Tracking, Analyzing and Preventing EMERGENCIES

“If that wire bothers you, just come on in and we’ll clip it for you.” Does that sound familiar? Although the statement is friendly and supportive, wouldn’t it be better for both the patient and the practice if the patient didn’t need to make a special visit to the office for a clip or repair? What we have traditionally called orthodontic emergencies come in all shapes and sizes – the typical wire clip, a loose bracket or band, or missing separators. It is common to accept these situations as a normal part of practicing orthodontics; however, the entire orthodontic team and patients feel the stress and endure the deleterious effects they have on the practice.

As part of my clinical consulting, I conduct informal interviews with patients and parents. Their candid replies offer great insight into the public’s perception of the office, staff and doctor. Most patients and parents are very happy with the doctor and staff but express concern for the extra emergency trips to the office. Their tone of voice begs the question, “Can something be done to improve this?” Evaluating and understanding the type and source of emergencies is essential to enhancing their comfort and overall experience with the office.

Every emergency you encounter is expensive in lost time and takes profit out of your pocket. Each emergency individually may not seem costly but when you multiply several emergencies per day by the weeks and months in each year, the costs are significant in many practices.

Many teams could go on a European retreat every year for the money that is lost treating avoidable emergencies and excess appointments.

BEWARE OF EMERGENCIES IN DISGUISE

Often emergencies are disguised and waiting to be uncovered at a regularly scheduled appointment. Teams who communicate to their patients to call the office when a problem arises typically receive more calls than those who do not. In many practices often the problem is uncovered at the regular appointment, creating havoc with the appointment schedule and in some cases extending the patient’s treatment time (particularly if the repair is rescheduled).

With increasing costs and an unclear economy, the importance of practicing in the most efficient and effective way is essential for the spirit and health of the practice. Tracking the details of problems found during special visits and problems found during regular appointments, defining the cause and time needed for their resolution, and calculating the percentage of these procedures provides valuable information so corrective procedures can be developed and measured for efficacy. To calculate the impact in your practice, conduct a minimum two-appointment cycle study. Record every problem that is not in the treatment plan. Devote doctor time to see each special visit patient to aid in the analysis. Then, take the total number of clinic hours per month and divide this number by the hours spent during special visits and any repairs. For example, if a practice has 120clinical hours per month and spends 12 hours during this time repairing appliances, 10% of clinical time is consumed with nonproductive activity. Ideally, the total percentage of all repairs (scheduled or found at the chair) should be 5% or less.

To effectively change the situation, analyze each special visit to develop preventative measures. Using a detailed emergency analysis form will provide the basic information needed for change. Use the form entitled “Patient Emergency/Repair Slip” to track patients who call with an emergency as well as those who come in for a regular appointment and need a repair. Keep a set of forms at the front desk and in the clinic.

Collect the forms weekly and then analyze the problems and frequency found at the chair and the percentage of time required for those extra procedures. Discuss ways to reduce problems by modifying protocols. Evaluate product quality, improve patient and parent education and/or pro-vide additional chairside training. Receptionists can be trained to offer over-the-phone solutions for some emergencies, preventing the need to come to the office.

When patients arrive with something loose, broken or poking, it is important to ask yourself, could this problem have been prevented? Could something have been done differently? Here are just a few examples of problems that could possibly be avoided with specific protocols.

STRESS PROPER BONDING PROCEDURES

Because proper bonding is a cornerstone of effective orthodontics, every clinical staff member should know proper bonding procedures and why each part of the procedure is critical to bracket retention throughout treatment. Shortcuts can lead to a loose bracket months down the line, making it difficult to link the action. In addition to giving attention to detail during the bonding procedure and providing excellent patient education, check the patient’s bite after bonding to see if the patient is occluding on any of the brackets. I sometimes hear doctors say, “Just try not to bite down hard.” A few hours later the patient returns, complaining of a bracket being loose. Ideally, check the occlusion during diagnosis to determine if Bite Turbos or occlusal buildups are indicated so that the appointment time can reflect the amount of work required.

HOW TO HANDLE HI-TECH ARCHWIRES

Many orthodontists are now bonding brackets 7-7and using lighter, more flexible archwires. These wires have a tendency to slide, irritating the patient. Crimpable stops can be used on the archwire to reduce sliding. Dimpled archwires can be used, although care must be taken to prevent the “V” bend from migrating into the bracket slot, causing tipping of the central incisors. Dimpled wires are used most effectively with self-ligating brackets. For those offices that band the terminal teeth, anneal and cinch wires to prevent sliding. (Of course, this would not be advocated in cases where you wish to increase arch length.)

PROMOTE PATIENT/PARENT EDUCATION

Good communication with your patients and parents starts at the beginning of treatment. The clinical team has a great opportunity to be educators to new patients. Remember that the words you use may sound like a foreign language. It may be the one-thousandth time you’ve said something this year, but it’s the first time they’ve heard it. Their confidence in the entire team will increase if you take the time to appropriately explain the appliances and their function. People learn best when they can see a visual, hear the explanation and then touch or even practice with the appliance. Prepare a hands-on show by letting them hold a band, bracket, wire, elastic or expander. Explain each part and how it works. Include a diagram to support what you say. Explain the importance of checking their braces everyday when they brush their teeth. If something becomes loose or broken, the patient can then be more precise about describing the problem. When the patient or parent calls the office, you can better schedule the repair visit.

REMEMBER THE MAKEUP OF YOUR AUDIENCE

Little Cindy Lou is sitting in the chair for her first delivery appointment. When you’ve finished, you look at her with great sincerity and give her a lengthy description of all the instructions she is supposed to follow. Can she realistically remember all that information? The attending assistant then flags down the parent in the waiting room and briefly describes some instructions. It is more effective to invite the parent and patient into the operatory or patient education area so that both hear the same information at the same time, and whenever possible, divide the information into smaller, bite size pieces. Some information can be given at the previous appointment followed with a question and answer review at the subsequent visit. You can make it fun by rewarding them for having the correct answers. Additional wooden nickels, ortho bucks or a coupon for a frozen yogurt can be a good incentive. Many offices also give well-written instructions for the family to refer to later.

SCHEDULE ONGOING STAFF TRAINING

I routinely see a common thread that runs through practices regardless of the size, location or age. That is how differently each assistant performs procedures. It is vital to the practice for every assistant to follow protocol for each procedure they perform, from preparing for bonding, to fitting bands, to how an archwire is tied in. To ensure continuity, it is important to review the protocols and confirm understanding. Monthly training sessions that include all employees, regardless of seniority, can be extremely valuable. More-seasoned staff members can work with the doctor to provide training so it stays interesting for them as well. Cover a different procedure every month throughout the year, and then at the beginning of the next year, start all over again. Continual training keeps the staff on track, aids in cross training and helps prevent emergencies. These suggestions are just the beginning. Once you start to closely study the specific situations, you will be able to develop your own protocols to reduce procedures. Even after the initial study, statistics should still be kept to watch improvement over time. This insight will provide answers for making each patient visit a productive, efficient and enjoyable