintenance, all the adult prophies, just put those numbers in there and it will spit out the perio percentage and then it will even show you where you should be and kind of where you stack up. So if that is 25% or higher then you are doing better than most practices, although I would say that we have quite a few clients that come to us that they are already there and they know that they can do better. We have a client that we recently highlighted in our e-zine and they came to us at 30% perio, and within just a couple months they were over 40%, so even the best can get better. We know that because we work with a lot of those practices that are already doing very well. Productivity, you want hygiene to be producing one thousand to twelve hundred dollars a day consistently, profitability benchmark is at three, production at three times salary plus benefits, hygiene open time should be at about 8-10% or less, and then obviously having a varied mix of services though not prophy heavy, so even when you do that perio percentage tool, it’s good to look at what’s the difference between the perio maintenance and the SRPs. If in a year you did four hundred perio maintenances and you only did eighty SRPs, then even though your perio percentage is pretty high, it’s weighted heavily with the perio maintenance, so then you have to look at what’s going on. Are we not enrolling any of our existing patients back into the treatment? We need to look at that. Those are some real specific benchmarks that can be tracked, and those are the things that are easy to measure, right?

Madow: Definitely. They all make a lot of sense; nothing is too oblique or whatever. I don’t know if that’s the right word, but everything is pretty tangible as you said, definitely.

Wall: And really, I think tracking, it’s important to, engaging the hygiene team in taking an active role in that, so teaching them how to read those stats, so whether you are using an automated kind of monitoring system where the information feeds from your system into a tracker and it’s real easy to use, or they’re manually entering the information, just making sure that they know what all that means, and there is nothing worse, and we’ve had this happen where maybe we didn’t explain well enough why we are tracking or what it means, and the hygienist feels like this is a busy work, so you want that tracking to make sense and to trigger a celebration or trigger an inquiry: “I’m curious, why is this number going down? What are we doing differently? What is it?”

Madow: Gotcha. I like the celebration. That’s a good thing.

Wall: Me too.

Madow: Couple things to wrap. I know you covered this quite a bit but just to clarify. Let’s talk about the trust thing a little bit. How can we really get the doctor to be comfortable, to unleash the hygiene department, be self-managed, be responsible for their own everything; for their production, their treatment plan presentation, ordering their equipment? When you tell me that offices are using dull ultrasonic inserts, I just thought that is just disgusting. Why would anybody do that? So how can a doctor trust that all these things are going to be taken care of, and let’s face it, I’m a dentist; I know thousands of dentists; we are sometimes picky, micromanaging geeks. How do you get over it?

Rachel: Well, I think, look at what you guys do every day. You kind of need to be that way. For the clinical skills to be at the right level, you can’t just say, well, that sounds good enough, like we are just going to let it go. It’s a part of your nature. So I think that open communication is really the key to that, and because, again, sometimes we go into practices and the doctor says, “I don’t know why we are working with these dull instruments, I told them before if they need something they can order it,” and yet the hygienists have a completely different perception of that. They are nervous to go and order new instruments and maybe because they have heard, “Oh my gosh, we just spent all this money on the CAD/CAM technology” or “We just spent all this money on updating the practice,” so again, they are kind of reluctant to present something that is in your patients’ best interest. So I think open communication and being willing to see where am I in micromanaging and what do I need to feel good and what do I need to trust the system, and so I think that I’m kind of giving you a long-winded answer but I think communication is key. I think having systems are key because then you can always go back to the systems; that’s not a people problem. If you say, “Okay, so we have a template for our notes,” everybody is really clear on the expectation, and I think expectation is a huge piece, and it’s a written system. Everybody knows, everybody understands that in order to participate in the bonus, your notes have to be finished every day before the end of the day, and so that’s the expectation. Then all the dentist really has to do if it’s not happening is say, “Hey, this is what we agreed on, so what’s getting in your way with this? What do we need to adjust in the system to make this work?” So I think it’s clear communication, it’s having really clear expectations spelled out on what does the dentist need to know is happening in order to trust the process, and then in that happening, so the tracking, and then celebrate when it is and just say, “Okay, I released that one thing; now I can release the next thing.” So I released the need to explain every procedure again when I go in because now the hygienist is letting me know she told him why she recommended crowns on premolars. She talked about splitting teeth, right? The photo is up and she’s already said, “We talked about the photo here. You can see, this premolar has a big old amalgam on all these surfaces and we talked about how these teeth often split.” I don’t need to say that, so I think it’s also once the doctor sees it happening and sees the proof in that, then he’ll be willing to release some of the things one at a time. It doesn’t happen overnight.

Madow: Gotcha, that makes sense. Exactly, you can’t do everything at once. I don’t know if I’ll put you on the spot here but what can a practice look forward to if they decide to work with Inspired Hygiene or a hygiene coach? I would imagine some people saying, ”Well, I don’t know, a hygiene coach; that sounds a little esoteric.” What are some success stories? What are some of the great things you have seen?

Rachel: So, to address your specific comment about it maybe being not a real tangible thing or kind of esoteric, and that could not be further from the truth, because one of the first things that we do is this analysis. We will look at what’s working really well, where are the gaps, and even so much as doing some virtual chart audits is one of the analysis things that says, “Hey, you know what? Your hygienists are doing perio charting on every single patient, every time. They’re charting bleeding and everything is in there, but there is a gap because we are seeing active infections and it’s not getting treatment planned.” So now we know where we need to work. I think the key when you want to work with a consultant is making sure that that consultant knows what you are starting with. So, we don’t want to fix what’s not broken. We want to start with where are you now and how you can even get to the next level. So I think our team works hard to be very specific to working towards the doctor and the team’s goals; what is it in the hygiene department that the practice as a whole that they want to address, and specifically teaching towards that, and then giving measurable results reporting. So if we worked on the perio teeth, and you were at ten quads of SRP a month; now you are at 30 quads of SRP; that’s a pretty measurable result and pretty clear result. Your hygiene production has increased by this, open time has gone down by this, and your hygienists are saying it’s uncomfortable to do something different at first, but now all of a sudden, I don’t feel like I have to treat all this periodontal disease in a prophy, and now I am having some more meaningful conversations with my patients about their overall health, and the patients are saying yes. So, I think you just want to make sure that when you work with any kind of consultant that there are going to be pieces that are more tangible than others, and you just have to figure out what your goals are and if your goals are specific measurable things, then how do we know it’s working, and if we are not seeing the results that we want, what’s our role in that? Have we done what we said we were going to do, have we kept ourselves accountable, and are we implementing? Rich, I’m sure that you guys have specific things that you say, “Here’s the way you do this, and when you do this, your patients are going to be more comfortable saying yes to treatment,” or “Are you taking the picture?” “Well, no we really don’t do that very much.” Well, that’s the key piece that’s affecting the result, so just having a coach really help you look at all those different pieces. So, we look at teams and we obviously have specific things that we work on typically with clients but we also want to listen to what their needs are and meet them at what their objectives are, whether that is dramatically increasing restorative codiagnosis from hygiene, implementing a really clear perio system, and creating a self-managing hygiene department.

Madow: Sounds great. Well, Rachel, thanks so much for all your insight, and I know that you have developed so many great programs, with so many great practices, and it’s good to hear too that you are not a cookie cutter, you really focus on what is that practice doing well, what can they do better, what are their goals, what are their needs. It’s just good stuff because I know so many people that just come into a practice and do the same thing for every practice, and that’s not always helpful. So if people want to find out more about what you are doing, could you give us some contact information, website, phone number, telex, fax, whatever you got.

Rachel: Absolutely, our website is inspiredhygiene.com. We have a free CD on our website, so if you like what you heard today, you can find out even more by requesting our free CD, and we do a weekly e-newsletter so you will be included in that when you request the free CD, and we would love to share with you a lot of free video tips and a lot of good client highlights. We also have a lot of client videos on our YouTube channel and just reach out. My email address is Rachel@inspiredhygiene.com and we would love to hear any questions that you have or just interested in how we might be able to help, and we would love to speak with them and just have a chat, see if it just might be a fit, and I just want to acknowledge you and Dave for all that you guys do in just really helping dentists and dental teams to just fall in love with what they do again and just get really excited, and you guys just always have such a positive way of doing that and I really appreciate seeing that.

Madow: Well, thanks, that’s really nice to hear. Yes, after 25 years we really still love doing it, so something must be going right. Rachel, thanks again for some great information, great insight. You’ve really done so much to help the world of dental hygiene and the world of dentistry. So we are going to sign off now; this is Dr. Richard Madow and again, our guest today was Rachel Wall, RDH, the president and founder of Inspired Hygiene. Thanks for some great stuff today, Rachel.

Rachel: Thank you so much, it was my pleasure. Take care.

Madow: You too.

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