Team-Building: Predictable Approaches to Dental Practice Success for an Unpredictable Future

TEAM-BUILDING

Traditionally, the dentistry profession has been exemplary in promoting a stable work environment, with dental practices in general having an extensive track record of hiring and retaining small, intact teams that often remain unchanged for years or decades, in many cases until team members reach retirement.¹ During the course of the COVID-19 pandemic, however, most dental practices have experienced an unprecedented turnover and reduction of staff. Significantly fewer patient appointments, especially in the earlier phase of the pandemic, made it necessary for many practices to lay off staff or implement shortened work-weeks or reduced hours for its employees. Although patient volume has since then rebounded, replacement of team members has been fraught with challenges; applicant submissions have been low and interview no-shows have increased over the past year,² while the costs of rehiring have been predicted by some to be approximately 20% of a midrange position's salary.³ These staffing challenges and workforce instabilities have contributed to an overall lowering of morale throughout the dental industry, requiring increased efforts on the part of dental practices to support and motivate their existing team members.

Hiring: A Team Venture

In a survey undertaken in May 2021 from the American Dental Association (ADA) Health Policy Institute, 70% of owners of dental practices reported that they found hiring of administrative staff "extremely challenging" and 80% reported equivalent difficulties in recruiting dental hygienists and dental assistants.² Workforce shortages caused by voluntary departures in the dental industry have been attributed to pandemic-specific factors, such as employees' workplace safety concerns and lack of childcare, as well as to a range of less easily quantifiable reasons, including "early retirements" and the need for better work-life balance.² As reported in ADA research of August 2021, 5% of dental hygienists who left or were laid off from their jobs at the start of the pandemic still had not returned to work, many of whom had reportedly left the profession permanently.⁴ Some practices have turned to temporary agencies to resolve staffing problems,¹ but according to anecdotal reports, some practitioners have noted that temporary staffing services often have had limited or no availability.² This workforce shortage in the dental industry has prompted the ADA President Cesar Sabates, DDS, and Executive Director Raymond A. Cohlmia, DDS, to request the Senate Committee in a February 2022 hearing to increase funding for the Oral Health Workforce Development Program.⁵

Because of this shortage of job applicants for positions in the dental profession, the stakes have clearly been raised for the interview process and for ensuring that the right candidate is hired. Considering the cost involved in rehiring to replace a potential "bad fit," prospective team members should be selected carefully not only for their professional qualifications, but also on the basis of their attitude, personality, communication skills, and perhaps most importantly, their level of motivation for building a career in dentistry. Current team members, in turn, can be instrumental in helping identify candidates who are best suited to join the practice. According to Allison House, DMD, chair of the ADA Council on Dental Practice's Practice Management Subcommittee, the ultimate goal of the hiring process should be to find the individual who will work well with your current team and who puts patient care first.⁵ Involvement of the team in the hiring process can be approached in any number of ways, depending on the preferences of the individual practice. For example, at the author's practice, the initial screening of applicants includes not only the standard job interview, but a process in which the applicant "shadows" the team for one day, which includes a 2-hour lunch with the current team. After this day of "shadowing," the team members convene to discuss whether they believe the prospective staff member would be a good fit. In the author's experience, this hiring strategy has proved to result in the successful recruitment of well-qualified team members. Including team members during the new candidate's job interview, either as a group or separately (or as a "tag team" interview), are other possible approaches. The ADA has several resources available for navigating the hiring process, including "Dental Team Staff Recruiting: The Interview Process," "Recruiting: Working Interviews vs. Skills Assessment," and "The Dental Hiring Challenge."⁵

Gaining Team Input on Practice Management Decisions

In the current workforce environment, retention of staff members is just as important as their recruitment. One important factor in retaining team members is demonstrating appreciation for their contributions and opinions, particularly by including them in decision making processes that affect the practice as a whole. The team members will amply reward the dental practice by serving as ideal resources for critiquing practice management options. When determining what new practice management software or patient communication systems to select, the practice's team should therefore always be involved and their advice solicited. In the author's practice, the business team typically interviews salespersons and tests multiple systems before the practice makes a final decision about a purchase. Entrusting the team members with this responsibility has in turn been shown to result in a higher level of ownership, pride, and job satisfaction. Team members can be included in determining what equipment purchases should be made, for instance, by attending lunch-and-learns hosted by sales representatives from trusted companies. If members of a dental practice are unable to learn about and test for themselves the latest advancements in, for example, oral hygiene instruments, they will be hard-pressed to recommend them to their patients. Teams ideally should be vested in what the practice is recommending as "Best in Class" for its patients, and this can happen only if the team members are actively encouraged to take part in decision making processes. In a study by Chilcutt⁷ that recruited ten dental practices for in-depth interviews, the researcher concluded that dentists should engage in participative decision-making processes that include staff members, as such processes directly affect the degree of team identification that staff members experience. However, in a recent study conducted in India, using a five-point Likert scale ranging from strongly disagree (score =1) to strongly agree (score = 5), only 50.2% (mean score of 2.97) of dental practitioners surveyed agreed that their practice encourages staff input for making changes and improvements⁶; the only other comparable study to date, conducted in Germany in 2015, demonstrated a higher mean score (3.89) for this same survey item, ⁸ but nevertheless indicated that much room for improvement exists in most teams with regard to soliciting staff input and opinions. 

FOSTERING COMMUNICATION

Clear and ongoing communication is key to creating an environment where optimal, relationship-based patient care can thrive. Patient-centered care models recently developed by clinicians and researchers in Canada and the United Kingdom have emphasized the importance of communication during clinical encounters and the need for dental professionals to understand patients' expectations and needs.^9-11 Patients have reported that they value interchanges in which clinicians take sufficient time to communicate not only about matters related to their dental health, but also about topics beyond those of dentistry, and that such conversations have been helpful in allaying general anxiety associated with the dental visit.⁹

While communication between the clinical team and patients is of paramount importance, positive dialogue and clear exchanges of information between other members of the practice team and the patient, and among the team members themselves, are also essential for the efficiency and morale of the practice. "Business is nothing but relationships" is one helpful idea promoted in team-building and coaching exercises. Indeed, facilitating communication among staff members is one of the more crucial leadership roles that a dentist must undertake, according to the ADA.¹² At the author's practice, one helpful strategy for inter-team communication that is implemented on a daily basis is a "morning huddle," where each department presents their challenges for the day and any possible roadblocks they may be experiencing, a brief review of the practice's goals, and a motivational message to start the day. This daily exercise has proved to be tremendously helpful in encouraging exchanges of ideas-and in preparing the team to meet patients' expectations before the day begins.

Communication During the New Patient Visit

While it is clear that the new patient visit represents the first opportunity to assess the patient and elicit the necessary information to make an accurate diagnosis of any potential oral health problems, dental practitioners should bear in mind the flip side of this encounter: the new patient visit is likewise the first chance that the patient has to assess the practitioner and the dental practice. Importantly, studies have shown that many patients select a dentist primarily on the basis of a perceived "good fit" in terms of relationship compatibility, rapport, shared values, and respect.¹¹

To this end, the new patient visit should also be viewed by the clinician and the entire practice team as the first opportunity to provide patient-centered care to the patient. Patient-centered care has been defined as a process consisting of four foundational components: exploring disease and its context, considering the patient as a whole person, demonstrating empathy and compassion, and finding common ground and sharing responsibility.⁹ Not coincidentally, these are the care components that patients look for in their dental provider. In a survey of individuals from underserved populations, who may be considered representative of those in greatest need of dental care, patients indicated that the qualities they valued most in their provider were friendliness and a respectful attitude, and that they felt the absence of these communication traits could lead to unproductive and potentially "harmful" clinical visits.⁹Patients also ranked empathy and good "listening skills" as important traits in clinicians, and stressed that having an unhurried visit in which sufficient time was allotted for communication with the clinician was a top priority.^9,11 Patient-centered care has furthermore been recognized within dentistry as a crucial factor in improving patient attendance at office visits, particularly as it plays a role in reducing anxiety associated with dental treaments.¹⁰

Generally speaking, personalized care applications work best when they are not reduced to a checklist of mandatory steps,¹³ as patient-centered care is essentially by definition an approach that emphasizes the individuality of the patient. As one group of researchers points out, a "recipe" approach would go against the very foundations of PCC; they also stress that "the way dental clinics are organized, which includes the composition of the dental team, may greatly vary from one place to another and influence the way professionals apply our person-cent[ered] model."¹³

Because communication that focuses on the patient's needs and concerns is central to patient-centered care, every member of the dental practice team should be familiarized with the overall communication style to adopt during the new patient visit. Although the "checklist" approach should be avoided, it is nevertheless helpful to have key questions, subject to flexibility, that clinicians should ask patients during the new patient visit. A protocol that has worked well at the author's practice begins with the treatment coordinator's introduction to the patient. At the start of the new patient visit, the treatment coordinator walks with the patient to the private consultation room to meet the clinician, who greets the patient with a warm welcome. A careful discussion then ensues regarding the patient's goals for their health, teeth, and smile. (It is worth emphasizing that this interview with the patient should not include questions about dental insurance.) The following are ten "key" questions that may (depending on the individual circumstances) be asked during this discussion:

1. Whom can we thank for referring you?
2. How can we help you?
3. Tell me more?
4. How does that make you feel?
5. What did your last dentist tell you?
6. Why are you seeking help now?
7. What are your long-term goals for your health, teeth, and smile?
8. Who else has input here (ie, are there any family members who would like to share their concerns about your health)?
9. Do you have a budget in mind?
10. When would you like to be finished [with your treatment]?

One of the most critical aspects of adopting this communication style is the clinician's personal outlook on his or her role as a care provider. The clinician may often need to reframe or reconsider his or her objectives in helping the patient decide upon a treatment plan; in other words, the clinician should refrain from telling their patients what they need, and instead prioritize listening to what the patients want from treatment. Ultimately, the patient interview should focus on eliciting the patient's feelings about their health and help him or her articulate their treatment goals (including the timeframe that they have in mind for these goals)-and it should facilitate the patient's commitment to working with the dental practice to achieve these goals.

ENCOURAGE CONTINUING EDUCATION

As an essential aspect of team-building, the dental practice should be committed to helping equip every team member with the resources necessary for personal professional growth. While team members of course greatly benefit as individuals from continuing education, their value to the team as a whole is also enhanced by these efforts. As mentioned earlier, soliciting the input of team members is an integral part of a fostering highly motivated practice team. It is therefore highly worthwhile to help further the competencies of team members through advanced education, as doing so will increase the value of their input across a range of practice-related processes.

Training and professional coaching, such as that offered by Jameson Management and Marketing, Spear Education, and others, should be provided for the staff on an ongoing or regular basis. At the author's practice, this investment has yielded tremendous growth in terms of productivity, proficiency among clinical staff, and staff retention. The practice can also encourage advanced education and continuing education for staff by facilitating access to programs offered by educational institutes such as Pankey Institute for Advanced Education, and Spear Education. Courses, seminars, and workshops offered by the Dale Carnegie Organization are another helpful resource for staff.

Technological advances in dentistry have enabled dental practitioners to provide their patients with an unprecedented level of care. Keeping abreast of these advances, which are continually evolving in today's environment of seemingly exponential technological growth, can be daunting at times, and team members may require guidance and mentoring in navigating what topics and courses most deserve their attention. For example, digital dentistry, including intraoral scanning, cone-beam tomography, and CAD/CAM dentistry, is a field that is rapidly and continually changing, and its tools have become priorities for most dental practices. Because dental assistants are key players in ensuring that dental procedures run smoothly, these staff members  need up-to-date knowledge of the digital technologies used in dentistry. Dental hygienists who are taught how to operate intraoral scanners can help expedite treatments by taking preoperative images or impression scans during the dental hygiene visit, thus saving the dentist time during the restorative phase of the treatment plan.¹⁴ Courses on advanced systems and innovative clinical techniques, such as advanced isolation systems and new strategies for providing pain-free local anesthetic injections, should also be encouraged. As mentioned earlier, lunch-and-learns hosted by trusted companies are another means of learning about new product advancements. E-learning and online continuing education courses have proved to be great time-savers for dental professionals of all types, as they enable learners to work autonomously and have more flexibility in terms of when and how to study.¹⁵ 

Cross-training of team members can prove to be another valuable approach to facilitating staff education; business staff can learn to perform a CBCT, load the autoclave, or perform basic assistant tasks. By the same token, the clinical team can learn reception and business tasks such as processing dental financing forms, so that they may help undertake these duties for the front office on days when the practice is understaffed in this area.

CONCLUSION

The dental practice that is best poised to deliver efficient, high-quality care is invariably supported by a dedicated team that is vested in the interests of the practice. Team-building, which has been beset with challenges during recent years owing to the COVID-19 pandemic, should be one of the foremost efforts of the practice's leadership. Recruiting and retaining top-notch team members is the necessary first step toward building any team, but a "snowball effect" of success is ensured when team members themselves are enlisted to contribute to the venture of hiring new staff candidates. Involving the team in other practice management decisions and in the collective concern of patient-centered care are other team-building initiatives that promote higher standards in the dental practice. Finally, the dental practice should nurture the personal success of individual team members by encouraging and facilitating continuing education both during the workday and beyond. Building a team and motivating team members to grow a career in dentistry will ultimately yield dividends for the practice for years to come.

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