Weighing the Risk of Termination

By Stuart Oberman, Esq., Oberman Law

Editor’s note: Unpleasant as it may be to fire a staff member, it’s sometimes necessary to protect the practice from risk. An understanding of employment laws can make the termination process less complicated.

Dental practices are subject to a variety of local, state, and federal employment laws. While dental practice owners assume they are justified in their reasons for firing employees, employment laws can make the termination process complicated.

Claims may arise from bad employment decisions. These claims may be asserted by any employee and could include – but are not limited to – workplace discrimination or retaliation, harassment, breach of contract and defamation. Employment litigation can bring its own set of challenges, including attorney’s fees, loss of time, disruption of services and stress.

Hiring an incompetent employee could lead to certain claims against a dental practice. The practice could be held liable for the unlawful action of employees. Hiring dishonest employees may also cause difficulties in running the practice.

Practice owners should balance the relative risks and choose among an assortment of different options when it comes to handling employment matters. They should ensure that their employment decisions are justifiable and fully supported by employee evaluations and other documentation. When possible, they should give employees notice of their deficiencies and a reasonable opportunity to correct the problems. Even the most frustrating employees are to be treated with dignity and respect. Finally, if a decision to terminate an employee has been reached, careful planning of the actual termination and the handling of the transition is important.

Every dental practice owner should consider the following before making the decision to terminate an employee:

  • Are the employee’s problems serious enough to interfere with the efficient delivery of dental treatment and quality patient care?
  • Is there a larger point to be proven?
  • Is the timing of the termination decision risky because the employee has asserted his or her legal rights?
  • Is the employee’s behavior toxic to the workplace, placing the practice owner at risk of losing valued employees?
  • Will the practice’s retention of a difficult and/or incompetent employee cause harm to its reputation within the community?

There will be situations where the above factors outweigh the risk of liability for employment discrimination, and the dental practice has no choice but to accept the risk. At this point, the dental practice has an option to offer a severance package with a release agreement, prepare a vigorous defense, or reach a reasonable settlement.

Editor’s note: Stuart J. Oberman, Esq. handles a wide range of legal issues for the dental profession including employment law, practice sales, OSHA and HIPAA compliance, real estate transactions, lease agreements, non-compete agreements, dental board complaints and professional corporations.


How to Make the Hygiene Department More Profitable

Dr. Sami Bahri, DDS. Dr. Sami Bahri is the author of “Follow the Learner: The Role of a Leader in Creating a Lean Culture,” and of the DVD “Single Patient Flow: Applying Lean Principles to Heathcare”. The book won the 2010 Shingo Prize for Research and Professional Publication and the video won the same award for 2013. The Shingo Prize Conference also recognized Bahri as the “World’s First Lean Dentist.” He is a soughtafter speaker and lecturer nationally and internationally on implementing Lean management in dentistry. Dr. Bahri can be reached at Sami@bahridental.com

By Dr. Sami Bahri

Lean Management

Hygiene is undoubtedly the beating heart of a practice. When the hygiene department is busy we are, when it is not, we are not. Thankfully, hygiene is well organized in most practices, but as we like to constantly improve, we want to make it more and more productive.

What will make that possible? Systems thinking; more specifically lean thinking where one views hygiene not as a separate entity, but as a component of a larger managing system of a practice – or even multiple connected practices. Here are a few ideas on how to move closer to a unified management system where hygiene and dentistry are not two separate departments.

Organizing work
The element around which you organize work will determine how you run your hygiene department.

Organizing work simply means that, at the center of the organizing diagram, we place the most important element – the one element around which everything needs to revolve. Change that center element and you will change how you navigate the system efficiently. For a simple analogy, you would navigate the solar system differently if you thought that the planets revolved around the earth, instead of the sun.

In dentistry, we can put either the provider or the patient at the center. This choice will determine how we run the schedule and consequently, how efficient we are. So far we have placed the provider at the center of the dental universe. We have scheduled according to provider time and assistant time – in the hygiene case, according to hygienist’s time. Conversely, the new lean way puts the patient at the center, and organizes the schedule around how much work they wish to do and when. We like to perform all that work in one visit, if the patient conditions allow, and if it leads to patient satisfaction.

In the following paragraphs I will attempt to show the difference between the two schools of thought.

Organizing around the provider
Organizing work around provider tasks is the most widespread concept in business and dentistry today, but not the most productive.

Here, hygiene functions as a separate department. Some even call it a “Profit Center” and manage it as an independent business. Peter Drucker, the legendary management guru, originally coined the term profit center around 1945. He later recanted, calling it “One of the biggest mistakes I have made.” He then asserted that there are only cost centers within a business, and “The only profit center is a customer whose check hasn’t bounced.” 1

In this line of thought, you calculate the department’s production independently from its contribution to the profit of the entire practice. When you make changes or introduce new services, you try to increase the production of each hygienist independently, and when checking the results of that change, you look at the hygiene production report (As we will see later, Lean looks at a different report)

The biggest flaw in this system is that when you improve profit centers independently, they tend to grow at different rates and the whole system tends to become dysfunctional. It is like placing tires of different sizes on a car, or an excessively powerful engine.

Organizing around the patient
If you organize work around the patient experience, you will try to finish the patient’s treatment in one visit. Your schedule will revolve around their schedule.

In such an environment, hygiene cannot be viewed as a separate department anymore, but as one component of the patient’s treatment.

You will study the influence of hygiene on the profit of the whole practice, not only on the hygienist’s work.

If you introduce a change in hygiene, you will study its influence not in the hygiene production report, but in the practice profit and loss statement. The perspective here is more global than when you look at hygiene as a separate department.

You will seek to improve whole system metrics like patient satisfaction, treatment plan acceptance rate, lead time – the time it takes to complete the entire patient treatment.

The most profitable hygiene department is the one that does not exist separately unless the patient needs hygiene treatment only.

There is no problem thinking of hygiene as a separate department when only the hygienist is involved in the treatment – like when a patient needs a simple cleaning, for example.

Any other time, when more than one provider is involved, it would be more profitable to look at the hygiene department as an inseparable part of the entire dental practice managing system. The hygienist will come to clean a patient’s teeth during treatment, in the dentist chair. This becomes even more practical if you use CAD/CAM technology. While the crown is milling and while it is fired in the porcelain oven, the hygienist comes to do the cleaning. That saves an appointment and makes the treatment flow efficiently.

Combining functions in this manner is called “crossing the functional barriers.” It is not to be taken lightly. Talking from experience, I can assert that it is a very important factor in increasing productivity and most importantly, facilitating a smooth flow of treatment, which in turn reduces the level of stress dramatically.

1 (Drucker, Peter F. (2002). Managing in the Next Society. New York, New York 10010: St. Martin’s Griffin. p. 84. ISBN 0-312-32011-6.)

Improving Lives

Editor’s note: When it comes to supporting the community and helping to ensure that patients have access to essential dental care, ADSO members are first in line. Efficiency in Group Practice recognizes those who make community giving a priority. This month: Great Expressions Dental Centers and Affordable Dentures & Implants®.

Affordable Dentures & Implants® recently announced it is partnering with Brighter Way Dental Institute of Phoenix, Ariz., to deliver free dental implants, oral surgery and prosthetic treatment to hundreds of U.S. military veterans and homeless citizens. The network of affiliated dental practices expects to contribute about $3.25 million in pro bono implant and prosthetic services in 2017 alone. About 400 volunteers – including affiliated practice owners, dental technicians and other auxiliary staff members – will travel from across the U.S. to Phoenix as part of the effort.

The pro bono program will take place at Phoenix-based Central Arizona Shelter Services. Brighter Way Dental Institute will facilitate six three-day sessions throughout the year. Formerly known as the CASS Dental Clinic for the Homeless, Brighter Way Dental Institute provides comprehensive dental care and a dental home to adults, homeless individuals and military veterans, many of whom do not receive dental benefits through the U.S. Department of Veterans Affairs. Dr. Kris Volcheck, Brighter Way Dental Institute CEO and founder, and Dr. Justin Moody will oversee clinical care at each of the sessions.

“This program reflects our affiliates’ shared commitment to deliver tooth replacement care with dignity and respect to those who often have nowhere else to turn,” says Doug Brown, President and CEO of Affordable Care, the dental support organization affiliated with Affordable Dentures & Implants. “As a national dental support organization, we have a special opportunity to use our network size and resources to give back to underserved communities.”

Twelve Affordable Dentures & Implants affiliates participated in a successful pilot session in late 2016, delivering free care estimated at $440,000.

Affordable Dentures & Implants’ participation in the 2017 Brighter Way program will build upon a record year of volunteer service and charitable work. In 2016 alone, the dental provider network reached out in the following ways:

  • Over 100 dentists, lab technicians and business support staff gave their time at more than 20 Mission of Mercy pro bono events across the U.S. Throughout the year, technicians produced more than 700 partial dentures and other appliances at Mission of Mercy events.
  • Affordable Care renewed a significant annual contribution to America’s Dentists Care Foundation and to more than 20 state-level Mission of Mercy organizations.

In addition, over 200 dentists within the affiliated practice network have taken part in international implant volunteerism since 2014, including through a partner clinic in Guadalajara, Mexico, performing more than an estimated $5 million in implant surgery and related services in that time frame.

For more information about Affordable Dentures & Implants®, visit www.affordabledentures.com.

Giving back

Great Expressions Dental Centers makes it a point to provide more than great dental care. They become part of the fabric of the communities they serve by making donations to dental schools; participating in local partnerships, charities and events; visiting schools to educate students about brushing, flossing and diet; and educating people about the importance of their oral care.

Last year alone, GEDC was a sponsor of the Michigan Missions of Mercy – the state’s largest free dental clinic – and the Jarvis Landry Camp in Miami, Fla. GEDC set up its SmileCenter at the two-day camp, and team members handed out water bottles and Oral B Travel Kits to the children, as well as raffled off a signed, Jarvis Landry football both days. In addition, GEDC participated in:

  • Backpack Donations. Over 600 backpacks stuffed with dental and school supplies were donated to school classrooms across the country. GEDC patients nominated the classrooms on its Facebook page, and GEDC presented the winning classrooms with backpacks and an oral hygiene presentation.
  • NOVA Scholarship. Each year, GEDC awards a partial scholarship to a NOVA Dental student.
  • Feeding Children Everywhere. GEDC team members have packaged over 100,000 meals annually.
  • Breast Cancer Awareness Month. Together with the Breast Cancer Research Foundation, GEDC helped raise awareness throughout the month of October.
  • Dental Deputies. GEDC introduced its Dental Deputies to the Texas market, encouraging partnering schools to collect oral hygiene donations for victims of domestic violence.
  • Michigan Dental Association. When GEDC learned that MDA was $8,000 short of its 2016 fundraising goal, it stepped up and donated the exact amount.

The DSO has continued its community support and service this year. To honor Martin Luther King, Jr.’s dedication to community, GEDC marked the national holiday by donating 5 percent of all revenue generated through patient services from all of its offices that day. (Through the years, GEDC has donated over $400,000.) In addition, it is participating in GEDC’s own Dental Deputies program throughout the year, where the DSO raises donations for women’s shelters via school presentations and oral care products given to the school and shelter. The program will expand to include women’s shelters in Atlanta, Ga., Cleveland and Columbus, Ohio, and Texas. Upcoming events scheduled in 2017 will include helping raise awareness during Oral Cancer Awareness Month, Missions of Mercy, Team Smiles and more.

For more information about community and charitable events sponsored by Great Expressions Dental Centers, visit the organization’s website at www.greatexpressions.com.

Publisher’s Letter

The DSO Roadshow

Bill Neumann

Q1 is a busy time of the year for travel if you follow the group practice / DSO roadshow of meetings. Heidi Arndt of Enhanced Hygiene held her first ever Dental Group Evolution meeting in Austin, Texas in mid-January. It was well attended by emerging dental groups and DSOs that took advantage of the various breakout sessions for startup and mid-market dental group practices.

In early February, the American Academy of Dental Group Practice held their annual conference. This year the theme was Building Better Groups…Together. Some of the stand out speakers included Katherine Eitel Belt, David Waltzer, Tom Clark, Roy Shelburne and one of our very own contributors, Dr. Katherine Schrubbe of Dental Associates. Henry Schein also conducted a pre-meeting event for several group practices and DSOs prior to the AADGP conference.

Late in February, on the Wednesday prior to the Chicago Mid-Winter meeting, McGuire Woods held their 14th annual Healthcare and Life Sciences Private Equity and Finance conference at the Four Seasons. While not strictly a dental event, the private equity conference did have a dental sector breakout session that included a panel made up of Rich Beckman of Great Expressions, several executives from private equity firms invested in DSOs, and Michael Kryza of The Guardian Life Insurance Company. Guardian Life currently owns two geographically different DSOs and is looking to grow its presence. The highlight of the conference was the keynote speaker, Ben Stein, who moderated a discussion around the Affordable Care Act and the Trump administration’s repeal and replace strategy.

The biggest DSO event of the year will have already occurred by the time you read this issue. The ADSO is holding their annual summit in Orlando, Fla., at the Walt Disney World Swan. Last year, the ADSO had their largest meeting ever, with close to 800 attendees, and this year’s event should be even bigger. ADSO summit attendees will take over the entire hotel so networking opportunities will surely abound. I was also asked to participate in a panel discussion called “Promoting the DSO Story.” I will have the opportunity to discuss our mission here at Efficiency in Group Practice and how we assist DSOs in getting their message out to industry partners, dental students, practices owners and dental career seekers.

If you haven’t had the opportunity to attend any of these meetings, it is worthwhile to set some time aside to network with peers in the DSOs space. There is plenty of collaboration that occurs at these events, and the networking opportunities are extremely valuable.

As you read the pages of this issue of Efficiency in Group Practice, please take note of our feature story on the ever-increasing importance of your hygiene team. Speaking of teams, we get some feedback from Kool Smiles and their commitment to building and maintain well-functioning dental teams for the sake of creating the best patient experience. Check out these articles and a whole lot more in this March/April issue.

Bill Neumann