How to Find and Pay a Hygienist
As we progress with how to hire and pay various members of our team, one thing to remember is that you must discover the best way to find the top candidates. While Facebook, online ads, Indeed.com, Dentalworkers.com, etc., are certainly where most people start, there is a little-known secret that might just help a large percentage of doctors to find the best of the best. There are 30 plus states that are “open record” states. That means that you, the doctor, can access your Dental State Board site and actually view the names, addresses, any State Board actions against, and the year that their licenses were issued for any dental employee that has to be licensed through the state: Dentist, hygienist, assistant. The list is set up as a spread sheet which allows you to organize it by location, age (if we consider their licenses would have been issued at about age 26 for dentists, or about 23 for hygienists), and for assistants, the date of the license issuance would define experience. You might identify males and females by name, etc. You get the idea. Define your target and then send a personal letter to each potential candidate. It should be hand addressed, not a white #11 business envelope, have a real stamp (not metered), should have your return address but not your office name or doctor’s name, and have all the text fit on a single piece of paper. What you are really looking for is the best candidate. Not an out-of-work, average employee. I want someone that is killing it where they are and looking to move up in a better practice she or he chooses. I even put a collage of photos of my office and team on the back of the letter I sent. Here is an example to help you get started:
In your lifetime, you’ll spend more hours with your coworkers than you will with your significant other. The right coworkers should feel like family. Your work environment impacts how you show up where it counts the most: at home.
We make sure that those hours at work are as enjoyable and fulfilling as possible. No nights, no weekends, no emergencies. Most importantly: no negativity for you to carry back home. We provide a positive atmosphere, with owners who seek and receive input from our team. We entrust you to innovate with a great team – we don’t micromanage. For the right candidate, we’d love nothing more than to invest in your growth.
Don’t take it from me (I’m just the boss), take it from one of our team leads: “Even a bad day with this crew beats the best day anywhere else I have ever worked.”
- Open to coaching, mentorship, and performance management support (we’ve got your back)
- Engaged in patient flow and patient experience
- Excellent communication skills
- Sound decision-making skills, and contributing back to our community
- Ability to multi-task and take initiative
- Ability to drive a team and hold people accountable
- Strong attention to detail
Well written, inspiring, and anyone who is great at what they do will want to pursue the type of office that has this culture. Make sure you become the type of practice that would say the things in this ad as you move down the highway on this 180 Degree Dental Journey. Become that practice, that team, that leader.
Let’s look at hygienists and how to pay them. Much, if not everything, we discuss would also be applicable to associate doctors. I am probably going to get a lot of negative feedback from this area of the 180 Degree Dental Journey, but it needs to be said. I want to talk about underperforming hygiene departments. Whether you have one or a dozen hygienists you need to look at hygiene as the hub of your entire practice. They should be bringing in at least 33% of your entire production. They should partner with you to help patients want what they need while building up their doctor’s image in the mind of the patient. Cleaning teeth is the last thing on the list of important functions that hygienists perform. If you, like many others, find your hygienists are thinking their job is just cleaning teeth, you definitely will be challenged to grow your practice.
Not long ago I got bullied into reopening a Facebook account by one of my clients. While this may or may not be his real name, Nathan Ho is a great dentist with a great product called Envision Stars that creates a Facebook software that can add to your marketing outreach. Anyway, I reopened my account, and, at his insistence, I joined his group, Dental Win Win, as well as The Business of Dentistry and Dental Nachos. I like reading the challenges and the posts offering solutions to various predicaments. For the most part, I rarely respond to any questions in these groups. I am always surprised the range of solutions “posters” offer and usually with little or no understanding of the real problem. Yesterday someone posted about how expensive it was now to hire a hygienist and that in his area they were being paid as much, if not more than, an associate dentist. I read about 20 of the resulting suggestions and then just couldn’t help myself. It seemed that everyone was missing the point. I agree that hygiene pay has moved way out of the realm of reality when we look at pay, reimbursement, overhead, and profit. It is as if the universe of commerce and economics doesn’t apply to hygiene pay. As you read this keep in mind that my hygienists all took home over $150,000 a year and had medical insurance, 401k, continuing education, uniforms, a cruise once a year, etc. In other words, I want my hygienists to make more than they could anywhere else while partnering with them to offer the best service we could deliver to our clients.
I am going to state my case by offering a solution that is long overdue. If we begin with the end in mind, we should seek a system that allows our hygienist to make more and more while lowering the actual percentage of production/collections that they are paid. Reread this. They make more money and it costs us less of the overhead.
Here is the original post without the sender’s name:
I practice in the North Los Angeles area and have been interviewing to replace my hygienist. Every applicant has been asking $430-$500/day (regardless of how many hours worked, but will not work more than 8 hours a day). When asked what their daily production was at their previous practice to justify their salary, the majority of them did not know their production numbers. One applicant required 1 hour for 1 Quadrant of SRPs, while another told me she “prefers to work on her own terms”. Is this the norm for hygienists in the LA area or have I been dealt an anomaly hand of demanding applicants? What are you guys paying your hygienists, and how much time are they requiring for recalls and SRPS? If I remember correctly, aren’t new DENTIST graduates being offered $500/day in SoCal? Surely hygienists can’t be paid as much as a dentist??
Basically, the responses bordered on a pity party and weird off-hand quips with no real resolution to his inquiry. This was my response:
This is a wake-up call for the business of dentistry. For decades the average dental office has been increasing its participation with insurance companies. At the same time, we find that in the average city, 76% of the working population has dental insurance. Keep in mind that when you are in-network the reimbursement rate for hygiene procedures is at a much lower rate than other dental procedures. Looking back over the last two decades, reimbursement is less (write-offs of 50% or more for hygiene procedures), overhead is higher, and yet hygiene pay has not been impacted. This in in direct opposition to the fact that dentist employees (associates and even owners) pay rate has continued to be adjusted downward or stabilize in response to these economic pressures.
Please do this to see the actual impact of not understanding this reality. Run a production by provider report for all of the last 12 months. Then have your CPA or look at your QuickBooks and list the total pay for each hygienist. Be sure to include taxes, benefits, workman’s comp, continuing education, uniforms and the cost of an assistant if they do assisted hygiene. Just to be clear: You now have the total pay for each hygienist and the total production by each hygienist. (NOTE: You must have “net” production numbers – after all write-offs.) Divide each individual hygienist pay by their net production. While most hygienists are paid hourly or per day, this math will convert this format of pay to a percentage. Welcome to the reality of not understanding the business of dentistry. Most offices, for the first time ever, will see that the actual percentage paid to their hygienist is 35%-55%. Would you pay your associate doctor that amount? Of course not. Hygiene is not and should never be a loss leader. You would end up jeopardizing any profit you might reap. This is the basis and a strong argument to leave hourly wages or per day pay for any producer and replace it with a fair commission that would also allow other benefits. Don’t get me wrong. I want my associates, hygienists, and team members to make more than they could anywhere else. Net after expenses is the bottom line for a well-run and managed business. The ripple effect of this change will magically have your hygienists engineer their schedule to be more productive, recall will climb because hygienists will feel the pressure to inspire their patients to return, they will feel the need to be accountable for their performance because it will affect their pay for the first time. This form of pay answers every concern this doctor has about fair pay and time given for procedures. Our practices are consumer driven businesses where our patients vote with their feet and wallets. How you structure your pay has to be tempered by the realities of a sound business strategy. There is no position in our office immune to the effects of economics including our own.
So how do we reset the image that many hygienists have of their role in our practices? How do we find hygienists, how should we pay them, and how can we keep them as part of our team? How do we elevate the importance of their part in a successful practice? How can we create incentives and consequences to ensure their growth and engagement in the business of dentistry, while not having them act like a privileged prima donna where the world revolves around them? Why would this ever happen? Far too many hygienists and doctors just don’t get it. There is a pandemic of hygiene departments that just fail to launch.
Failure to launch in your hygiene department is the result of “no pain”. We are all familiar with the phrase: “no pain, no gain”. When you work out, that leg exercise, if done correctly and consistently, is going to hurt in a couple of days. Striving and straining increases the likelihood of physical gain. The pain of putting off gratification in order to succeed in life has become a worthy goal. When I say, “no pain” here is what I am talking about. If you pay your hygienist hourly you have created a one-sided accountability formula for mediocrity. Decades ago, we paid a cost of living raise every year to keep up with inflation. We even added a “longevity” raise for those that stayed with us for the long haul. We added benefits, better hours, technology to make their jobs easier and more productive. At the same time more and more offices increased their in-network insurance participation. This only drove up the cost of hygiene to the point of many offices losing money after paying their hygienists. As we raised their salaries, there was a greater reduction in reimbursements for what they did. So much so, that if you convert what you pay your hygienist in hourly wages to a percentage of what that dollar amount is to their actual adjusted net production, you will find that you are paying your hygienist 40%-65% of what she brings in. Just so you grasp this, if we factor in all of the costs of having a hygiene department, you are losing money and this cannot continue. Hygienists need to be affected by the economics of what and how they fit into an overall overhead and realities of the business of dentistry. Hygienists that are paid hourly do not feel the pain of:
- Cancellations and No-Shows: When someone does not show up for their appointment or cancels at the last minute, an hourly employee has no skin in the game: They feel no pain. They get paid whether they produce or not. Especially if that hygienist feels that making recall phone calls, reactivation efforts, or cleaning up a room for a busy assistant is beneath the station of an educated, degreed hygienist. Most good hygienists are more than willing to pitch in and help the team, but most good hygienists also should be responsible for their schedule by anticipating recidivistic no showers, and late shows. They should constantly follow their own schedules to be productive every minute of the day regardless of the circumstances. Your hygienist must be engaged to the point that they will not tolerate anything less than a 90%+ utilization each and every day.
- Few if any Scaling and Root Planing appointments: The number one indicator of a poorly trained hygienist and a marginal standard for clinical excellence in your dental office is having anything less than 20% of your patients needing Periodontal procedures. Hourly hygienists don’t feel the pain when they fail to keep up with technology, clinical excellence, and patient education. They get the same pay regardless of whether or not they continue to learn and care for their patients at the highest possible standard of care.
- Poor hygiene recall: This falls squarely on the heads of hygienists as they interact with their patients. 100% of patients should be scheduled for future appointments for cleanings and exams, by the hygienist, while still in the chair. The sad truth is that the national average is 41%. We spend all this money on marketing to attract new patients and yet fail to maximize our return on our current patient load by not continually and consistently caring for those already in the practice. Check for yourself. You will be horrified at what you see. Just look out 3 or 4 months on hygiene in your schedule and see what you find. Most of the time you will see 3 or 4 patients scheduled and those are all early in the morning or late in the afternoon. The very times that new patients will demand. Not only are they not pre-appointing their current patients, but they have undermined the front desk by not guarding the peak demand times that new patients will want. Poor recall happens when there is no pain.
- Weather: How many times have you made it to work only to find that only one or two employees show up, and none of the hygienists. If you pay hygienists by the hour, there is no pain or at least not enough to get them to try and make it to work. No pain, no gain.
- Poor production per hour in hygiene: Being paid hourly allows you to stop looking at your own productivity because you make the same regardless of the day. The office takes all of the risk while the hourly hygienist takes home an hourly wage. The reality of business is that systems that encourage mediocrity should be challenged. Hygienists and doctors are the only people who can control their productivity by improving their efficiencies and effectiveness.
- If you don’t measure a hygienist’s results: What is measured, gets done. That is why policy manuals, job descriptions, and benchmarks for every position are so important. They create a black and white score card for excellence. We measured the hygienist’s production per week, the number of scaling and root planings they did per week, and the number of crowns they presented per week. This was kept on a graph posted in the staff area where everyone could see. The hygienist was tasked with keeping this up to date weekly. While their job descriptions may have dozens of other requirements, these three areas, if done well, will insure a super productive hygiene department that will continue to grow while offering the hygienist an ability to improve what they are paid in a commission based or hybrid pay system.
- Every recall patient gets an hour: In the face of increasing managed care and decreased reimbursements for hygiene, with the advent of technology to clean teeth better and faster, the use of electronic practice management software, hygienists continue to want more time for cleanings. Hygienists should have net adjusted production numbers of at least 3 times what they are paid. Hygiene should bring in at least 33% of your total collections. Because of a lack of knowledge of the business of dentistry, we have failed to react and adapt to an entirely different dental economy, and this is going to destroy your practice.
While we could probably add a few more areas where there is no pain in an hourly based pay scheme, I think you can see how consequences create an accountability that drives hygienists to re-engage in their jobs while understanding the business of dentistry. A bit further down the road, we will add profit sharing to everyone’s bottom line in the form of a “bonus system”. Like any trip, there will be challenging decisions to make and hazardous obstacles to avoid. Hygiene pay has been long over-looked and avoided by most practices. Now is the time to help your team understand the business of dentistry.
Michael Abernathy, DDS