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Many of the articles I write are as a of result of questions I receive by phone or email. Below you will find an emailed question from a doctor’s office. As is true in most things, asking the right questions will give you a better result. In this case the question was innocent enough but it belied a deeper question that never got asked. Why would you want to have a separate hygiene bonus? What do you think a “bonus” would accomplish? Is this strategy a last ditch effort to fix a symptom of a problem rather than the actual problem? Most doctors major on symptoms rather than on problems. “I have an accounts receivable/collections problem” (symptom – where the actual problem is poor financial arrangements). Or “I need more new patients” (symptom – where the actual problem is a lack of consumerism). I hope the logic of this shines through the question and answer below. When legendary football coach Vince Lombardi was asked how he motivated his players, he responded: “My job isn’t motivating my players. My job is to keep 11 motivated players on the field at all times”.

Dr. Abernathy,

Can you give me some good examples of a hygiene bonus system? I am trying to base it on their production per month and how many appointments they have open at the end of the month. Let me know your thoughts. Thanks!

I would never create a stand-alone hygiene bonus system. Instead, I would create a commission based pay system for the hygienists in your office and create a “team bonus” shared equally among the entire full-time staff. Creating individual bonus systems is the quickest way to subvert a team building effort by establishing a system or protocol that rewards one group while excluding others. It creates an “us vs. them” mentality instead of a more desirable mindset of “this is our practice” and rewarding a united group effort.
Hygienists and doctors are the only ones that can actually increase their productivity through engineering their schedule by being both efficient and effective. The traditional model of paying them by the hour only creates an hourly schedule where every hygienist, regardless of patient needs, takes exactly an hour to see a patient on recall. Are you kidding me? There should never be a patient who needs exactly an hour: Maybe 42 minutes or 63 minutes, but never exactly an hour every time. You basically will have created a system that rewards poor results. Your question brings up several areas I would look at.

1. If I asked your hygienists if they were pre-booking their recall patients in the future they would all say yes. If asked what percentage they would all reply over 90%. So do this: Go out 5 months and see what is really happening. One, they will only have 3-4 people scheduled and scheduled only during the early or late hours of that future day which means that they booked over the only hours that a new patient would want: Peak demand times of 7-9 AM and 3-5 or 6 PM. In this case they have lied to me and are not doing what they said they did. Two, you look and find the whole day is full and once again there is no room for a new patient. Both scenarios are horrible because they handicap the office in the realm of a healthy recall system. 67% of all of the production on the doctor’s schedule comes out of hygiene recall. You should always pre-book 100% of your recall patients for the exact amount of time they actually need, but you only pre-book 70% of any future day while making sure that you save the peak demand times for new patients. The other 30% would be placed in a second column knowing that when that time rolls around you should need to hire another hygienist.

2. Look at your practice management software and look up the demographics of your office: Male to female ratios, area codes from which your patients come, age percentages of your patients, those that have insurance and the number of current patients who do not have an appointment. You goal is to have over 80% recall. If it is below 40%, you occupy the Hall of Shame and pay for it by an increased overhead because you continually spend money to chase new patients while you actively omit any system that propagates keeping the ones you have.

3. Look at the number of new patients you get monthly. An average office with terrible hours (8-5 M-T-W-TH), few services, and poor consumer practices get 30 per month or about 360 per year. A hygienist can only see about 500 patients a year if they see them twice a year, and fewer if you do a lot of perio or have more frequent recall visits. That means that if your office actually inspired the new people that came in you would need to hire another hygienist every year and a half. If that is not the case then there is something drastically wrong with your office. In most cases, offices find a tipping point of losing as many patients as they get and find themselves in low/no growth limbo. If you are not growing, you are not meeting your patient’s needs.

4. If you don’t have at least a 50% direct referral rate from existing patients, and I said at least, then your time would be better spent finding out why people don’t like you and fix it. Any percentage less than 50% means a majority of patients that come to you don’t like something. Consumers vote with their feet and in this case they have voted you off the island.

5. Never use money to try and motivate people. When hiring, you need to understand that you hire for two traits: People skills and internal motivation. Everything else can be trained/learned. You can never train people skills or internal motivation. You would just waste your time. On the other hand, creating a “profit sharing” system that rewards all of the staff equally for a more profitable and productive practice makes sense.

6. There needs to be twice the number of hygiene hours as doctor’s hours. That means at least two hygienists per dentist to insure consistent growth.

7. Hygienists should produce at least three times what they are paid. Pay would include taxes, salary, uniforms, benefits, continuing education, everything. Not just the net amount on their paycheck. While I never suggest assisted hygiene, if you are doing this, then that three times pay would include the pay for the assistant also.

Back to your original question: I realize you didn’t expect such a complicated answer but staff salaries should not exceed 25% of office collections. Everything you do creates a certain culture in your practice, so everything matters and has some form of a ripple effect on everything else. Let me suggest that you take the time to read these articles: How do you recommend compensating a hygienist?; Learning How To Present Change In Hygiene; To Bonus or Not to Bonus; and The Bonus Question — One More Time. Then give me a call and we can have an in-depth discussion of what this should look like. I look forward to speaking with you in the very near future.

Michael Abernathy, DDS
972-523-4660 cell
[email protected]