THE PATIENT HANDOFF, when done correctly, can be the pivotal point to helping patients be healthy and schedule treatment. Done wrong or not at all, it can lead to a second opinion or, worse, leave a patient untreated. These real-life examples of common mistakes made during patient handoffs analyze everything from body language to information gathering and language. Study up, and you can help your office avoid making a fumble. SCORING THE PERFECT PATIENT HANDOFF How to help your team reach the goal, every time 84 SEPTEMBER 2016 // dentaltown.com
by Emily Miller-Lehr Emily Miller-Lehr has spent nine years as a dental professional and is passionate about dental office success. At 5 Fold Marketing, she helps dental offices grow online. Miller-Lehr educates future hygienists part-time as clinical faculty for Fortis College, and previously represented Philips Sonicare in Arizona and New Mexico. In her spare time, she enjoys traveling, hiking, yoga, Polynesian history, ceramics and time with family and friends. dentaltown.com \\ SEPTEMBER 2016 85
The scrimmage line Physical positioning is probably the primary mistake teams make. It s important to know what your body language is saying to your patients. How do you line everyone up? A scrimmage-line scenario: It s time for the exam and the hygienist-to-doctor handoff. The doctor walks into the room and I notice my room is missing a chair. No big deal, right? I ll stand and the doctor can have the only chair. The doctor pulls his chair up to the 11 o clock position and leans the patient back to thigh level. I think, He knows we re supposed to be seated at 5 and 7 o clock, but if he wants to hang out at 11 well, I m not his boss. Moving on, I confidently stand at my 5 o clock position and share information gathered from our appointment. The patient is interested in learning about Invisalign, the periodontal assessments were stable, and I noticed a brown spot where the patient is getting food stuck. The intraoral photo is blown up and onscreen so the doctor and the patient can see. Nailed it, I think. The doctor diagnoses a cavity on tooth 4 and says the patient is an excellent Invisalign candidate. With the patient still lying back, the doctor asks if she has any questions. She shakes her head. Second, laying the patient back and standing over her puts her in a vulnerable position. Remember: Some people have a difficult time gathering their thoughts during an exam, especially if problems are found. If she s afraid or apprehensive, this will further inhibit communication. In the above example, the patient was immediately laid back and the hygienist, chairless, stood over her while sharing personal information. This closes off communication, and lost communication loses treatment-plan acceptance. Instead, start your handoff at eye level and share important information before the exam. Lastly, in this scenario you probably noticed that I didn t believe I had the freedom to tell the dentist where to stand or what to do. This is huge. All team members should feel empowered to help the team reach the ultimate goal. Dentists, please have the it s OK to call me out politely conversation with your staff. Coping with the quick handoff Gathering the tools needed for a great patient handoff is critical. In the hygiene appointment, information such as chief complaint, blood pressure, radiographs, cosmetic With time and direction, we are able to provide optimum care, have meaningful patient conversations and perform clinical evidence-gathering, all of which leads to handoffs with great information. The patient goes to the front. She doesn t want to schedule her filling or Invisalign right now, and asks the front office to give her a call. What went wrong? I wonder. That was a rock-star presentation for the doctor. Well, yes, it might have been a rock-star presentation for the doctor, but body language wasn t helping the patient. First, the doctor diagnosing and speaking to the patient at the 11 o clock position (or in other situations with a mask and loupes on) cuts off communication and doesn t really allow the patient to ask questions comfortably. When communicating at the handoff, all clinicians should have masks and glasses off. Ideally the doctor, hygienist (or hygiene assistant) and patient should be in a triangle of communication: the patient at noon, and the doctor and hygienist between 4 5 o clock and 7 8 o clock. This allows for open communication the patient can comfortably make eye contact with both of us. 86 SEPTEMBER 2016 // dentaltown.com wants, intraoral photos of suspicious areas, missing cusps, recession, occlusal wear, bleeding points and probing scores should all be covered. In my experience, getting enough time to complete these duties for the handoff is critical to success. I m not suggesting that anyone wink at poor time management however, I ve worked in an accelerated model and it s a special challenge to complete a decent handoff. In essence, the dental hygiene assistant is giving the handoff to the doctor, after getting a handoff from the dental hygienist. This game of telephone leaves a lot of room for error and confusion. For the purposes of this scenario, we ll review a one-hour appointment. The quick-handoff scenario: Patient Lucy is due for her periodontal maintenance, full-mouth series of radiographs, oral cancer screening and exam. In this one-hour appointment, Lucy is running 10 minutes late. This office s policy allows patients to be up to a half-hour late. I seat the patient, take Continued on p. 88
Continued from p. 86 blood pressure, update medical history, take the radiographs, provide an oral cancer screening, take periodontal assessments and now, 30 minutes after the appointment started, begin the cleaning. I feel rushed as I start the maintenance appointment. During the cleaning, I notice some occlusal wear and a missing cusp on tooth 15. I ask Lucy if she wears a night guard or has noticed the missing part of her tooth. She denies both. We quickly review oral hygiene instructions. Due to the time crunch, there s no real opportunity for cosmetic questions. I notice malocclusion, but don t want to start a conversation for fear of running late the rest of the day. If it s important, I reason to myself, the doctor will cover it. I finish just in time to grab the doctor. He has about five minutes before I need to turn this room over for the next patient. Aside from feeling like an auctioneer firing words as I rattle through the cusp and the occlusal wear, things seem to go well during our superfast handoff. The doctor recommends a night guard and wants to crown tooth 15. I bring the patient to our consult area and say to the patient coordinator, Doctor wants a crown and a night guard. The patient turns down the guard, but opts for the crown. Why was part of this treatment plan denied? One answer that can t be ignored is that a rushed appointment weakens the handoff. Hygienists are often in a rush as we pass on intraoral photos and try to cover critical patient conversations. Even worse, I ve sometimes missed the handoff altogether because I needed to start the next patient in another room. Given more time, intraoral photos and great patient conversation that allows for questions could have saved the day. With more questions, communication and time, this example could have had a completely different outcome. We never asked if the patient wanted straight teeth perhaps braces or Invisalign could have been part of the solution. Maybe the patient has other cosmetic desires, like whitening. Slowing down may seem counterintuitive, but it increases the quality of care and your outcome. Also, the rushed time with the front office handoff, along with the poor choice of words (we ll get to that later), may have contributed to this partially accepted treatment plan. Ultimately, rushing an appointment means something will suffer. Later, I worked with the front office to create a new late-patient policy and scheduling policy that allows us to perform high-quality work through each appointment. The extra time has not decreased production; instead, the opposite is true. With time and direction, we re able to provide optimum care, have meaningful patient conversations and perform clinical evidence-gathering, all of which leads to handoffs with great information. For this office, the change has been a win-win situation. Calling the play Language is a key component in a stellar patient handoff. Using clinical or industry jargon, employing what I call minimizing language, and making first-person statements (e.g., I and me ) can kill a handoff. Here s the scenario: The patient, Suzie, is sitting up and the doctor and I are positioned to the left and right of her in a triangle, and the handoff begins. I ve had plenty of time to gather assessments and even chatted with the patient about her vacation to Hawaii. The dentist and Suzie greet each other. He turns to me: How were things today? Me: Well, Suzie just got back from vacation and wasn t able to use her electric toothbrush, so there was a little hemo 88 SEPTEMBER 2016 // dentaltown.com
when we probed. Because of the hemo, we re recommending laser therapy and irrigation today. Her periodontal probing remained within normal limits. On #3, under the amalgam, I noticed a little brown spot. Suzie says she notices that this tooth sometimes hurts and also gets a little food stuck in it now and then. We took an intraoral photo. (Photo is displayed largely in view of the doctor and patient.) Doctor: Great. Suzie, do you mind if I take a look? Suzie: Of course not. (The doctor lays Suzie back and performs exam.) Doctor: Emily, I see what you re saying #3 has a little carious lesion. (The doctor sits Suzie up and gets to proper conversation position with mask and glasses off.) Doctor: Well, Suzie, it looks like I m going to have to give you a crown on #3. Do you want a crown or a filling? We could try a filling or a crown and see how it goes? Suzie: I m not sure. Doctor: Let s try a crown. I walk Suzie to the consulting room where our office coordinator waits. Me: Hello! The doctor wants a crown for Suzie. I think she really needs it. Later, Suzie opts to wait and tells the front office it s really not hurting. Language killed this handoff. Dentists and hygienists routinely use jargon, but this insider language confuses patients and can make them feel as if they re out of the loop about their own health. Nobody outside of medical or dental is calling blood hemo or calling a cavity a carious lesion. When talking with patients, speak in terms they ll understand, using their language. Next, using minimizing language can leave a patient unsure of what s really happening in the mouth. For example, avoid using terms such as a little carious lesion, some plaque, or a few areas. Often we aren t talking about a little, few or some. We re minimizing what s happening to make the patient feel comfortable, but really we aren t telling her the true nature of her clinical condition. This leads to declined treatment plans and patients who remain unhealthy. In my experience, being specific, honest and direct works. Instead of saying, I m noticing a little bleeding or a few bleeding spots, we could instead say, As we discussed, bleeding is a symptom of a bacterial infection. I m noticing bleeding on every back tooth. This is specific, honest and direct. Another way to minimize the importance of a treatment plan is to ask the patient if she wants the treatment. I worked for a wonderful doctor who did this from time to time and I can assure you that the answer to, Do you want a crown? is invariably No. Nobody wants a filling, crown or periodontal therapy. It s a need, not a want. Also, patients aren t clinicians; they depend on the dentist s expertise to understand what they need. Finally, speaking in a first-person tense should be avoided. For example, I think you have a cavity or, I believe this is periodontal disease should not be used. Take the me and I out of the situation. This isn t about me (the dentist or hygienist) this is about you, the patient. This isn t about me wanting or having to give you a crown this is about you needing a crown. Using the first person in a handoff, or clinical setting in general, sends the patient the wrong message. The patient handoff is a critical component in reaching our ultimate goal of giving patients healthy mouths. I hope these real-life examples of positioning, allocating sufficient time and using correct language help you and your office in your quest for compliant, healthy patients. If handoffs are new to you, start by just practicing through role-playing. Keep assessing the process and ultimately you ll grow your practice and keep happy, healthy patients. n FREE FACTS, circle 30 on card dentaltown.com \\ SEPTEMBER 2016 89