Error Proofing The Dental Team

June 16, 2020

Implementing an Error-Free Post-COVID 19 System in Your Dental Clinic

It would be a bit of an understatement to say that COVID-19 caught the dental industry completely by surprise.  As a result of this unexpected pandemic, dental practitioners are slowly finding a way to introduce more efficient measures into their standard operating protocols in order to recover. Dr. William Moorhead, owner of Stream Dental, has suggested various modifications to systems in order to adapt to the post-pandemic period and promote infection control. Most of these are centered around checklists, earning the doctor the nickname “Dr. Checklist.”

Dr. Moorhead’s game plan for practice recovery includes the following points:

  • Improving presentation skills
  • Same-day dentistry
  • Marketing methods that reassure patients they can safely visit their dentist after COVID-19.

The Pitfalls of Tribal Training

Tribal training is a popular method used to impart knowledge within a dental team. In tribal training, the one with the most knowledge passes it on to the newest members. It is a trickle-down method of disseminating information, which unfortunately gets watered down when it gets to the last recipients. This training technique also produces a “queen bee” who will claim to know everything, hindering productivity and the overall knowledge of processes within the team.

The Importance of a System

According to Jim Collins, author of Good to Great, “The mark of mediocrity is not the unwillingness to change; rather it is inconsistency.”  This is why to ensure consistency in your practice, you need to create a system for your office. A system, according to freedictionary.com, is “an organized set of interrelated ideals or principles, or an organized coordinated method.” In dentistry, systems are often considered as checklists. These checklists detail every step of the system and describe the necessary tasks to perform at each particular point.

The Checklist Manifesto

According to physician Atul Gawande, one of the co-authors of the World Health Organization (WHO)’s Safety Checklist, all learned occupations have a code of conduct.  Additionally, all codes of conduct have three common elements:

  1. Selflessness – accepting responsibility for others
  2. Skill – aiming for excellence in knowledge and skills
  3. Trustworthiness

All of these factors go into the principle of creating a checklist. However, a checklist is only an aid, and it always needs revisiting and refining, with the goal of simplifying the process.

The Effect of a System on Your Practice

It’s better to have a system that needs improvement than to not have one at all. Here are the benefits of incorporating checklists and systems into your dental practice:

  1. Get organized and minimize errors. With a refined system in place, everything is provided on cue, allowing your team to function solidly as a unit. The checklist will be your foundation and you will be better because of it.
  2. You will also leave your patients with a much better impression, as your practice will visibly be more efficient and thorough.
  3. You can increase treatment acceptance through exams.
  4. As a result of your system, you can add to your daily production by factoring in Same Day Dentistry (SDD) from hygiene and emergency-based appointments.

Examples of Systems in Dentistry

Devising a checklist can take on many forms. Here are the different methods used when making a checklist:

  • Multi-codes and Procedure Buttons in Practice Management Systems
    For your dental practice management system, you can set up multi-codes which include several treatments (e.g. root canal, crown, crown cementing). By placing the code into the procedure button, you can automatically arrange treatments for your patients.
  • Morning Huddle
    During the morning huddle with your staff, go over what happened the previous day and compare your goals with what you have accomplished. Review yesterday’s case presentations and see if you need to accomplish any record transfers, etc. You can then proceed to the patients for the current day, identify special issues, and check on any pending treatments.For larger offices, you may need more morning huddles. For example, you can have a huddle for reviewing financial issues with the front office staff, and procedural issues with the practitioners.
  • Whiteboards
    Even with the advent of new technology, the whiteboard is still a dependable tool. You can create a system by dividing the whiteboard into rows and columns according to Room, Task, and Staff Member Assigned. You can also freely employ extra symbols in this exercise (for example, a checkmark in a row indicates that a person is seated). When a procedure is done, you can erase the markings accordingly and begin again.
  • Hygiene Visit Slips
    Hygiene visit slips are small pieces of paper that can serve as guides for your team. The slips include the duration of the operation, the staff member assigned, the equipment used, and the recommended treatments.
  • Inventory Control
    In a world recovering from the coronavirus, having a complete inventory is a must. Audit your items once a month to prevent unnecessary shortage or surplus. If you can, use transparent tilt-out bins for storage. Not only does it make it convenient to take out the items, it also helps you know what you’re going to take out without having to open every single drawer.

 Get Your Systems Up and Running

Let the end of the COVID-19 lockdown be a fresh start for your business. Improve your efficiency and productivity by creating checklists for your procedures. As Rory Vaden, author of Take The Stairs – 7 Steps to Achieving True Success stated,  “difficult short-term choices lead to easy long term consequences.” Best of luck to you

Butts in The Chair: System-Based Ideas to Increase Productivity Post-COVID-19

The COVID-19 nightmare is almost over, and many of you are now raring to get back to your clinics. One of your objectives is to get operations up and running again and recover the losses that you have incurred. To be thoroughly productive, you need to implement systems within your dental team in handling your operations and affairs. These systems will also be instrumental in creating an error-free practice for you in the post-COVID-19 era.

Benco Dental’s Productivity System Ideas

Chuck Cohen, Managing Director of Benco Dental, developed a “Butts in the Chair” series of ideas to restore productivity after COVID-19. Dr. William Moorhead DMD of StreamDent has also recently contributed his own ideas to this series. Let’s examine them one-by-one, and learn how each of them can contribute to your practice’s productivity.

Promote Infection Control
Dr. Moorhead has recommended the following infection control measures:

    • Promote social distancing in the reception area
    • Have hand sanitizers on each desk
    • Have your entire dental team always use protective equipment and to change that equipment between each patient
    • Sterilize your handpieces with every use
    • Use disposable barriers for dental equipment such as suctions and syringes as well as other items like computers and clock timers.

Some error-proofing tips to combat infection include:

    1. Use either the Isolite or DryShield isolation systems for suction purposes.
    2. Utilize the timer to cut down on errors for procedures such as doing local anesthesia, mixing impression material, etc.

Checklists for patient checkouts, scheduling appointments, daily front office tasks, patient recalls, and inventory control

Modified Phone Skills
Create a system for phone calls. You have to implement a more empathetic type of communication with your patients. Post-COVID 19, you should do the following: be reassuring, be caring and have patience. These will go a long way in ensuring the patient feels comfortable and will continually visit your clinic.Dr. Moorhead suggests the following system for making phone calls for general dental practices:

    • How to answer
    • Look up appointment
    • Time codes
    • Financial
    • Scheduling scripts

Implement Teledentistry and Develop Related Systems
Ideally, a teledentistry wish list would include the following:

    • HIPAA Compliant
    • Digital patient registration
    • E-prescribe medications
    • Payment collection

You need a system that will allow you to delegate effectively. An example of such a system includes the following:

    1. Account Registration: The business assistant creates accounts in the portal and Practice Management System.
    2. Patient: fills out medical and payment information.
    3. Dental assistant: Reviews medical history of patient, and DA schedules Dr tele-visit
    4. Doctor: sets tele-visit when doctor is free, indicates that it is an appointment.
    5. Doctor: does a video call. Ideally it can be recorded and screen captured by the system.
    6. Doctor: does documentation in Teleportal
    7. Patient: is scheduled an in-office visit, and billed from insurance.

Digital Photos to Elicit Patient Interest
This includes a new patient profile with a checklist/system using either digital photos or an intraoral camera. The attrition system shows them the different angles of the teethFurthermore, you should train using flexible scripts to address patient concerns. There should be a script for each condition, such as a large filling or cavity, a script for replacing missing teeth, and a script for tooth wear. Highlight keywords on the script so that your staff can navigate issues more seamlessly.

Using Handoffs for Continuity
Create a script for every handoff or interaction between staffers in the clinic. Have a conversation outline ready between doctor and dental assistant, dental assistant and hygienist and so on. Within these handoff scripts, the facts of every patient’s case can be easily addressed.

New Patient Interview
Ideally done by the assistant, the purpose of this interview is to gather information such as the chief complaint, motivating factor, pain, past dental appointments, et cetera. This is done before the patient goes to the room. During handoffs, the doctor is furnished a copy of the information, giving a clearer picture to the doctor.

Delegate Complex Medical Histories
The dental assistant and hygienist should thoroughly vet and document medical history before inputting it into your system. This saves doctors’ time and helps avoid unnecessary incidents during dental operations.

Flexible Payment Arrangement
Devise a system that will incorporate the preferred payment method of each patient.

Techniques to Prevent or Manage Cancellations
To help reduce cancellations, a system of dummy codes can be used for your practice management system. Your programming is key. For example, when adding the codes, have the failed appointments appear in caps.

Assisted Hygiene
This system is crucial due to the public fear related to COVID-19. Make sure that your clinic’s hygienists and dental assistants are properly matched through your practice management system to each applicable appointment, with enough cushion time in between appointments.

Same-Day Dentistry
If the hygienist sees a potential problem, they should then notify the doctor to do an early exam. Prepare scripts so that the doctor knows what to say. Give the same day treatment script and then provide anesthesia if necessary.

Charitable Dentistry Practice Promotion
You may want to promote a free or discounted dental day to promote the grand reopening of your clinic. To do so, create registration forms, donation requests, and treatment day logistics.

Conclusion
Developing a system is hard work at first. However, in the post-COVID 19 practice, you have to be more efficient, and serve more clients to recover your losses. With a checklist driven system, the roles of each clinical staffer become more defined, issues are addressed faster, and the margin for error is minimized.


Q&As

Q: How are you handling your PPE when you’re jumping from room to room?

Dr Moorehead: Well, it’s going to be more difficult because the latest guidelines that I’m seeing are that it’s going to be smart for us to stay in the room and not be going from place to place. And when we leave that, we’re going to need to remove all of our PPE. I can tell you that in the past I have taken my mask off and left it in the room. I have discarded the gloves. I haven’t had to worry about the coats and the hair nets and that kind of stuff. But if I’m going to use expanded duties, I’m going to get everything done that I have to get done. I’m not going to leave the room for a hygiene check. I’m going to see the advantage of the pink slip is I’m going to be able to do those hygiene checks in between patients when I’m ready to leave anyway. So if I’m able to continue using expanded duties, which I hope I’m going to be able to do, I’m going to be going through more PPE. And that means Benco is going to be happier. But I’ve got to weigh the cost of the PPE versus the productivity that the expanded duty can accomplish because it’s got to start all over from fresh every time you go in and out. 

 

Q: Should the doctor be in the morning huddle?

Dr Moorehead: Absolutely. It’s important for the doctor to know what’s going on. You see, the advantage of the morning huddle is the dental assistant and the hygienist and the business assistant are able to brief the doctor so that the doctor can quickly get on board on everything that needs to go on. And then if there’s any particular questions that gives the doctor an excellent chance to be able to ask them at that time.

 

Q: On some of these checklists, is this what you’re doing to prepare to reopen your practice after COVID 19? Is that what you’re doing? Yeah. Again, I know everyone has to check their own states. Every state is different. But it’s this kind of what you’re doing to make sure that you’re up to protocol in your state?

Dr Moorehead: We will modify the room setups to be able to include those. I’ve got popups or room setup and I’ve got pop-ups for clean up afterward. And those are going to have to change for sure.

 

Q: So if we don’t have these protocols and written policies, how do we start implementing that with the staff? And how difficult is it?

Dr. Moorehead: Well, one of the reasons I think this is a timely topic is when we go back to work. I wish I had the crystal ball and I forgot to ask, I want to ask Chuck to get those in to be able to sell them a Benco, working crystal balls. Because we don’t know if our chairs are going to be sold because of backlog of not being in the office for a month or two or if they’re gonna be empty because patients are going to be scared to come in the office and they need to earn a paycheck because they haven’t been able to work for a month or two. With that said, if you wind up with the latter scenario where your team is there, they’re being rewarded with the people, the salary that you can pay them with the PPP loan. Then why not make the time, go through the list, making some notes, go through the rest of this presentation on the things that you feel like can have the most impact on the checklists. And some time that you got available where there’s no patients in the chair, have team meetings and decide where your priorities need to be to start implementing.

 

Q: Post-COVID, are you thinking about collecting in advance?

Dr Moorehead:I have systems for both check in and check out. We are going to have to be able to schedule the next visit. So we’ve got to talk that one out there. The advantage of check in before is the patient can leave immediately. If you also have systems in place, and that’s one of the beauties of checklists, you can cross train easily. So if you have your system for checking out and you have it available to the dental assistant in the clinical area, they could check out the patient or make the patient’s next appointment because they’ve already had the financial stuff done and people let them head straight out the door. And that is ideal from what they’re teaching us so far.

 

Q: So would a hygienist be able to use Isolite or Dry Shield on her own or will she need to have an assistant to use it properly? [7.1s]

Dr Moorehead: The reason I have more than one isolate like to start with is my hygiene is kept taking it. Now what they’re saying of the latest guidelines, so they’re recommending the isolate be used and in HVE. So if a high Jenice can be able to use an HVE and a cavitron at the same time, I think that’s doable. But they’ve got to hold the HVE properly. I mean, this is the proper way to do it. And if they’re handling it improperly because you’re trying to do it all themselves, then it’s not going to protect them. The hygienist or the patient, you’re going to play around with it and say you can you can watch and see where those aerosols are going to some extent to get an idea. We’re gonna have some guidelines coming out, too.

 

Q: Does your SLR camera automatically upload into the disks?

Dr. Moorehead: They do not upload to the practice management system. You have to do that in a manual operation. And that’s why there are Wi-Fi camera cards that you can get that will transfer it. But we didn’t find that much advantage in them versus putting the camera card in the computer. It’s going to take a couple of minutes for the business assistant to put those in the software and be able to crop them. That’s why we do that before we do the health history.

 

Q: In teledentistry, what system do you use? There’s two questions to this one. What system do you use and will you still use that when you reopen?

Dr Moorehead: I won’t mention the one that I signed up for and canceled. I will say that they left one that I canceled would allow free setup and the one I signed up for cost a $3m set up and then 150 a month. But it’s patient pop and patient pops. Primary product is not teledentistry. They do marketing that I don’t do with them yet, but they have the ones that I checked out. It looks the slickest. And it has those features that I talked about, or almost all of them.

 

Q: So would you still use it after the coronavirus is over? And if so, how would you use it?

Dr Moorehead: I think that there is a place for it because you can productively be able to screen a patient, find out what their problem is. Instead of having to delay that emergency patient a few days to be able to get the man, you can be able to go ahead and do it that day when they call, which looks good for your practice, go ahead and get them on an antibiotic if it’s needed and then be more likely when they come in to be able to get a definitive treatment done.

 

Q: How does a hygiene not create aerosols, Polish or Cavitron?

Dr Moorehead: Again, I’m not a hygiene expert. I do know that it’s going to take some extra effort with cavitron in anything that I’ve read. It is the biggest risk going in is the cavitron. I don’t know how we’re going to be able to get off calculus like I saw an emergency patient on Monday and had I had him on an antibiotic before because they were swollen from the perio condition. But I don’t know how we’re gonna do that yet, so we’re gonna have to wait for some guidelines. I’m sorry. I don’t have that crystal ball.

 

Q: Does dry shield take only a high speed suction?

Dr Moorehead: It has to have a HVE. Yes. High speed.

 

Q: Can you prescribe any medication to a new patient through teledentistry?

Dr Moorehead: You can. Except for a controlled substance and then you can do the controlled substance. If you have a recorded video call. I don’t know if that is going to change when the closures stop. I don’t know how I know right now. You can.

 

Q: Will there be new gowns for every hygiene check?

Dr Moorehead: I think it’s going to be likely. Yes. I don’t know how it’s gonna pan out, but it’s gonna be expensive. Yeah, and then we. What I need to find out from the guidelines yet is if it’s a new gown for every patient or for every patient with an aerosol procedure, there’s a big difference there.

 

Q: Will we be able to pass on the increased PPE cost and participated to our patients per visit? Will that dental insurance create a code for this?

Dr Moorehead: Well, I can go back because I’ve been practicing dentist for thirty nine years. I can go back to what happened with HIV because that’s when we had the first huge bump up. That’s also why dentistry is more ready than most other health care professions to start with, because we were where higher risk. We had the most stringent guidelines from OSHA back 30 years ago when HIV happened.

And there was a time when we did and it wasn’t billable insurance at the time, but we did set fees per appointment for the infection control and that may happen temporarily again. The hard part now that wasn’t happening 30 years ago, PPOs were not around that set our fees for us and we didn’t have the flexibility. Now, they set the fees so we may have to do an add on fee that is not billable to insurance either. And then what if we get into a having to do an expensive test? It’s several hundred dollars just to document whether the patient has the virus before we can put him in the chair.

 

Q: What’s the software that you use on your checklist? Will it work with like Open Dental and other software?

Dr Moorehead: My checklists are not specific to practice management systems, so there are checklists for training a team on how to do so. They don’t need to integrate since they’re customizable. You can add things specific to your practice management system. I have one set of forms because I use a particular 42 percent of the market that it covers more for those things. But it’s not meant to be a software training tool. It’s meant to be a training tool to be able to train new employees, to be able to cross train and to be able to error proof. And I’ve got to brag on something. I can be able now with all the systems typically industry standard, to be able to bring someone into dentistry that doesn’t know dentistry. Yeah. Not only is it great. It’s usually a three to six month learning curve and that’s to account to that level to accomplish competency, which I define as being able to work on their own and know where to look it up. I can accomplish with the checklist competency in 30 days front or back office, and I’ve done it over and over again.

 

Q: To be able to do reusable gowns, are you going to use disposable gowns? Have you decided on that, whether you’re gonna use washable or disposable?

Dr Moorehead: It will depend on what the guidelines are. The decision may be made for us. So it’s too early to tell that yet.