Winter 2002

Table of Contents

Sally McKenzie, CMC
President, McKenzie Management and Associates

Moving to 'Hire' Ground
The real vs. perceived need for more staff

Sally McKenzie

Sally McKenzie, a certified management consultant, is a nationally known lecturer, author and consultant to the Council on Dental Practice of the ADA. She is President of McKenzie Management and Associates which provides: in-office analysis of the business, clinical and hygiene department; conducts on-site staff training; and offers a full line of educational management books, audiotapes and videos. Since opening McKenzie Management in 1979, Sally has developed the most expedient practice systems, methods and technologies as well as the most effective management approaches for the dental practice. Additionally, her 34 years of experience and expertise are now available as on-tap resources for her new online ventures: and For information on what these companies can do for your practice, call Sally toll free at 1-877-777-6151 or visit her Web site at


Right now, your front desk receptionist, Mary, looks like she is ready to lunge over the counter and go straight for your throat. Her eyes are bulging, the veins in her neck are popping, and you are certain that at any minute her head may even start spinning. "Doctor, we have a problem," she says from her tightly curled lips. "Insurance EOB's aren't being filed and are stacked so high that I'm using them as bookends. We have $88,000 in treatment plans that haven't been scheduled, accounts receivable are so backlogged that our patients think we are providing zero interest loans, and the recall system no longer exists!"

Needless to say, Mary feels the need for increased front desk help. Being the erudite individual you are, you conclude that based upon the evidence presented to you by Mary during the course of her catharsis, she does in fact need a helper. Makes sense, right? The employee is overloaded, so the logical answer is to provide additional help.

Not so fast.

When determining the need for more business or clinical staff, doctors often look to the most obvious problem - that tasks are not getting done. Dirty instruments are stacking up, collections aren't being made, recalls aren't happening, and the hygienist is taking inventory of cotton balls. The resulting stress on the practice is high, and there is an understandable desire to throw more people at the problem, thinking that will solve it. After all, hiring more staff is quicker and easier than pursuing alternatives like streamlining staff duties, evaluating the time spent on tasks, and examining the mechanics and/or the materials involved in performing those tasks.

By attempting to solve the problem by adding personnel, are you actually just creating a bigger, more costly set of problems? Well, before you place that ad in the classified section, let's determine if your practice really needs another employee and whether it can handle the financial impact of a new hire.

Run the numbers, not from the numbers

Look at the total wages paid in your practice - include the hygienists', but exclude yours. The total should be no more than 19% to 22% of the gross income. That figure does not include payroll taxes and benefits, which run an additional 3% to 5%. If the current gross salary expense is hovering around 22%, adding another person will increase gross wages to 27% - and this additional 5% will have to come from your pocket. But before the thought of further cash outlay causes you to scrap the idea entirely, consider the possibility that the person you hire may be a worthwhile investment that will ultimately boost your production numbers.

For example, you can potentially increase your practice revenue by hiring a patient coordinator who makes sure appointments aren't lost. Or by hiring a hygienist who will enable your practice to meet the demands of your growing hygiene schedule. The negative financial impact of your new hire should only last for about 60 days. Beyond that, your production should be increasing, and the wage percentage of gross income should return to the 19% to 22% range. If it doesn't, you have either hired the wrong person or filled the wrong position.

The rule of 10 not 20

Dental practice mythology has it that you need a front office person for every $30,000 to $40,000 worth of production each month. Passed down as the gospel truth, the notion is better described as a half-truth, and that's being kind. One of the best indicators for the need of additional front desk help is the amount of time this person spends with patients. Patient check-ins and check-outs take approximately 10 minutes. There are 480 minutes in an eight-hour workday. If your practice is seeing 15 to 22 patients per day (which totals 150-220 minutes of patient contact), one person should be able to effectively handle the front desk duties. If the front desk business coordinator is spending more than 240 minutes (or half the day) handling patients, the practice should consider hiring an additional staff member.

As with all positions in the dental practice, clear job descriptions need to be spelled out to both the current business coordinator and your new "helper." If the assignment of responsibilities is left to the senior business coordinator, you can bet s/he is going to pass the least appealing tasks to the understudy. It's human nature.

Your goal should be to have two well-trained individuals who take ownership of their "systems" and are accountable for them. Preferably, you'll have one person taking responsibility for the financial aspects of the business like scheduling dedicated, uninterrupted time to handle billing and delinquent account follow-ups and insurance claims. Meanwhile, the other person, who is serving as a patient coordinator, handles telephones, schedules treatments and is solely responsible for the recall system.

Assess your assistant

Use the total number of your existing patients - not the number of treatment rooms - to determine your practice's need for another assistant. If the doctor has 14 or more scheduled patients a day (not counting hygiene exams), that indicates the need for a second assistant. On the flip side, our time and motion studies in dental practices across the country show that if procedures are streamlined, one assistant can efficiently maintain two treatment rooms for a general dentist using two operatories and seeing 13 or fewer patients a day. This would include setting-up the room, seating the patient, assisting the dentist, dismissing the patient and cleaning up.

"How is that possible?" one puzzled doctor once asked me. "She has to write up the lab slip. Then she has to go to the desk to find out the seat date. And that takes up time." In this situation, like many others in the dental practice, the doctor and the assistant are so immersed in doing what they have always done that they are stuck getting what they have always gotten. Take the time to step back and objectively look at how you and your assistant are accomplishing a task. There are naturally occurring breaks in most dental procedures that provide opportunities for multi-tasking. The doctor's assistant could have written the lab slip during one of these lulls. Then the slip can accompany the patient's chart at dismissal and the receptionist can write the seat date. Motion is time and time is money.

Through maximum use of time and motion efficiency, patient dismissal should take two minutes, while disinfecting a treatment room and cleaning/sterilization of instruments should take less than five minutes. Covering counters, chair switches and light handles with plastic wrap take less time than spraying to clean and disinfect surfaces. The assistant can effectively utilize the time while the doctor is anesthetizing a patient to ready the second treatment room, sterilize instruments, and prepare to seat the next patient. In fact, several states have passed legislation allowing for expanded functions for assistants. Whether your office has one assistant or two, utilize them!

The smoke and mirrors of six month scheduling

Long ago, someone handed down a credo that hygiene appointments must be scheduled six months in advance. Offices have bought into this system for decades, and guess what? It doesn't work for today's dental patients. Therefore, it doesn't work for today's dental practice. When the hygiene schedule is booked for the next six months and new or existing patients can't get the appointments they need and want, it certainly looks like hygiene needs additional staff. But what about the time the hygienist is spending taking inventory of those cotton balls? Last minute cancellations and appointment failures translate into not only down time for the hygienist, but also lost revenue for the practice. Patients who cancel as soon as they get their recall notices or those who fail to show up for their appointment should not be pre-appointed six months in advance. They are most likely to create holes in the schedule and cause the hygienist's salary to consume a higher portion of the practice revenues than it should. But if you subscribe to the system of pre-appointing six months in advance, you must call to confirm at least two days in advance, and you must block out time for new patients.

Determining the number of days needed for hygiene is a guessing game for most dental offices that becomes further complicated by a hygiene schedule that is booked for six months. I have yet to walk into a practice that really knows how many hygiene days they should have available. Too many or too few, either scenario causes problems. But I have a formula for determining the exact number of hygiene days your practice needs per week. First, determine the number of patients on your recall system and their recall frequency. For example, by knowing that you have 100 patients on four month recall that need three appointments per year - you will need to have 300 appointments available to service those patients in the next year.

If you are scheduling patients when they are due, rather than pre-scheduling appointments, your appointment schedule is going to be a far more reliable source of information in determining the need for additional hygiene staff. Examine how far ahead patients are scheduled for appointments. If there are no openings in the hygiene schedule for a solid three-week period, and patients are being bumped into the fourth week, begin increasing the hygiene department's availability in half-day increments.

Look before you leap

Dentists are primarily focused on providing quality care for their patients. So carving out time to closely examine the real, rather than perceived human resource needs of your practice may sound as appealing as performing dentistry on yourself. But know that the time spent on this kind of analysis will pay off, and that hiring more staff as a quick-fix alternative can easily turn into an even bigger management challenge.


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