November 11, 2022
by Gabriele Maycher, CEO, GEM Dental Experts Inc. BSc, PID, dip DH, RDH
THE CHALLENGE: Bringing together a group of team members representing different educational backgrounds, clinical experiences, patient care philosophies, and work ethics to provide a consistent standard of care.
THE SOLUTION: Team alignment! If your practice suffers from conflicting diagnoses, misguided treatment planning, or inconsistent client service, chances are you need alignment. The good news is that it isn’t as hard as you may think, and it can lead to better morale, improved systems and practices, and outstanding client care. In fact GEM Dental’s most successful practices – as identified by level of satisfaction and revenue – have structured systems in place to promote team alignment, starting with front-to-back-office meetings.
Monthly team meetings
Everyone needs to align to the practice’s vision of client care. If the vision hasn’t been defined, the doctor needs to take accountability in creating and communicating one to the practice team. This includes everyone from front-end team members to the clinical assistance and hygienists, dentists and even the sterilization personnel. To achieve practice success, the entire team needs time to develop systems and processes that make sense for everyone, and these meetings can help solidify those protocols.
Productive monthly meetings typically last a couple of hours, and I recommend giving team members a document to complete that asks three questions:
- STOP: What systems are not working?
- START: What new protocols should we consider adopting?
- CONTINUE: What systems should we continue to use because they are working well?
This becomes the agenda for the meeting. And everyone gets their say. Although meetings involve lost production time, there will be a proven return on investment, including fewer human resource (HR) issues and less staff turnover. This is the first step in creating alignment.
Monthly hygiene meetings
The purpose of these meetings is to bridge the gap regarding the different educational backgrounds, clinical experience, client care philosophies, and work ethics among hygiene team members. They also create accountability with regard to practice standards, code of ethics, the established office systems and protocols, and to the literature.
These meetings should be two hours and consist of an educational component, a systems and protocol discussion developed around the process of care (ADPIE), and a patient chart audit or case study.
1. Educational Component.
There is a big divide in most practices between recent grads and experienced hygienists based on the periodontal classification they learned. If some hygienists learned the 1999 American Academy of Periodontology (AAP) periodontal classification and the more recent graduates learned the 2018 AAP periodontal classification, perhaps this is where the education should start. Assign one article for review per meeting (AAP published 23 original articles that can be found on their website www.perio.org) and have a discussion on what you learned and how it can be integrated into client care. But don’t stop there! There are many other clinical topics that could and should be discussed. I would initially pick topics on the process of care. Also consider taking educational workshops as a team through your local colleges and universities, supply companies, conferences, and independent consultants like GEM Dental Experts.
Discuss what you learned during your monthly hygiene meeting and decide together what you will integrate into client care. Try to remove all personal opinions and subjectivity and leave it up to the literature and expertise of the American Academy of Periodontology and the European Federation of Periodontology to guide you clinically. Before long the team will be aligned to the most current evidence-based literature. This is the second step in creating alignment.
2. Systems and Protocols.
Identify the breakdowns in client care and then establish systems and protocols based on the literature to fix them. Touch on all aspects of your practice standards, ADPIE, consent, and documentation. Consider the following questions:
• Assessments—How long should a new client be booked for a comprehensive oral exam, and what assessments are required by your college? Do you need a hygiene assistant or software to assist you? What type and number of radiographs are recommended for gingivitis vs. periodontitis clients? Is rationale given for the type and number of radiographs exposed? How frequently are you probing and measuring recession? Are you calculating percentage of bleeding on probing (BOP) or making a general statement? What oral self-care products are you promoting (ideally, you’re promoting best-in-class, products if any)?
• Diagnosis—What periodontal classification are you using? How are you documenting a periodontal diagnosis statement? Are you identifying the predisposing and acquired and developmental factors causing a reduced periodontium due to non-periodontitis causes (i.e., open contacts, Orth forces, iatrogenic restorative, vertical defects due to extractions, etc.)? Are you documenting them as localized or generalize “as evidenced by” and “due to”?
• Treatment Planning—How many appointments are you recommending to achieve endpoint for healthy, gingivitis, and periodontitis patients (Stage I, II, III, IV)? Are more appointments planned if there is radiographic evidence of deep old calculus? At what level of periodontal disease are the new grads referring treatment to a more experienced hygienist? Are you presenting both a recommended and accepted treatment plan to the client, and what do both entail?
• Implementation—Should your team be using power instrumentation vs. hand instrumentation or both? Do you polish or not? When do you use local anesthetic vs. no anesthetic? What type of fluoride do you administer?
• Evaluation appointments—What is the clients’ re-evaluation interval for gingivitis, peri-implant mucositis, periodontitis: 2, 3, or 6 weeks? What about a client who presents with poor wound healing? What is the protocol during the appointment? Are you retreating or referring to a periodontist? What is the referral rationale? What is the recare maintenance rational for a 2-3-, 4, 6-, or 9-month?
• Consent—Are you getting written client consent? What’s the difference between implied and informed consent? Are you giving clients enough information to make an informed refusal?
• Documentation—Do you have appointment templates for every appointment type (i.e., NP Exam, recall, HYG Only, nonsurgical periodontal therapy appointment [NSPT], post-care)? Does your documentation conform to college requirements? Do you have billing templates so treatment isn’t missed or forgotten?
Again, your systems and protocols should be based on the most current evidence-based literature and not on anyone’s opinion. This is the third step in creating alignment.
3. Patient Chart Audit or Case Study Sessions
Chart audits are one of the most valuable educational and alignment tools. This exercise allows you to evaluate if the most current evidence-based literature has been integrated, if your established team and hygiene systems and protocols are in alignment, and if you agree with treatment. The way the session works is that each team member forwards a name of a client to be audited. Only one client chart will be chosen, based on its educational value. It can be a case where the hygienist is still confused about their diagnosis, unsure of why the parameters of health weren’t reached, or are proud of the outcome.
The team will review the following client information together:
1) Medical dental health history
a. Did the client require a medical consultation due to INR, blood pressure or HbA1c issues?
b. Did the client require any treatment modification due to recent surgery, stroke, or heart attack?
c. Have you elaborated on all the positive responses so if another team member reviews the medical dental history they are just as informed as you?
d. Are the reported predisposing or acquired and development factors considered in the diagnosis, treatment, evaluation, and prognosis?
e. Are the reported modifying factors (smoking, diabetes) considered in the diagnosis, treatment, evaluation, and prognosis.
f. Did you consider the client’s age in your diagnosis?
2) Radiographic interpretation
a. Do you agree on the radiographic interpretation?
b. Have you documented the radiographic interpretation in terms of distribution, extent, and pattern (i.e., generalized moderate horizontal bone loss)?
3) Hard-tissue assessments
a. Are the hard-tissue findings factored into the diagnosis (reduced periodontium due to non-periodontitis causes)?
b. Are you making the correlation between the periodontal and hard tissue findings?
4) Periodontal assessment
a. Are the assessments factored into the diagnosis (reduced periodontium due to non-periodontitis causes or reduced periodontium due to periodontitis)? Health, gingivitis, or periodontitis?
b. Do you agree on the periodontal diagnosis?
c. How do the assessments translate into treatment? Do you agree on the treatment plan?
d. Do you agree on the prognosis? Has the control of biofilms, predisposing and modifying factors been considered, and do you agree?
5) Client notes
a. Are the notes completed as per your college requirements?
b. Is there enough detail on client discussions so that any clinician could continue treatment?
c. Is there enough rationale given for diagnosis, recare interval, and referral?
d. Did you include a personal note about the client to build rapport and trust?
This is when you will determine if you agree with all aspects of treatment. Again, discussion and recommendations should be based on the most current evidence-based literature, and the systems and protocols you have established as a practice and team. This is the fourth and most important step in alignment.
Never doubt the return on investment for everyone involved when you spend resources on team alignment. In my experience, to truly build a TEAM where each member respects and trusts each other, alignment is crucial.