Written by Cynthia Hughes, RDH, BS, MEd, Wednesday, 31 May 2006 19:00
The success of your or any other general dental practice depends on a myriad of factors, not the least of which is whether patients return to your office on a regular basis. Two goals of a continuing care/recall system are to efficiently maintain the patientís oral health and to ensure that a maximum number of patients receive periodic oral care. Returning patients will eventually require evaluative, restorative, or cosmetic care, creating production for both the hygiene and dental departments.
The health, appearance, and comfort of your patients are paramount. But do not underestimate the value of the investment necessary for them to arrive at peak health. A successful recare system, which maintains necessary information for both patient and staff, transcends any additions or changes in staff as you grow. Patients have many excuses for not showing up for recare appointments. We will discuss these further to provide insight into overcoming objections to advanced scheduling or booking of appointments.
An effective and productive continuing care/recall system ensures that a maximum number of patients receive periodic oral healthcare. Not only is this an ethical means of building and maintaining a practice, it ensures a steady flow of patients within your practice to stabilize your income. A side benefit of this system is that satisfied patients will want to maintain their investment. You will begin to benefit from their trust in your treatment, and each returning visit will build the strong relationship necessary for long-term growth. When patients are confident and trust your judgment, they will refer others for similar care.
In addition, regular visits prevent emergency treatment, eliminate the "pain" of going to the dentist, and work to continue the education of the patient. With the revelation of the links between periodontal disease and systemic conditions such as stroke, diabetes, low-birthweight babies, and preterm deliveries, opportunities for patient education increase at each appointment. When fully educated, the responsibility for maintaining health falls directly on the patient.
Photo Illustration by Nathan Zak
TYPES OF CONTINUING CARE SYSTEMS
In my experience, there are almost as many systems for continuing care/recall as there are offices. Because recare systems take the shape of the individual practice, patients can become confused when they transfer from one office to another due to relocation or changes in insurance coverage that dictate where they receive their care. Generally, recare systems fall into three basic categories: waiting for the patient to call; chasing the patient; and a pre-appointment system.
"Waiting for the Patient to Call" has some advantages over the other two systems. Appointments are often available for patients when they need them; the responsibility of making the appointment rests solely with the patient. However, the disadvantages outweigh any advantages. Prime appointment times may not be available upon patient request. Most commonly desired times, such as early morning and late afternoon, are filled by the first person who calls. Patients who do not call regularly-and therefore don't receive their first-choice appointment time may decide that your office is too "booked up" to see them and move on to another practice. Otherwise, scheduling when patients call pushes their appointments further into the future, and critical treatment or preventive care appointments are not completed on a timely schedule. When appointments are moved into the future, one runs the risk of losing the patient to a more convenient office. Or, the patient perceives that his or her care isn't as critical as you said and may begin to doubt your motives. As you can see, "Waiting for the Patient to Call" is rife with serious disadvantages.
"Chasing the Patient" is a second system that many offices fall into due to busyness of the office and an overall lack of attention to the objectives of building a sustainable practice. The chase usually begins with a card mailed to remind the patient that he or she is due for a "routine" preventive or "maintenance" visit. Many times the patient sees no compelling reason to return to your office. If the patient is comfortable for the moment, he or she may place the card onto the refrigerator with other reminders, some of which may be of greater importance to the patient.
At the office level, when there is no response to the reminder card, a phone call is made, and the chase continues. Calling the patient at his or her place of employment may be effective if the patient is reachable, but your message may simply be another one on an already busy voice-mail system. The patient may forget to call you, disregard your call, or simply place your request in a mental holding bin to be dealt with at a later date. When the first call is not returned, a second call is made, perhaps to the patientís home, as a further attempt to capture and schedule. Once again, a message is left with a slightly more urgent tone, requesting a call back. As you can see, this method is only as effective as your patients are responsive. Their preventive cycle is disrupted, and maintenance is no longer preventive. Emergencies may occur, patients blame you for not getting them in on time, and rapport is dissolved.
For patients who find it impossible to schedule appointments in advance, this system may be effective. It is the same as a "short call" list and can be an efficient way to fill your schedule. However, it is not reliable and places great stress on your front desk personnel to keep your office productive. It is also difficult to give patients the time necessary to complete thorough appointments, as they may be scheduled into a time not totally convenient for you. Compromising on patient care due to lack of time is not a way to build a successful practice. In that situation, everyone loses.
Another disadvantage of this system is the need for a staff member to actually place the phone calls. This chore is time-consuming, yields minimal results, and often is delegated to the employee with the least experience. Repetitive calling often interrupts and irritates the patient and may give your office the appearance of being desperate for patients.
A BETTER WAY
Scheduling in advance or "pre-appointing" is a better system for a variety of reasons. Quite frankly, it is a far more efficient use of staff time. It avoids the wasted first reminder card, avoids the first voicemail, and raises the importance of routine or maintenance care in the patientís eyes. Education regarding continuing care and the need to evaluate restorative or cosmetic treatment can occur instantly. Questions can be answered immediately, and care of each individual patient receives the priority it deserves. Incorporating this system within a practice may yield a few bumps at the onset, but staff members quickly learn ways to build pre-scheduling into the appointment time.
Ever wonder what staff members are doing while waiting for you to examine the patient? This is an opportune time for the patient's next appointment to be scheduled. While patients are focused on their oral healthcare needs-and are enjoying the competent treatment of the hygienist they are more likely to be open to planning for continued care. Future recare appointments can be made chairside while patients are waiting for their dental exam.
A big advantage of this system is reduced checkout time and fewer bottlenecks at the front desk, where financial arrangements now become the priority. Patients previously heard, "Do you want to schedule your next appointment?" Now they hear, "We will be seeing you on (date and time)." It serves as a recommitment for them to your practice and a reminder that they are important.
Other advantages to this system include the ability to schedule each patient for the time necessary to complete his or her specific treatment. Only the hygienist knows how cooperative each patient can be, how much conversation the patient needs to become comfortable, and how responsive the patient is to each treatment sequence. Home care evaluations can be made and educational information given to each patient as an individual. Many patients may take less time than the usual appointment allotment, and some may take more. Longer appointments for periodontal therapy can be scheduled at the best time for both the provider and the patient. Confirmations are easier, as the patient has already agreed to the time and date; there are fewer "disappointments" in a schedule the patient has planned in advance. When changes need to be made, they can be cooperative. Changes are made to the appointment date and time, not to the procedure scheduled ("cleaning versus perio therapy"), as there is already agreement on how much time to allocate. Patients are also more aware of what to expect at this appointment, as it was made with their input.
KEY COMPONENTS OF A SUCCESSFUL PRE-APPOINTING SYSTEM
There are 3 major components to success with pre-appointing systems. One is the need for flexible time built into the schedule to allow for additional procedures that may arise. These may include placement of sealants on children and young adults at the time of a preventive appointment, thereby eliminating the need for a return visit; the option for new patients to proceed directly into the hygiene schedule when they have arrived for a comprehensive examination; and the need for scheduled time off in the event of weather-related days (snow days, hurricanes, etc), dental meetings, continuing education courses, vacation days, or office closures for maintenance of computers, equipment, or office refurbishing. When schedules are blocked in advance with flex-time, stress is reduced, staff members are more focused on their patients, and the day flows more smoothly.
A second component of the pre-appointing system is the postcards mailed to patients; they can now contain a more positively worded confirmation message such as "looking forward to seeing you." Third, phone calls made 2 to 3 days in advance are likewise more positive and upbeat. Broken appointments or "disappointments" in the schedule are reduced by the accent on commitment.
Cancelled appointments leave time in the schedule for other patients who might need to reschedule. Staff members can predict how to structure their day for maximum effectiveness, equipment needs, and assistance of other team members. The morning huddle is focused more on patient care and less on "who will show up today."
Organizing your schedule and pre-appointing patients into a "ready-made block" of time can assist you and your staff in other ways. When the focus is on the schedule, time management becomes easier and the flow within the office becomes more efficient, all with reduced stress. Suddenly, there is time for lunch, and the day ends as it should...on time!
Preappointing and blocking in advance can be accomplished in the schedule several ways once the commitment is made. Start as far into the future as necessary to find a clear schedule without any appointments. Develop a template of procedures and the necessary time for each to schedule in a day/week, and start reserving that time for only that appointment type. Another way to get started more quickly is to hold any immediate cancellations open for specific procedures. While the tendency for staff members has been to "fill any opening with any patient," they will need to be trained to hold the time and not give it up until 24 hours prior to the actual day. Only then can a different procedure be placed into the system. This allows the correct time units for each patient, similar to what you want for your longer and more productive procedures such as crowns, bridges, veneers, and implants. Shorter procedures, such as routine prophy appointments for healthy adults and most children, can be added around the longer ones. This system compares to filling a bottle with stones and sand. If you add the sand first, then there is no room for the stones. However, if the stones are placed into the bottle first, the sand fills in around them and you have room for both.
Protocol needs to be in place for the patient who arrives late; double booking is never a good idea. This places stress on the staff members, who are constantly monitoring their day in the hopes that not all patients show up. Productive procedures are not completed on the patient in the chair because another patient is waiting. Full attention is not given to either patient, and an opportunity for building trust is possibly lost. When rushing with a too-full schedule, there can be times when rooms are not properly or completely broken down or reset. Time is lost searching for instruments or equipment, and proper OSHA procedures may be compromised. Effective and efficient time management should not be considered in retrospect. It should be part of your everyday office routine, which begins with the morning huddle.
MORNING HUDDLE: AN EVALUATION OF TIME MANAGEMENT
A proper morning huddle involves the entire staff. Each person, from the collections department to the sterile tech, needs to be present and aware of expectations from both the practice and patient perspectives. The huddle is necessary, as it helps to focus each staff member on his or her work for the day. Itís the practice equivalent of the athletic pre-game huddle, and itís the best way for your team members to get their game faces on! The morning huddle can address a variety of areas:
•emergency times set for patients with trauma, bleeding, or swelling
• a review of patients needing financial arrangements, patients needing additional treatment, and new-patient information
•routing of patients within the office.
- "I don't remember making that appointment six months ago. No, I did not get a reminder."
- "I already know how to brush my teeth."
- "I only have a few teeth."
- "If I go, the hygienist will just yell at me."
- "My insurance only covers a cleaning every six months."
- "That scraping really hurts, not to mention that probe thing!"
- "I have been coming here for years, and now you tell me I have that bone-loss thing. I think you are just trying to make money off me."
- "The hygienist is done with me in 10 minutes, and I have to wait forever for the doctor."
- "Something came up."
- "It's only a cleaning!"
Some of these reasons speak to a lack of trust and rapport between your office and your patients. Some speak to a lack of understanding of the relationship between health issues and what your hygienist is trying to accomplish, and some speak to a lack of focus on your patients' individual needs. Building a productive and responsive practice depends on efficient systems within your practice. Having the hygienist pre-scheduling future appointments, with the patient in the dental chair and the center of attention, will ward off missed appointments. Stop "booking" your patients and start scheduling. You will see what I mean.
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