January, 2003
Emergencies and Their Impact on Your Practice
Carolyn Friedman
Each time there is an emergency office visit, it is costly to the practice.
A major factor in setting your fees is the amount of time (number of hours) estimated for the treatment. Your profit decreases each time a patient to returns to your office for an unplanned visit. Anytime you can reduce the number of "emergency" appointments, you free up time to see other patients, new patients.
In orthodontics, emergencies mean something totally different from other professions. In most medical professions, most emergencies are true emergencies and have to be handled immediately. In orthodontics, it is different – most "emergencies" are situations where there is a broken appliance or a wire is sticking. The patient is really not experiencing extreme discomfort and, in many cases, the problem can be fixed by the patient or a parent. Therefore, we are somewhat able to control how an emergency affects the practice.
Emergencies, and how they are handled, can make or break a practice. The practice that acknowledges that emergencies exist, and has a plan, is the one that will be successful. Emergencies are a normal, expected, occurrence in every practice. Though emergencies cannot be eliminated, they can be controlled and managed, minimizing the negative effect they can have on a practice.
How much are emergencies affecting your practice?
The first step in managing your emergencies is to determine the number and types of emergencies you are presently experiencing. Review your past records for the past year or start keeping track of your emergencies during the next few months or more. List the number and types of emergencies: broken appliances, loose bands, sticking wires, etc. By categorizing emergencies, you will be able to determine what your needs are in handling your emergencies, such as available chairs and the assistants’ and doctor’s time required. The time spent on these emergencies affect the livelihood of your practice. These numbers are your baseline numbers from which you will measure improvement. Each additional “emergency” appointment is using your valuable resources (yours and your assistants’ time) and, therefore, cutting your profit. The way you manage (or not manage) your emergencies can also affect your practice.
Why are these emergencies occurring?
Before you can reduce the number of emergencies you are experiencing, you must determine why the emergencies occur. There are many factors that could be contributing to your emergencies, ranging from your supplies and equipment to your schedule and staff.
The various supplies you use in your office can be the cause of emergencies. Have you changed your supplier of any of these materials? Though many products, such as adhesives and bonding materials are very similar, they are also different. They may differ in the recommended storage temperature, the ratio of the mixed components, the amount of mixing required, and the time frame in which they must be applied. Even though you believe you are aware of how to use these materials, carefully read the instructions (again) to ensure that you are using them as recommended.
Arch wires can also be a source of your emergencies. There are various manufacturers of arch wires and though they may be similar in function, they may have different characteristics. These different characteristics can cause the wires to behave a little differently and could be the cause for breakage or wire poking problems. To add to this problem, there are new "high-tech" wires being produced that behave differently than the standard wires.
"Bad" materials could be the factor if loose brackets (or bond failure) are a problem in your office. Make sure that the materials you are using are fresh; look at the shelf life. Different materials also require different care. Some materials require that they are kept cool and dry. Some bonding agents may loose some of their bonding properties when overexposed to light, even the light from the operatory. In this case, it is important that your supply containers are kept closed when not being used.
It is also important to make sure that your equipment is good working order. Some equipment have parts that wear out. If loose brackets are a major cause of many of your emergencies and you use a light-cured bonding agent, the light source (bulb) could be a factor causing the brackets to come loose. You will need to test your light source to make sure that you are receiving full benefit at all times. The bulb may need to be replaced due to age and you are not aware that it is loosing it strength. The instructions that came with the light should have information concerning the useful life of the bulb. There should be a routine time that the bulb is checked and changed to avoid any possible increase in the occurrence of loose brackets.
Your schedule could, in many ways, have an affect on the number of emergencies. Staff turnover can be one cause affecting your schedule. Your schedule was set many months ago based on a certain number of assistants, which are now not available to you. You are now short-handed and existing staff are trying hard to keep on schedule, and at the same time, possibly trying to train the new staff members. The situation of working faster to stay on schedule can create mistakes that can affect the number of emergencies you have.
Also, your new assistant typically is also not as proficient technically. Therefore, you may see an increase in the number of emergencies when new assistants are in your office. Not to fault the new assistant, but to acknowledge that this could be what is happening needs to be addressed when evaluating why emergencies are occurring.
Patient education can be another factor increasing emergencies. Are you informing your patients of everything they need to know about the procedure or appliance? If your bonding process requires that the patient avoid items such as soda’s etc., they must be informed and know the impact on not following directions. The first 24 hours after a bonding is the greatest chance of a loose bracket. Even their brushing should be very careful or they can knock off the brackets if they apply too much pressure and force. Educating your patients will eliminate unnecessary appointments. The more your patients understand about their appliances, the less they will question and be unsure of what is really happening. By providing detail instructions on how to take care of problems, they can take care of some of the simple problems themselves.
Keeping Records
Documentation of your procedures helps to determine problem areas. When you record your bonding procedures, make sure that it is noted in the patient record as to what kind of bonding process or bonding agent you use. This will help when you look back at which patients have had repeated emergencies. Is there a technique problem with what you are using or maybe not an understanding of exactly the set times involved with this particular type of agent?
When a patient comes in for a regular appointment and has a loose bracket or broken wire, it is also important to document this. If these are included in your "emergency" numbers when trying to monitor how many emergency situations you deal with in a period of time, your records will be more accurate and meaningful.
Every time a patient is in for an appointment, it should be noted as to which assistant worked with the patient. This helps in many ways. If there is a question after the patient has left, the person answering the phone knows who to talk with concerning the question. The other thing that will happen is that it’s easier to detect a technique problem when the same assistant has a higher number of bond failures.
Monitoring emergencies is an ongoing task. By keeping track of all emergencies on a continual basis, you will be able to determine if your office is experiencing an improvement (decrease) or an increase in the number of emergencies.
Your emergency schedule
Doctors, do you ever feel, due to circumstances in the office, you are hurried with procedures, or in trying to survive the schedule, you are doing procedures previously done by assistants? Maybe a staff member has routinely assisted with the procedure and now you have to do it alone. You are certainly able to do the procedure alone, but feel like you are being pulled in too many directions at the same time.
Since emergencies are a normal part of everyone’s schedule, having designated emergency appointment times each day helps plan for these normal occurrences, and also helps you stay on schedule. Again, totals and types of emergencies should be tracked in order to know the number of emergency appointments and the types of emergencies so that you and your staff’s time can be allocated and planned for. There should be a standardized length of time for certain type of emergencies. For instance, a loose bracket may be scheduled for 15 minutes whereas another type of emergency would require 30 minutes. Some types of emergencies can be handled primarily by an assistant, while other types may need primarily your time. If you have certain chairs that you place certain types of procedures, that will also be a factor in where the emergency will fit in the schedule.
Though emergencies should be a designated part of your schedule, to absorb some of your emergencies, you can use cancellation times. When you have a cancellation, do not fill that time with a regular appointment. Leave that time open for emergency calls for that day.
Emergencies can also be discussed at the morning "huddle" where your staff discusses the day’s schedule. The orthodontist and the assistants, through reviewing the schedule, can "key" the scheduling team where the slower parts of the day may be in which to schedule that day’s emergencies.
Patients should understand they should not to just come to the office for emergencies, but to always call first. This again comes from education of, and information to, your patients. By explaining to your patients, in order to take care of them in the best way and to avoid a long wait for them, they should call to schedule emergency appointments.
When a patient calls with an emergency, it is a good practice to make a note for the file with information for the clinical assistant concerning the emergency situation. This gives them a heads-up on what to expect when the patient arrives. It also makes the office look more on top on things and shows communication throughout the office when the clinical assistant is aware of the problem when the patient arrives. This note, if written in red, also helps to bring it to the attention of the staff member working with the patient. If there is a question concerning this patient, you also have a chance to check this out ahead of time, again getting you prepared to handle the emergency more effectively.
Scheduling emergencies
The first thing that the scheduling team should determine is if the patient is uncomfortable, if so to what degree. If the problem can be solved over the phone, you can eliminate the need for the patient to make a needless visit to the office. If the patient needs an appointment, the scheduling team needs to determine how much of the doctors time will be required and how much of the assistants time. If the patient is not uncomfortable, you have a lot more options on scheduling during a time that is will not adversely affect your office schedule.
The nice thing about orthodontics is that most emergencies can be scheduled over several days. It may not be necessary to see them immediately. The patients should understand what is a loose bracket and what is a broken wire. If they cannot communicate what the problem actually is, it is difficult to know where best they can be taken care of in the schedule. Again, it is important for the scheduling team to be educated with general knowledge of the clinical procedures in order to ask the right questions of the patient in order to determine the actual problem, therefore scheduling the emergency for the time most appropriate for the patient and your schedule.
Again, many orthodontic emergencies are not true emergencies. Many of these emergencies can be handled by the patient or parent until the patient can get into the office. Some common problem-solvers are wax and pencil erasers. Erasers work but are not the most sanitary. There are a few repair kits available, such as the Ortho ER kit that includes many items helpful in temporarily repairing orthodontic problems, such as wax, two types of mirrors, a Soft Stick Wire Mender for adjusting sticking wires, and instructions for solving a few different problems. In many cases, the parent may even be able to take care of the problem, therefore eliminating the need for an appointment at all.
When mom or dad calls and they are going to school to pick up Johnny because he has a broken wire, the pressure is then on not to mess up the existing schedule, but at the same time to take care of the patient’s needs. When, where, and how? These are the first questions that need answering. And after they are answered, is anyone going to be upset: patient, parent, and of course, the clinical staff members.
It is also very important that if a patient calls with a problem and you offer an appointment that they do not accept, to make a note of this. It is not unusual for a patient to delay taking care of an emergency in order to better fit their schedule, and then come in the office only to state to the doctor "This is the earliest time they could fit me into your schedule." If there is a notation, then the response to the patient’s comment concerning the delay in getting an appointment can be "I am sorry the earlier times that were offered did not work out for you". This helps other patients that overhear the conversation to understand your office was not the problem.
The inevitable poor cooperation patient
Every practice has the patient that you routinely get calls from that something is wrong. This is the patient that the staff usually cringes when they walk in the door. It is because you know that their treatment cannot be progressing as planned: always repairing and redoing instead of making progress, and always "messing up" your schedule. It is so frustrating to feel like their lack of cooperation is directly affecting what you are able to do for them and your practice. You must have a plan established for handling the problem patient in a positive way.
Some parents know that their son or daughter is breaking things because they are eating things that you instructed them not to eat. When a parent calls and request that you yell at their son for not following directions, immediately let them know that you do not yell at your patients. Yelling or getting-on-their-case will only make them not want to return to your office. Address the problem with the patient with concern and care. By sitting down with a patient, showing concern and educating them on how they are slowing down their progress, you will gain so much more than taking a hard approach.
Many practices will establish a number of emergencies that they will correct without additional charges. Again, this policy information should be provided prior to beginning orthodontic treatment. The patient should understand that the length of active treatment time is only an estimate and is predicated on them doing their part to be able to achieve the final results. The main concern with making a charge for extra repairs is that you must be sure it is the patients’ fault and not one due to a technique problem in your office.
There are also practices that issue a certain number of certificates that are used each time there is an emergency. This can be done with keeping the certificates in the patient’s chart and removing or dating them as they are used. Another option is to have the patient responsible for bringing in the certificate at the time of the emergency or there will be a charge. If all the certificates are used and there is another emergency, there is an additional charge.
Charging for emergency appointments should be discussed with the responsible party prior to any charge being made. Remember, discontent comes from not informing your patients of your policies prior to starting treatment.
Scheduling Team Education
A large responsibility is placed on the scheduling team, regardless of the way you schedule emergencies. Where to place an emergency appointment in your daily schedule is a very difficult and trying task. Also, your scheduling team needs to have some idea how the emergency affects the patient’s treatment care. Is the patient wearing rubber bands? Is the rubber band suppose to hook on the bracket that is loose, which means that there will be lost time and progress in treatment?
To try to accomplish this without chair-side knowledge is very difficult. This is where the education of your scheduling team in what various procedures involve is important. Your scheduling team needs to understand what is involved with each type of emergency appointment. If there is no designated time for different types of emergencies, and your scheduling team is to determine where to "stick" this patient, your schedule can be very chaotic. When your scheduling team knows what is happening at each chair, a better decision can be made.
When there are scheduling "problems", the scheduling team catches the "heat". All offices provide at least some degree of training and education for their clinical staff, but few provide clinical training for their scheduling team. Though the scheduling team does not necessarily need hands-on training, as you can see with the responsibility you place on them, it is also important that they receive education in the procedures performed in your office. This can be accomplished through your established training program or through the use of a clinical education program such as OrthoAssist, Training for Orthodontic Assistants CD-ROM program, or a combination of both. If you can break them free from the front for a period of time, it’s very valuable for them to actually observe the clinical procedures, first-hand.
The cost of emergencies
The cost to your practice of not reducing emergencies can cost your practice. When you have emergencies, you are spending valuable time redoing work. If you can reduce the time you are repairing, you have more time to schedule regular appointments and new patients.
The cost to your practice of not planning for emergencies in your schedule can cost you new patients in different ways. First, if you are "fitting" in emergencies, you are probably not running on schedule – making patients wait. Second, if you are having too many patients coming in for emergencies, you are sending the wrong message to that patients; you are telling them you do not do quality work. You can bet that these patients are telling their friends that you do not run on schedule or that they are always going back to have something fixed. When their friend is looking for an orthodontist, this fact will be a factor when they make their selection.
Take Charge
Though emergencies cannot be eliminated, they can be controlled and managed, minimizing the negative effect they can have on a practice. Not monitoring and controlling emergencies can be costly to your practice. Take charge of your emergencies and make your office run more efficiently and profitable.
Contributed by:
Carolyn Friedman
OrthoAssist, Orthodontic Consultant and Staff Trainer. Carolyn Friedman continues to work in the same progressive orthodontic practice that she has worked for 30 years. She is the founder of OrthoAssist, a business focused on the training of orthodontic assistants. She the creator of the OrthoAssist interactive assistant training CD-ROM and other training programs and is a noted public speaker on orthodontic training, teamwork and practice-building.
