It’s staff review time again, and while you have been busy trying to understand how to give raises and still keep your practice within manageable financial limits, your hygienist has been cruising the Internet to discover what hygienists all over the nation are being paid. Chances are good that you are short on information and feeling pressured. Management consultants are in conflict over the best compensation solutions because each practice is unique. Guidelines have been established that can help, and a consistent approach to the review process is advised.
How would it feel to have the conversation with your hygienist be positive, with both of you understanding the professional goals and standards of care your practice represents? Annual reviews don’t always have to be a hassle or a lose-lose situation, where you feel that you are overpaying and your hygienist feels like she is at the short end of the compensation scale. Doing it differently requires some planning on your part, and it helps if everyone understands the basis for comparison. If your hygienist has been employed by you for a while, this new approach will be welcomed, and having it in writing is the best safeguard for all. Of course, the best plan overall is one that is implemented during the hiring process and continues for the lifespan of the employee.
LET’S LOOK AT THE HYGIENE SIDE FIRST
You know without my telling you that your hygienist is a special member of your office team. Not only can he or she produce revenue, but he or she also can forge relationships with your patients that bind them to your practice and allow them to become major referral sources, enabling your practice to grow far beyond what you can do alone. By combining clinical skill, communication excellence, and professionalism, hygienists serve patients’ expressed and unexpressed needs. The alliance that is forged by a good hygienist who is also a good listener and observer keeps patients in your network, allowing them to become healthy and accepting of your treatment recommendations.
It is one thing for you to talk about “rebuilding” a patient’s smile and enhancing their cosmetic outcome. It is another for your hygienist to reinforce your recommendations and schedule the patient to start treatment. When in doubt, your patients will likely ask the person they feel most comfortable with if they should accept the treatment offered.
If your hygienist is not in philosophical alignment with you and your practice goals, then your case acceptance may suffer. After all, home care instructions, diet restrictions, nutritional counseling, and continuing care all will be performed at some level each time the patient reappears. Positive reinforcement that the decision the patient made to accept the recommended treatment was a good one is vital. Even patients who opt for “staging” the recommended treatment should be congratulated at each visit. What better champion to have in your corner than the one person who has bonded with the patient over time?
Treatment issues aside, a skilled clinical hygienist can assist you with your examinations for oral cancer, which kills approximately 8,000 Americans annually,1 simply because your hygienist sees your patients regularly. Decay, periodontal disease, and changes in the general health of your patients are all areas that your hygienist can investigate and alert you to prior to your clinical examination. Working together and putting the needs of the patient first set a terrific example and are constant reinforcements to your hygienist that his or her services are valuable.
MEASURABLES VS. IMMEASURABLES
Patient loyalty to you and the practice has been established with a positive patient relationship built over time and a great clinical skill set, all offering themselves up for review. Your hygienist has financial goals in mind, some idea of the “going rate,” and most likely is not aware of your practice overhead and the ratio attached to hygiene production. Hygiene training programs do not generally have a management or business curriculum as part of the course work.
You may be inundated with options for compensation and have difficulty choosing the best one for your practice. Base rates, base plus commission, commission only, individual bonus, or team bonus plans all work in the right situations. Remember, however, the best always keeps the needs of the patient paramount.
Economically, how do you determine the reward without discomfort during the discussion? Do you opt for hourly salary or daily rate (based on other salaries in your area), commission only (works best for single hygiene practices), base plus commission, bonus compensation (individual or team), or incentives (including the sale of toothbrushes, fluoride, whitening materials, etc)? It is helpful to have a tool with which to measure and compare so that both of you are talking about the same thing. Your hygienist is thinking about a dollar amount in her pocket, and you (and your accountant) are adding payroll expenses, benefits, uniform allowances, health insurance, etc, to the offered amount. Your number and that of the hygienist are probably different. You will find that it is much easier to discuss the compensation package as a total amount, with line items broken out for the benefits you choose to include. A written proposal gives you a place to start and a much clearer picture of what you are spending.
For example, a practice in Massachusetts gives each employee a compensation package proposal each year, listing all benefits (except taxes), the total number of hours per week worked for the previous year, and a projection for the coming year. Clearly itemized are:
- Weekly salary based on hours usually worked (hourly rate listed) ... $;
- Paid vacation days at same rate of compensation as if worked ... $;
- Paid sick days if used or not used paid at same rate as if worked ... $;
- Medical insurance (annual amount) ... $;
- Uniform allowance (annual amount) ... $;
- Continuing education allowance ... $;
- Profit sharing estimate ... $;
- Holiday bonus ... $;
- Total available package ... $.
Included in the explanation is a sentence that shows the total increase in salary, in dollars and as a percentage. Thus, the employee has a clear picture of both the annual increase amount and the total compensation figure. The discussion begins with this presentation and clearly outlines all facets of the compensation issue. Both you and the hygienist are on the same page all the time. Questions can be answered and potentials discussed for both personal and professional growth. The paperwork becomes the vehicle for each subsequent yearly review, and if items are deleted or added, they can be discussed at that time.
DOLLAR OR PERCENTAGE INCREASE?
The rule of thumb that still holds in most situations is based on percentages. And frankly, it doesn’t matter whether you have 1 or more hygienists on staff. As long as the compensation is 30% to 33% of revenue produced, the formula works. By the way, this is a good time to remind your hygienist that there are times when the numbers do not add up and you pay for unproductive time. Establish a protocol for which staff member makes the phone call when a patient does not keep an appointment. (Usually, the person without the patient makes the call.) Decide if or how you compensate your hygienist for “working” recall, sending cards, and making calls to keep the schedule full. Do you reward the hygienist who assists you with an emergency patient, staying late and taking x-rays without being asked? This is the time to be proactive and discuss situations that happened during the past year. If improvements are needed, ask for cooperation. If you are reminded of “extras” done by your hygienist, say “thank you.”
Incidentally, it is always better to discuss situations as they occur, rather than saving them up for the review. If you can’t bring yourself to discuss an issue as it happens, make a note of the specifics and do it later when you both have time. Too much talking on the phone? ... address it. Use of long distance? ... address it. Cell phone or Internet use interfering with scheduled patients? ... address it!
As a consultant, it had never occurred to me that cell phones would become such disputed territory. I find them plugged into outlets (charging batteries) in many offices and ringing in lockers all day long. Between that and keeping the Internet access screen minimized, it’s amazing any work gets done at all!
A safe basis for an hourly or daily rate of compensation for the hygienist is 30% to 33% of revenue produced. That figure should not include taxes, FICA, FUTA, and other government dollars. If your hygienist is paid approximately $250 per day (8 hours), production should be a minimum of $757.57 daily, or $94.63 per hour. This should include all services performed by the hygienist, such as x-rays, periodontal maintenance, scaling and root planing, fluoride/ sealant placement, and any merchandise sales, such as whitening strips, touch-up whitening kits, toothbrushes, etc. (I recommend the examination fee stay with the doctor.) Take a look at your fees. Is this attainable in your practice? Are you expecting more than is possible? For instance, if you schedule patients on the hour with a routine prophy fee of $65, the numbers do not work, especially remembering the expected 9% cancellation/no-show number. If it can’t be attained, both of you will be frustrated.
I presently work with a practice where the senior hygienist, based on number of years with the practice and patient load, sees patients on a 45-minute basis and is booked for the next 6 months, leaving no time for new patients, scaling and root planing, or even sealant placement. Her patients love her and will reschedule if she is on vacation. She is rewarded by their loyalty, but cannot reach the ideal ratio on a regular basis and is frustrated by her situation. Solving this dilemma, which means blocking time in her schedule for potential new patients and more periodontal procedures, is complex; more of her patients will be shifted slowly to other staff, but this is necessary if she wants to receive a bigger paycheck. The whole practice is now focused on helping her attain her goal and producing a benefit to the overall financial health of the office.
A newly graduated hygienist has different needs, but the same clarity of purpose should be applied to the hiring package as at the annual review. The hiring process should include the written compensation proposal. If your benefits do not start until the 90-day introductory period is over, you now have something to review at that time, and later should the need arise. Remember, salaries for hygienists are based on supply and demand, not on experience and value to the practice. While new graduates are slower to perform routine prophylaxis procedures and x-rays, they still want to start at the top of the pay scale, and usually do, since finding good hygienists is difficult in most areas and the competition for experienced ones is fierce. Starting at a lower initial rate for 90 days can be effective, but a review needs to happen when promised, and a salary increase may need to be a priority in order to maintain a potentially good employee. Patients hate to be changed from hygienist to hygienist without good reason or without warning, so hire carefully, enlisting the help from your team members.
BONUS AND INCENTIVE SYSTEMS
Increasing salaries by bonus systems can be difficult to track, tough to promote, and a team-breaker if not handled well. Having said all that, full-team bonus rewards are helpful if instantly given when due. Bonus systems based on hygiene performance alone do not always produce the desired results unless your full staff benefits from goal attainment. With a large staff, bonus goals need to be established clearly and maintained during the reward cycle (12 months, 6 months, special time frame such as just before the holidays), and considerations need to be established for end-of-year situations and insurance reimbursements/write-offs.
If you are basing your reward on production after write-offs, make it very clear to all involved. If you are basing it on collections, make sure it is based on “monies in hand,” not monies expected from collections, insurance and patient promises. By the way, writing down the bonus system protocols for all involved can save you a lot of aggravation. Staff members who cannot remember the zip code of your practice can and will debate you on the exact wording they remember from the staff meeting when you outlined the system at the beginning of the year. Make sure the process is clear and understood by all before you start!
DOCTOR’S POINT OF VIEW
So, we’ve covered what the hygienist would like, and we know what the accountants generally recognize as reasonable. How would you as the doctor/owner/ manager/administrator like to reduce your stress over the salary debate? Here’s one person’s opinion. A client of mine is a doctor in Pennsylvania who is a partner in a newly developed, state-of-the-art group practice sharing 10,000 computerized square feet with in-house endodontics, orthodontics, pediatric dentistry (still searching for an oral surgeon), etc, and who has told me that there is “no amount of compensation that can reward an employee for the unmeasurables in making the practice a success.” Terry has said on more than one occasion that the “fit” must be right for both the employer and the employee. And further, he said, a staff member who works “for the money” will never be the right one. Of course, compensation must be competitive with the area and benefits reasonable, but at the end of the day, if your hygienist wants to leave on time and doesn’t help others out the door, then you need to start over. A highly compensated hygienist who is not happy with the practice or the doctor should be helped to leave. Patients are quick to pick up on the dissatisfaction. Hygienists are people who are happiest in rewarding relationships. They try hard to please everyone, and what it is that binds them to your practice can be very subtle.
THE LAST SIDE
Your first order of business is to form a plan and develop a vision of your practice as you want it to become. People who set attainable goals and write them down have a much better chance of succeeding. The act of aligning your conscious and subconscious thoughts, and being clear about what you want, can and does produce results. Secondly, at your next dental meeting, talk with your peers about successes and failures in their practices. Discover how they found and rewarded their best employees. Develop mentors from practitioners who have “seen it all.” Find out what they did to keep staff in place and happy for 5, 10, 15 years, and more. The discovery you will make is that you have to love what you do and attract others who feel the same way.
Don’t be afraid to bend the rules and do what you think is right, even if it deviates from the norm. Your practice is special; it is a reflection of your personality and your skill. Good staff should be mirrors and reflect the best back to you. Exceptional staff members can help when the reflection is not the best. They can help you steer a clear course when you momentarily lose your way. In a solo practice, you are the leader, the accountant, the administrator, the inspiration, and when times are bad, the magician to make all things appear normal. In a group practice, you are one of many voices. In either case, to your hygienist you are the one person they try to please.
Whether one or more are employed by you, hygienists choose a career to be of service and to be excellent clinically. Their rewards are in doing a good job, keeping patients happy, and being part of a team where they can be recognized. Rewarding good behavior produces good behavior. The reward needs to be more than a dollar figure, since it is based on more than money. Advanced planning can make the annual review a win-win for you, the hygienist, and the practice.
- Silverman S Jr. Demographics and occurrence of oral and pharyngeal cancers. The outcomes, the trends, the challenge. J Am Dent Assoc. 2001;132(suppl):7s-11s.