Suggestions on Staff Correction

It would be nice if employees never made any mistakes and always did a perfect job. But, we are all human, and mistakes and on-the-job errors are part and parcel of running a practice. That raises the question, what do you do when your staff err and how do you correct them? Here are some suggestions on staff correction.

As part of this overall process you must have written job descriptions and office policies that clearly delineate what tasks a person is responsible for on their job and the overall working guidelines for the office. The reason these are so important is that you use them as part of your correction procedure. Unfortunately, very few practice owners have proper job descriptions and office policies in place.

For starters, if you are in need of correcting a staff member, make sure you know of any specific disciplinary policies that you have issued so that your actions are consistent with these. For example, if your policy states that theft is an automatic discharge, you would not work up the disciplinary gradients and only reprimand someone caught stealing.

The first level of addressing correction is normally directing the staff member’s attention to whatever policy he/she violated, what was not done or what should have been done, all of which is delineated in their job description or in your written policies. Have the staff member reread the policy and/or job description. Ensure that they understand it and clear up any confusions or misunderstandings. This is usually enough to handle the first offense.

On the second offense the office manager or practice owner should review the situation with the staff member and have them sign a copy of the policy or procedure that covers what was violated as an attestation that he/she understands and agrees to the policy and/or job description. We then recommend for you to put a copy of the signed document in the personnel folder of the staff member and give a copy to the staff member to put in their staff binder. One can consider that this constitutes a warning.

On the third offense, we recommend that you do the following: give the employee a written warning, a copy of which goes in their personnel file. Sit down and discuss this situation with them; go over the fact that they’ve been corrected on this twice before; and tell them that, per office policy, continual violations could result in a suspension or dismissal.

Practice owners normally find that this type of action on a third offense either puts a stop to the problem or points out clearly that they have a real problem staff member on their hands and that proper actions, including excellent documentation, will need to be taken in order to suspend or dismiss the staff member for future violations.

What do you do with a staff member that you have corrected three times and who messes up again? You’ve already given them a written warning, discussed that continued violations could result in suspension or dismissal, but you still find them doing it again.

At this point you should check their production record (although you should have done that already as part of correcting earlier violations). Hopefully you have a simple statistical method to keep track of key production metrics for each staff member and the office as a whole so that you can monitor their productivity. If the person is an excellent producer (which is unlikely given that they keep messing up), you might consider the next step to be a suspension without pay for a certain number of days. If the person has a poor production record, dismissal may be in order.

Again, the importance of having proper office policies and job descriptions in place in order to properly deal with staff cannot be overemphasized. You can easily put yourself in a legal quagmire if you attempt to discipline staff without these in place.

We also strongly recommend that you check with a good employment attorney when you are looking at dismissing any problem employee to insure that all of your legal bases are covered.

Real Office Policy Examples and Checklist

Below is a list of items that should be included in any basic office policy or policies:

  • Patient Relations
  • Sexual Harassment
  • Orientation and Training
  • Work Hours
  • Fringe Benefits
  • Solicitation
  • Equal Opportunity Statement
  • Terms of At-Will Employment
  • Definitions of Full Time and Part Time
  • Pay Periods
  • Vacations
  • Sick Leave
  • Maternity Leave
  • Tardiness
  • Personal Time Off
  • Absenteeism
  • Staff Meetings
  • Breaks and Lunchtime
  • Unemployment Insurance
  • Problem Resolution
  • Wage and Salary Guidelines
  • Retirement Plans (if any)
  • Holidays
  • Funeral Leave
  • Leave of Absence
  • Jury Duty
  • Disciplinary Measures
  • Continuing Education
  • Workers’ Compensation Insurance
  • Health and Safety Rules
  • Appearance
  • Office Security
  • Telephone Use
  • Where to Park
  • Voting
  • Job Performance Reviews
  • Uniforms
  • Dating of Patients
  • Confidentiality of Records and Information
  • Cleanliness and Maintenance
  • Reimbursement of Expenses
  • Outside Employment


Policy is very important to establish so that the entire group understands the rules and agreements upon which the office operates. When you have good policies known and understood by all staff, you get an effective and efficient team that coordinates and cooperates at a high level.

Below are some sample policies about the subjects suggested previously. Always consult with a good employment attorney before implementing your policies to make sure that they conform with the laws of your area.

Example General Policy Introduction

Welcome to our practice. The following policies are designed to provide working guidelines for all of us. Written office policies help to:

prevent misunderstanding and lack of communication;
eliminate hasty, unrefined decisions in personnel matters;
ensure uniformity and fairness throughout the practice; and
establish the basic agreements that everyone in the office operates on.

Our practice is open to change. Changes happen as a result of internal growth, legal requirements, competitive forces or general economic conditions that affect our profession. To meet these challenges the practice reserves the right, with or without notice, to change, amend or delete any of the policies, terms, conditions and language presented in this manual. Changes in personnel policies are made after considering the mutual advantages and responsibilities of both the owner and staff. All of us need to stay aware of current policy and, as revisions are made, new pages will be given to the personnel to place in staff manuals.

Remember, your suggestions are welcome. Just notify the office manager whenever problems are encountered and wherever you think improvements can be made.

Example Harassment Policy

This practice is committed to providing a work environment free of discrimination. This policy prohibits harassment in any form, including verbal, physical, religious and sexual harassment. Any employee who believes he or she has been harassed by a co-worker, manager or agent of the practice is to immediately report any such incident to the office manager or next highest authority. We will investigate and take appropriate action.

[As harassment is a big legal issue in today’s world, we also suggest to all practice owners that a more extensive policy be written that further defines the types of harassment and the exact steps to follow should it occur. We also suggest that you check with your attorney on proper policy in this area.]

Below is a sample policy on employee classification. These classifications are important for any employer to know because they affect the type of working hours, pay, benefits and bonuses that various employees are eligible for. Some of these classifications and their accompanying benefits or restrictions can vary from state to state. Therefore, it is important that you consult with an attorney who is familiar with the employment laws in your state before implementing this type of information.

Example Employee Classification Policy

  • New Employees: this category would include those employed for less than a specified number of days, during which they are on probation.
  • Regular Full-Time Employees: this could include staff who work a minimum of 32 hours a week.
  • Regular Part-Time Employees: this would include staff who work less than the minimum required.
  • Temporary Full-Time Employees: this would cover staff who work full time but are hired for a limited specific duration.
  • Temporary Part-Time Employees: this would include staff who are hired for a limited duration and work part-time.
  • Exempt Employees: this covers staff who qualify under the Fair labor Standards Act as being exempt from overtime because they qualify as executive or professional employees. Make sure you know the exact rules and regulations on this before you exempt anyone from overtime.
  • Non-Exempt Employees: such employees are required to be paid at least minimum wage and overtime.

Example Overtime Pay Policy

Overtime pay is paid according to the Federal Fair Labor Standards Act and our state’s wage, hours and labor laws.

Exempt Employees: employees exempt from the minimum wage, overtime and time card overtime provision of the Fair Labor Standards Act do not receive overtime pay.

Non-Exempt Employees: employees not exempt from minimum wage, overtime and time card provisions of the Fair Labor Standards Act do receive overtime pay.

Overtime hours must be authorized by the office manager or owner in advance of extra hours worked or as soon as possible thereafter. Time not worked but paid for, such as vacation, holidays and sick leave will not rate or count for overtime calculation purposes.

Example Time Tracking Policy

Each staff member is individually responsible for recording work time on the attendance sheet and/or time card when reporting for work, leaving for lunch, returning from lunch and leaving at the end of the day.

The attendance sheet and/or time card is a legal document and must not be destroyed, defaced or removed from the premises. Never allow another employee to enter your time for you and vice versa.

Overtime must be authorized in advance of extra time worked or as soon as possible thereafter. Overtime, changes or omissions on the attendance card must be authorized by the office manager and initialed.

When you leave the premises, let us know. If you have to go out of the office or the building on personal business during your scheduled work hours, first, get permission from your supervisor. Then, check in and out on your attendance sheet or time card.

Whether you use the above examples or not, having written office policy is vital to the smooth operation of any practice. It is the foundation of education, training and correction in your office and can make the difference between a well oiled machine and a machine that is constantly having problems and is in need of repairs.


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Forming Office Policy

Forming Office Policy

All doctors are extremely well trained in their profession. Unfortunately, very few doctors are trained in business or employee handbook policy creation and their appropriate implementation.

Every healthcare practice is a business that provides a beneficial service to its patients and clients. The less the practice owner knows about business management, the less service he or she will be able to deliver. The more he or she knows about practice management, the more successful their practice will be.

Forming office policy is one of the most basic and important practice management tools that any owner can implement to make a more successful practice.

Why is policy so important? Why do we consider it a fundamental practice management tool? The answer is simple but important.

Policy is important because it sets up the group agreements, the rules of the game, the procedures to follow. It is usually based on what has worked and what legal guidelines are important to know and follow. Without good office policy, you get a chaotic environment because people end up making up their own policies. This results in inefficiencies and lack of teamwork.

Policy that is understood, agreed upon and adhered to will strengthen the office and provide the best means to achieve practice goals. Even those policies that are unspoken and assumed to be known should be put in writing. By putting all policies in writing, problems and confusions that could otherwise surface will be curtailed and even eliminated. Additionally, in this litigious world, having written office policies that are attested to as read and understood provides a layer of protection from potential disgruntled employees who have violated the policies.

Policy is vital to achieving teamwork, cooperation and efficient coordination in any group activity. If everyone knows the rules of the game, the game is much more easily played. These rules and procedures are outlined in office policies.

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Internal and External Marketing

There are two areas in a practice that are targeted when marketing your practice. The first is internal; the second is external.

“Internal” deals with dissemination and promotion within your practice and to already-established patients. It includes things such as:

  • In-office patient referrals
  • Reactivation of old patients through letters and calls
  • Newsletters
  • Mailings to existing patients
  • Events, such as open houses and patient appreciation events
  • “Thank you” notes for referring patients
  • Welcome-to-the-practice letters

“External” deals with locating and reaching markets outside of your practice. It includes things such as:

  • Prospecting outside of the office for new patients
  • Advertising by using direct mail, yellow pages, etc.
  • Forming referral networks with other professionals
  • Having events and/or lectures for groups within the community

When starting out on a new marketing plan it is usually smartest, easiest and most cost effective to begin with internal marketing, as you have ready access to information about your current patients. Current patients are also more valuable because they are familiar with you and your practice.

Once you have an effective internal marketing program going, you can then look at what external marketing actions you want to do to potentially increase your stream of new patients.

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Claims Against Dental Amalgam Lack Scientific Evidence

PANEL REPORT FINDS HEALTH CLAIMS AGAINST
DENTAL AMALGAM LACK SCIENTIFIC EVIDENCE

The American Dental Association recently announced that a review of seven years worth of scientific studies concludes there is insufficient evidence “of a link between dental mercury and health problems, except in rare instances of allergic reactions,” according to a report released today by the Life Sciences Research Office, Inc. (LSRO) in Bethesda, Maryland.

Established in 1962, LSRO is a non-profit, independent organization with a worldwide network of experts that studies issues in biomedicine, healthcare, nutrition, food safety and the environment.

LSRO conducted the independent scientific review of dental amalgam at the request of a work group made up of representatives from the National Institutes of Health, Centers for Disease Control and Prevention, Food and Drug Administration and the U.S. Public Health Service. The report, Review and Analysis of the Literature on the Potential Adverse Health Effects of Dental Amalgam, updates and reaches the same conclusion as two earlier reviews by the U.S. Dept. of Health and Human Services of the dental material, which is an alloy made of silver, copper, tin and zinc, bound by elemental mercury. The silver-colored material is widely used to fill dental cavities.

“This report further substantiates the American Dental Association’s position that dental amalgam is a safe, effective material to fill cavities, based on science and clinical experience,” said Dr. James B. Bramson, ADA executive director. “Countless people’s teeth have been saved by using amalgam, which is one of the most durable and affordable cavity filling materials available, especially for large cavities in the back teeth where chewing forces are the greatest.”

The LSRO report was based on a review of nearly a thousand papers from peer-reviewed scientific literature along with public comments submitted to the Federal Register and involved a multidisciplinary panel of experts in fields such as toxicology, allergy, pediatrics, epidemiology and pathology.

The American Dental Association is the nation’s largest dental association, representing more than 149,000 members.

Are Lasers the Wave-Light of the Future?

New applications and lower prices might allow lasers to replace traditional dental tools

CHICAGO (Academy of General Dentistry) -Would you spend more than $40,000 on equipment that would allow you to complete oral surgeries with virtually no pain or blood and a vastly reduced healing time? Today’s dental laser manufacturers think so, and many dentists are exploring the possibilities that this new technology affords practitioners. An article in the May issue of AGD Impact, the newsmagazine of the Academy of General Dentistry (AGD), provides an explanation of how dental lasers work, what different types of lasers have been developed for dentistry, and why dentists should consider purchasing a laser for their offices.

Since the first dental lasers-approved for soft tissue applications and hardening of composite resin dental fillings-were introduced in 1991, dental lasers have become more sophisticated, varied and applicable for more procedures. Today, there are more than 17 different dental laser applications that can help patients achieve better oral health. They are being used to clean out cavities and root canals, reshape gums, and whiten teeth, among other uses.

But, as with every new technology, there is a period of induction. The market must be educated about why lasers are superior to other equipment. Ohio dentist Louis Malcmacher, DDS, says “The benefits to the patients are many-there is less pain, less trauma, less need for local anesthesia or postoperative pain medication, [and] less fear of drills and of the dentist.” He also highlights benefits for the dentist saying “[dentists can] do more procedures they may have referred out, such as crown lengthening procedures, soft tissue procedures like frenectomies, gingivectomies, and the like, and the laser is a huge practice builder as patients find out the benefits of laser dentistry.”

More procedures and more patients usually equate to more money, which is music to a dentist’s ears. But, there is another obstacle presented to dentists interested in lasers: cost. Gene Antenucci, DDS, a general dentist in Huntington, N.Y., suggests that dentists interested in purchasing a laser should calculate a return on investment, as with any major technology purchase. He says “You have to calculate the dollar value of the laser versus the number of procedures to justify your investment. The return on a laser investment is fairly high.” Also, for users, there is a learning curve.

Although there are no state laws requiring dentists to have training in the use of lasers, it is to the dentist’s benefit to learn about them not only to purchase the right one for their practice, but to maximize their investment and ensure patient safety. The Academy of Laser Dentistry (ALD) has adopted the Curriculum Guidelines and Standards for Dental Laser Education, which recommends attending a Standard Proficiency Course (Category II), including specific laser proficiency and laboratory knowledge. Although manufacturers provide training, not all of their courses are recognized as standard proficiency.

The technology is constantly evolving and improving. Dr. Antenucci expects “to see a lower cost of the laser unit, and a more streamlined unit [in the near future],” and anticipates “improvement in hard tissue laser capabilities, such as it being more efficient with decay removal and tooth preparation.”

And with these advances in technology and reductions in cost, dentists’ may no longer wonder if lasers will replace their current instruments; they will wonder when.

 

Don’t Let Your Mouth Pollute Your Clean Heart

Levels of Bacteria in Plaque Beneath the Gum Line May Increase Risk for Heart Attacks

CHICAGO (American Academy of Periodontology) -Researchers have found evidence that the amount of bacteria in subgingival plaques, the deep plaques in periodontal pockets and around the teeth, may contribute to an individual’s risk of a heart attack, according to two studies appearing in the Journal of Periodontology. These studies further researchers’ understanding that periodontal bacteria may increase the risk for heart disease.

In one study researchers looked at 150 individuals with periodontal diseases and found that the total number of periodontal bacteria in subgingival plaques was higher in individuals that have suffered from an acute myocardial infarction (heart attack). The second study found that the same DNA from different kinds of periodontal bacteria in plaque was also in the patients’ heart arteries. Researchers believe that these findings may help substantiate what they have long known; if there is a sterile pathway, such as a bloodstream, near a periodontally infected area that the bacteria from this infected area cause inflammation in the gums that opens up pores in the surrounding blood vessels, which enables the bacteria to enter the bloodstream and travel to other parts of the body and cause great harm.

“It is like setting up a garbage dump on the edge of a river. You wouldn’t be surprised if the lake downstream ended up polluted with the garbage from the dump,” said Vincent J Iacono, DMD and president of the American Academy of Periodontology. “A patient’s bloodstream acts very much like the river in this analogy, in that it carries the bacteria from the periodontal plaques, possibly ‘polluting’ the arteries of the heart with periodontal bacteria, causing inflammation of the arteries which may lead to a heart attack. This potential effect of periodontal bacteria further supports the need for periodic deep cleanings to enhance overall health and wellbeing.”

These studies represent two in a large body of research that investigates the possible link between periodontal diseases and other systemic conditions such as heart disease. “Intervention data is not available to prove a causal relationship between the two. Right now we are currently advising patients that maintaining good periodontal health can only help not hurt,” said Iacono.

Referral to a periodontist in your area and free brochure samples including one titled Ask your Periodontist about Periodontal Disease and Heart Disease are available by calling 800-FLOSS-EM or visiting the AAP’s Web site at www.perio.org.

The American Academy of Periodontology is an 8,000-member association of dental professionals specializing in the prevention, diagnosis and treatment of diseases affecting the gums and supporting structures of the teeth and in the placement and maintenance of dental implants. Periodontics is one of nine dental specialties recognized by the American Dental Association.

Guest Column: Infection control By Barry Levy, DDS

In the last issue of Solutions, I discussed the problems with “minimum standards” of infection control and how the dental practice act in California mandated “sterile gloves” for surgical procedures that involve soft tissue or bone.

This is a situation that applies to almost all dentistry that is done in the office. This is especially so if one considers the definition of dentistry as being the treatment of diseases by surgery or other methods.

I explained that while there are questions as to the benefits of this ruling, as well as the costs involved to achieve this goal, those questions are irrelevant.

Those issues become irrelevant because this issue has been defined as a “MINIMUM STANDARD.” What others do or don’t do is irrelevant should you have a problem. It becomes impossible to defend a civil action should you fail to follow the code. I had cited a case that showed how this played out and what the costs were.

LEGAL TACTICS

I have been personally involved with two cases that relied on this section. I have seen this section applied in board hearings and I have been involved where dentists lost in the civil arena.

The issue that should come to mind should you be sued is – what tactics will an attorney take to win. You have to be prepared for your defense.

The tactic that I have seen attorneys use is to attempt to show that you have not followed the MINIMUM STANDARDS in a particular area, which is mandated and crucial to the patient’s health.

Having shown a dentist’s failure to follow minimum standards of infection control for patient safety, it would not be difficult for a jury to question the care that you did give.

Even if the care is excellent, you have already been tarred and feathered for failing to follow the Minimum Standards of Infection Control and placing your patient at risk.

If you are practicing below the MINIMUM STANDARD, that is demonstrable and very
objective, why should a jury believe that the care you render is acceptable?

X-RAYS AND ULTRASONICS
There are problems with infection and cross contamination between X-rays and ultrasonic cleaners that we should be aware of. There are standards that must be met so that you can realistically minimize this potential risk to you and your patient.

Let’s address your x-ray procedures if the patient has to be moved to another room when x-rays are to be taken.

Does your assistant remove her gloves and wash her hands prior to leaving the room before going to the x-ray room for this procedure? Does she then wash her hands prior to taking x-rays, and does the door to your x-ray room have protective barriers that are used and removed each time the assistant takes the x-rays and touches the doors to open and close them?

Does this sound silly to you, a waste of time and inefficient? Based on how dentistry was performed for years in the past, you might have answered yes to the previous question.

FOLLOWING PROTOCOL

How long can an infection stay viable outside the host is a legitimate question that should be asked. But the better question to ask is: are you following protocol as defined in the California dental practice act? If yes, you can defend yourself. If not, you might want to think about the potential liability that you could face.

After that, you can ask if the codes are really making the patient safer, or just creating problems to the practice of dentistry and increasing your costs, or the costs to your patients.

According to California Dental code section 1005 B(2) “Medical exam gloves shall be worn whenever there is potential for contact with blood, blood contaminated saliva, or mucous membranes.” I tend to think that the definition would be met when taking x-rays.

CD Code section 1005 B (3) “Health care workers shall wash hands and put on new gloves before treating each patient.” I am certain that all health care workers in your office are putting on gloves prior to treating a patient, though I do question if hands are being washed at all times.

But the kicker now comes from the following:

“Health care workers shall wash hands after removing and discarding gloves after the treatment of each patient OR BEFORE leaving the operatory.” (Emphasis mine)

CD Code section 1005 (6) “Protective attire must be removed when leaving the
operatories and work areas.”

One might question if taking a patient from the operatory to the x-ray room IS treating a new patient. If you have to take off your gloves when you leave the operatory it would then seem clear that you have to wash your hands and place new gloves before taking the x-rays, which is the treatment of a patient with the potential for touching mucous membranes.

So, are you following the code as written? Should a problem arise in your office, can you defend yourself that you have followed the MINIMUM STANDARDS and you are not practicing in a shoddy, haphazard manner?

When one deals with ultrasonic cleaning of instruments, the consensus was that instruments are placed in the ultrasonic cleaner, then bagged and sterilized. The question to be asked would pertain to the ability of the ultrasonic cleaner to kill bacteria.

If it doesn’t kill bacteria, what are the risks to your staff from the ultrasonic cleaner becoming the focal point for potential infection to your staff from handling the instruments? Do you have to change the ultrasonic solution after each use?

What are your liabilities should a staff member poke herself with an instrument coming out of the ultrasonic? Imagine what could become of an incident such as this.

LEGAL LIABILITIES

I am playing devil’s advocate. If I were to be retained by you I would be pointing out these issues and hoping that the other sides aren’t aware of the code sections, or that they wouldn’t think to use them. This was evident in the case that I worked on, because the first law firm dropped the case, when they couldn’t prove causality.

The second lawyer didn’t worry about causality, but only that MINIMUM STANDARDS OF INFECTION CONTROL weren’t followed. It became definitional that malpractice occurred, and the patient had been harmed.

But if I am retained by the patient, or the board is asking me to look into a case, I can tell you emphatically that these issues are high on my list to review.

And I will restate that should a case involve lawyers, it is about winning.

In a civil case it is about getting money for the client, which is a powerful motivator for an attorney on contingency to prevail.

If it is a board action, money is also a powerful motivator because the board can only collect the fees for the investigation when they prevail.

I have previously written that the board will always win. In your board hearing, the trial before a judge, allows only for the judge’s opinion to be expressed. The board can choose to ignore if it wants.

In a study of the board’s decisions, it was shown that the board reversed all judges’ opinions that favored the dentist. Money is a major motivator and, by reversing the judges’ opinions, the board collects from the dentist.

CONCLUSION

I have also taken the position that sometimes rules are being made by those that don’t practice, and may not even be dentists. If a professional abdicates his professional responsibility to oversee his profession then others will do so, and the results can often be deleterious to that profession.

This is coming to pass with the comments that I hear about the costs to comply and with the facetious remarks that the rules are impossible to comply with and have no basis because one can’t sterilize the mouth prior to treating the patient.

But the rules are changing all over the country. You can take it for what it is worth, but should you wind up with a problem, I hope that you have listened so as to minimize your risk of exposure.

Ask your local dental society to look into the issue prior to problems arising, because by then it might be too late, if it isn’t already so.

Barry Levy DDS

Dr. Levy is on the California Dental Board’s panel of expert witnesses for board investigations, is a guest lecturer at UCLA and UCSF and works as a consultant on dental malpractice issues.

(Note: The California Dental Board is mandated to review its infection control regulations each year. Amendments were considered at a May 14, 2004 hearing. The amendments were approved by the California Dental Board. This has changed some of the code numbers cited, but not the main point of this article. It is suggested that you read and review the changes as the new language specifically cites “A copy of this regulation shall be conspicuously posted in each dental office”)