Rachel Wall provides insights into creating and implementing effective practice standards to improve patient outcomes and team alignment.
About Rachel Wall
Rachel Wall is the founder of Inspired Hygiene, where she and her team provide coaching, workshops, and other products to help dentists in their pursuit of hygiene department profits. Rachel also serves the dental community as a consultant and speaker. In addition to private coaching Rachel draws from her 20-plus years of experience as a hygienist and practice administrator to deliver focused clinical articles and speaking programs. Rachel has written for, and been featured in, numerous industry journals including Dentistry Today, Progressive Dentist, RDH, and Hygienetown. She recently received the 2012 Dental Excellence Award from DrBicuspid.com for “Most Effective Dental Hygienist Educator”.
About Alex Nottingham JD MBA
Alex is the CEO and Founder of All-Star Dental Academy®. He is a former Tony Robbins top coach and consultant, having worked with companies upwards of $100 million. His passion is to help others create personal wealth and make a positive impact on the people around them. Alex received his Juris Doctor (JD) and Master of Business Administration (MBA) from Florida International University.
Transcript performed by A.I. Please excuse the typos.
This is Dental All-Stars, where we bring you the best in dentistry on marketing, management, and training. Here’s your host, Alex Nottingham. Welcome everyone. Our topic is practice protocols versus provider protocols, and our guest is Rachel Wall. Rachel is a CEO and founder of Inspired Hygiene, a coaching firm focused on elevating hygiene services, systems, and profits. She is an award-winning educator.
author of the book, Return on Hygiene, and has spent the last 30 years serving the industry as a clinical hygienist and hygiene productivity coach. Please welcome Rachel. Hi, Alex. Tell them practice protocols, provider protocols. Okay, this is a little over my head here. I’m not the clinical person. What is all this? Okay, so in the last few years, right, a lot of dental practices we’ve seen have had change in team.
And one of the things that we’ve heard from our clients, and really this is something that’s happened for decades, is, man, we had a great periaprotocol, and then our hygienist left and now we have nothing. Or we had a protocol in place, and then we hired a new hygienist, and that hygienist came in and changed the protocol, because there was a different way that he or she wanted to do things. So what we’re really teaching, and one of the things that we help our clients do
protocols for the practice so that we have practice protocols rather than provider protocols so that we have these standards of care, the practices have these standards of care in place and they’re founded on science, right? And the team participates in creating these standards and they stay in place regardless of who comes and goes within the practice. Okay.
can tell me more. Okay. So these protocols are things, they can be anything from how we diagnose and treat periodontal disease. It could be what adjuncts we use with patients that have periodontal disease, what we do during a periodontal maintenance, do we use adult fluoride, what types of, when do we take blood pressure? So all of these are critical clinical pieces.
that keep the ball rolling and create that continuity of care for the patient and deliver that level of outstanding care. But it’s really, it is interesting, Alex, is sometimes they’ll have a change in team member and all of a sudden none of those things are happening anymore. And often it takes the dentist a few months to recognize that. Yeah. So that’s where really focusing on, hey, we’re creating as a team, these practice protocols and what we believe in clinically, and then those really staying in place.
So, and then it becomes part of that onboarding process, right, for any new team members is here are our standards, here are our practice protocols and systems. So what I’m thinking as an attorney, we have our standard of care, which is what we have to do so we don’t get sued. Then we have certain protocols or processes so that we create a great experience. So we can add on to the standard of care and we have to make sure that those protocols are where they need to be.
start, I like to start like big picture and then kind of come down a little bit into this. So what are you, what’s the outcome of, of a good, uh, what does that look like to have great practice protocols? Well, it looks like everybody being on the same page, you know, everyone on the team understanding the value of what it is that we’re delivering. So if you have a practice, um, and you have three hygienists, for example,
What we see a lot when we work with our clients is there’ll be varying thresholds for, let’s use periodontal disease as an example because that’s kind of hygiene, you know, other than preventive care. It’s our primary, you know, therapeutic service, we’ll say. So if you’ve got three hygienists and you have varying thresholds that each of those
make the diagnosis with the doctor of periodontal disease and begin treatment. Then if a patient sees Rachel one day and then they see Heather the hygienist another day, the patient can get really confusing messages if they’re not hearing the same thing from both of them. So the big picture is having clinical protocols that are consistent with the vision and mission of the practice according to the practice owner.
And then how do we as a team execute on those protocols so they support that vision and mission? And that involves everybody, not just clinicians. So certainly if I’m a hygienist and I have a patient that sits in my chair, I’m responsible for the data collection and collaborating with the doctor to come up with the proper diagnosis. If I am a business team member or a treatment coordinator,
then my responsibility is a little bit different, but it’s just as great to take that treatment plan and then communicate to the patient or reinforce with the patient the value of that treatment that the hygienist had earlier communicated. And then, you know, if I’m a dental assistant and the patient comes back, let’s say, you know, three months later for a restorative procedure and we see that we’ve recommended periotherapy,
and the patient has moved forward on that. What about a dental assistant saying, hey, I noticed this when you saw Rachel, you know, I’m noticing some bleeding when we were doing this crown, your gums are obviously inflamed and doctor and you know, Rachel had recommended this type of treatment. Tell me about that. Tell me about your thoughts on that. How can we help you move forward with that? So the ultimate goal is that those clear clinical processes and philosophies are in place that they’re written.
And then when a new team member comes in, then the existing team is educating on, hey, here’s how we do things here. Rather than a new hygienist coming in and there’s no protocols in place, so they’ve got to do something, right? They have to create some type of framework for diagnosis and care. So they create it themselves. And then all of a sudden it becomes that provider’s protocol.
And they take ownership in it, right? Because they created that, but it might not line up with what the doctor has envisioned for the practice. And it might be completely different than, you know, the other, the other clinicians, that’s kind of the big picture look of, of why we should do this. I love it. I love big picture. And I like the vision and mission you were talking about. What are things or what are, what are practices doing wrong that you’re seeing when it comes to standard of care and protocols? Yeah. What are some of the common mistakes?
Number one is not having anything written. So there might be something like, oh yeah, we talked about that, that we were gonna start treatment when we see bone loss and five millimeter pocket depths and bleeding, but they don’t have anything in writing. Or the other thing is they have a star hygienist and let’s say their partner gets a job in another city and then they leave and then all of a sudden the patient’s
were receiving this really high level of care and being carefully monitored, if they’re in periodontal maintenance, and then all of a sudden unbeknownst to the patients, they’re not receiving that same level of care because no one ever wrote down that protocol and nobody ever really knew what the thresholds were when we moved the patient into care or when we refer the patient out to a specialist, for example. So I would say what…
what we see a lot is just not having any protocol in place at all. And not only knowing when to diagnose and treat, but then how do we, like, what procedures are we using? You know, what have we found? What has been, you know, in our own anecdotal experience to be beneficial to our patients to help them get well, if it’s like an adjunctive service? And then is there research to back that up as well? And then I think just,
uh, avoiding the conversation and what tends to happen with hygienists that or practices that don’t have a very clear protocol for how the hygienist hygiene team operates is the default is to do a profie with every patient, regardless if that’s appropriate, because it’s just like the easy, it’s kind of the path of least resistance, right? So that’s what we see a lot. How do teams create their practice standard of care?
So, you know, nobody likes to be told what to do. So you have to do this because you work here. So we always, when we’re guiding teams in developing the standard of care, and this is something we facilitate during our coaching time with them, is there has to be participation from the team, particularly if we’re creating a hygiene protocol, right? Obviously, particularly the hygienists need to participate in that. So that it’s not a, you know,
the doctor kind of sits over the weekend and creates this plan and says, okay, this is what we’re doing. And nobody has an opportunity to give input or the consultant creates it and says, okay, this is what you should be doing. And, and then, you know, works hard to kind of put that square peg in the round hole instead of saying, okay, here instead what we do is say, okay, here are the, here are the standards for health versus disease as set out by the American Academy of Periodontology. So not Rachel Wall, right?
but this body that has a lot of experience and a lot of research and a lot of data to support these recommendations. And so then what, so where do you fall on this spectrum practice team? And what have you found to be most beneficial for your patients as far as like, okay, I’ll give you an example is, one of the things that we see a lot is that there is no continuity between when we’re collecting diagnostic data
to make that diagnosis for periodontal disease. So it used to be, I’ll say 20 years ago, when I first started Inspired Hygiene, it was just me. I would go into practices and not, it wasn’t that uncommon that they didn’t even have a periodontal probe on the tray in the hygienist operatory. So clearly they were not, you know, diagnosing. Now I think in our world, the way technology is being developed, we’re probably not gonna be using the periodontal probe that much longer.
But for right now, it still is part of our armamentarium for making that diagnosis. And so now what we see is that there’ll at least be a partial periodontal chart maybe once every one to two years, but we do clinical chart audits. And so we even look between hygienists. This hygienist is doing a complete periodontal charting once a year, and this one is not. It’s about calibration as well. So…
I kind of got off on your question was, how do teams do this together? So it’s a collaborative model, right? And in order to grow in any endeavor, we’re going to have to get a little uncomfortable, right? So if we’re wanting to grow our fitness, for example, we’re going to have to exercise to a point where we’re uncomfortable. And so if we’re wanting to grow the level of care that we’re providing for our patients,
what we’re treatment planning, maybe a little more proactively. And that’s just part of that growth process. However, it’s important for those that are providing that treatment like the hygienist to be willing to say, okay, all right, so that if we’re now diagnosing periodontal disease at this level, and we’re recommending, you know, periodontal therapy, non-surgical scaling root planning, for example, at this level.
that’s different than what we’ve done in the past that it makes me a little bit uncomfortable, but I’m willing to go for it like, okay, tell me more. Like what’s the benefit for the patient? That’s typically what teams wanna know, right? If they’re being asked to go out of their clinical comfort zone, what is the benefit of me doing this for the patients? And so it’s just being able to have a conversation about these standards to the point where the final decision maker is the dentist, right? But to the point where the team says, okay.
I understand that we are taking things to the next level and here’s why, because it’s going to provide the patient with XYZ benefit. And so for that, I’m willing to agree to these standards. Now what if the team is not on board? What if they’re not following the standards? So then you’ve spent time. So this takes, this is like…
you know, those investments of time that we have with our team, whether we call it a team meeting or a planning meeting or whatever it is. So I’m assuming in this instance, we’ve taken the time and the team has collaborated on that standard of care. They’ve, I mean, you could even have them sign off on it in the, you know, in the guidebook for the hygiene department. And then what you’re noticing as a dentist is you’re going in and doing the exams and all of a sudden, there’s bleeding everywhere and
you’re seeing that there’s bone loss on the x-rays, but yet the hygienist says, okay, well, there’s a little bit of bleeding. We’re going to check it again next time when you agree that, hey, when we see this, we’re going to stop and we’re going to have a discussion on whether or not it’s time to move the patient into therapy. Um, so in that instance, it needs to be a conversation that happens with the dentist and the hygienist is, Hey, so, you know, here are our standards of care. Bring those out, right? We, we work through all of this.
And what I’m noticing is that it seems that your standard of care is differing from this. Like your threshold of when you feel like we’re, when we see this, we’re moving them into care is not matching up with us. So how can I help? Tell me what’s going on and just listen. And it could be that, you know what, I’ve been recommending treatment at that level and I feel like I’m continually getting pushback from patients.
Or it could be, you know what, I know that we agreed clinically that we were going to recommend treatment at that level. But, you know, I’ve been going out to lunch with Linda, who’s our insurance coordinator, and she’s telling us that it’s getting denied every time we submit it. And those conversations haven’t been brought to light. And so you’ve got to get to the bottom of like, why? And sometimes it comes to the hygienist just saying, I don’t believe that. I just…
I believe I can treat periodontal disease in a profie and I don’t think our patient should have to pay for that treatment. And then as a leader, you have to decide, does that match your vision and mission for the practice? Makes sense. Now, on a daily basis, we went from the big picture, you know, and down. How does this play out the standard of care on a daily basis with the team? So it gets the standard of care gets so detailed.
I mean, it can be as detailed as you want it to be, and it can be for all the different aspects of clinical care. And I think as dentists expand their practices with associates, right? Again, we’re not telling people how to practice, but we’re providing these guidelines of, when we see a, it could be something like, when we see an MOD on a premolar, maybe your practice, your clinical philosophy is,
that if it’s a certain width, it’s gonna become a crown instead of another three surface filling. And the way that that guides day to day is those clinical decisions that are being made, right? That thought process of, okay, so this is what our standard of care says is if I’m seeing bleeding, I’m seeing bone loss, and I’m seeing clinical attachment loss slash pocket depths of a certain level, then I’ve gotta change the conversation I’m having with this patient today. And
that takes time for those changes to happen in our mind. And so what we do, you know, some practices say, we’re full in, we’re going to practice a standard of care with every patient that comes in now, from now on, no matter what. And some say, you know what, we’re going to, we’re gonna ease into this and we’re gonna look at who are the patients on our schedule today
untreated periodontal disease and they’re at, let’s say, a higher level of active infection. And we’re going to present treatment to them. And we’re going to get that communication muscle, that treatment presentation muscle really strong. Then we’re going to go to our patients maybe that have early periodontal disease, and then we’re going to start presenting to them. So sometimes we have to kind of ease into the use of the standard of care. But really ultimately what it does is it changes our whole, it can change our whole workflow.
Now, I suggest if you’re in a situation where you’re like, okay, we’re not taking blood pressure, we’re not doing all cancer exams, we’re just in this rut where the patient sits in the chair, we say, have you had any changes in your health history? And then we start scaling in five minutes and that’s not uncommon. And we really wanna completely rework our whole hygiene workflow so that it’s more health focused and we’re doing these diagnostics and we’re really
then it can’t just turn on a dime in one day. So you might wanna pick one thing, right? One of those standards of care, we’re gonna apply this for 60 days and get really good at it, and then we’re gonna add another one. So it might be, we’re gonna start by taking blood pressure on every hygiene patient. And then when that’s a habit and it’s part of our workflow, then we’re gonna insert the intra and extra oral cancer screening. And then we’re gonna do that for 60 days.
and come back together. How’s it going? Yeah. But it really, it really guides our whole, all of our clinical decision-making. Yeah. I like that idea of chunking it down little by little demonstrating that you can do it and then moving from there. Yeah. Well, Rachel, so you have some links for us that I can put in the show notes. What do you have for our listeners? Yeah. So I would say the guide that is, um, or the tool that’s the best to really develop this is our standard of care worksheet.
And so I know you’ll include the links, but everybody can go to inspiredhygiene.com slash standard of care, and you’re welcome to download that worksheet, use it as a guide, change it up, however you wanna utilize that. Hopefully it will be a good starting point so you don’t have to start that process from scratch. Excellent, well, Rachel, thank you so much for being on our program again
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