Dental hygiene duties when paid by commission: The job description is often too vague

By Dianne Watterson, RDH, BS, MBA

Dear Dianne,

I’m writing to you because lately there have been many issues that have come up in my office. I’m a hygienist in a very successful, multimillion-dollar office. There are many days that I love my job. They offer great benefits, including paying for two-thirds of the cost of my medical insurance. We have seven hygienists and eight assistants working with four doctors.

The hygiene department is paid on straight commission, which has led to many problems in the office. We do not have a “base pay,” meaning that if we do not have a patient in the chair, we do not get paid.

Lately the assistants have been complaining, because they feel that the hygienists do not help enough in sterilization. A huge argument arose when the assistants left work over an hour early and did not finish making trays for the hygiene team as well as their own. We keep a log book of how often the sterilizers are started and who started them. A doctor at the practice took home this book to see how many times the hygienists have “helped” by running the equipment. We (the hygiene team) were under the impression that when we have some downtime and are waiting for a doctor to check our patients, we are to help as much as we can. But we did not know that we would be expected to stay late or when we don’t have a patient, to essentially be doing the assistants’ jobs.

The assistants have also recently decided that they will only be laundering our scrub tops and that we are to take or wear our pants home and launder them ourselves. (We do not wear any other form of PPE.)

I’ve read many articles before about hygiene pay on commission and that the only expectations should be to perform chairside hygiene, take care of our own instruments, and stock our rooms. Our office is expecting us to also catch up on the sterilization on top of all of our other duties. I am just seeking some advice if this is fair or if their expectations are a bit farfetched. What do you think?

RDH Needing Clarification

Dear RDH,

There are three separate issues swirling here: (1) petty jealousy and “pecking order” problems, (2) job descriptions, and (3) sterilization and laundry protocol. Let’s look at each issue and put things in perspective.

It is not that unusual to find petty jealousy between assistants and hygienists. All it takes is for one bad apple to plant seeds of jealousy, and pretty soon, the whole work atmosphere is toxic. The number one reason for jealousy is over pay differences between the two job classes. Hygienists are producers, and if assistants want to make hygienist pay, they should

do their diligence and get a hygiene degree. My question is who empowered assistants to make job decisions that affect their coworkers without management being involved? This brings me to the second problem of definitive job descriptions.

Every staff member should have a job description. And yes, someone has to be in charge of laundry, just like someone has to be in charge of managing the schedule or collecting money. If management decides that hygienists will be paid on straight commission, laundry is not one of their duties. It is a peripheral task not related to direct patient care. Sterilization is a necessary part of patient care, but it is peripheral to direct patient care. Setting up trays in advance increases office efficiency, but it is not part of direct patient care. All these tasks have to be part of someone’s job description.

The whole idea of commission-based pay for hygienists is primarily so that dentists don’t have to compensate hygienists when they don’t have a patient in the chair. Hygienists working on straight commission are not being paid to do anything outside of direct chairside duties.

Sometimes, assistants (who are typically paid hourly) do not understand that concept. Management can’t “have their cake and eat it too,” which is the case when they expect straight commissioned hygienists to perform peripheral duties. It is simply not legal to expect people to perform work with no expectation of compensation.

However, just to show you how people think, I was once approached by a hygienist who related to me that she was being paid by straight commission. She further stated that she did not feel she should be asked to perform periodontal charting, because it was not something she could bill separately. What?! I told her that periodontal charting is a part of direct patient care, and even though she cannot “unbundle” that task, it is her job to see that it gets done. It is just as important, if not more so, than scraping calculus off teeth.

The third problem is related to OSHA standards. Laundry is one of those subjects that seem to generate lots of opinions. For information, I consulted my friend and colleague, Noel Kelsch, RDHAP, who writes the infection control column for RDH magazine. According to Noel, scrubs function as a uniform and are supposed to be covered by a lab jacket or gown that covers the wrists, neck, and knees. Lab jackets and gowns are PPE and are required to be furnished and laundered by the employer. Dental personnel that do not wear lab jackets or gowns are exposing their arms and lap area to aerosols from a variety of sources. No jacket or gown means no PPE, which means the employer is in violation of the blood-borne pathogens standard by having employees launder exposed garments on their own. If your jacket does not cover your knees, your employer should not require you to launder your own garments. (See PPE requirements at osha.gov and search “PPE general requirements 1910.132. Also, search Blood Borne Pathogens 1910.1030(d)(3)(iv).)

As you might guess, straight commission is not my favorite way for compensating hygienists for many reasons. First, I believe straight commission creates a temptation to upcode or inflate treatment that a few hygienists will act upon in order to increase production. Second, it is inevitable that on some days the schedule will fall apart, and the hygienist will see very little take-home pay. That’s definitely a downer for a hygienist with bills to pay. Third, the team concept will suffer, which is precisely what is happening in your office. As jealousy builds, the office work environment can become toxic. The solution is clear job descriptions and firm leadership.

It would not be difficult for your office to figure out a fair and equitable base plus commission for hygienists. That way, hygienists can be paid to help out with the myriad of peripheral duties without compromising their commission.

In an office as large as yours, I recommend the position of office administrator (OA). This person should be in charge of making sure that everyone has a clear job description. The OA would also be in charge of human resources and ensure that no labor violations are occurring. A good OA will handle disputes like this with a generous helping of tact, fairness, and respect for all parties.

All the best,

DIANNE

RDH

DIANNE GLASSCOE WATTERSON, RDH, BS, MBA, is an award-winning author, speaker, and consultant. She has published hundreds of articles, numerous textbook chapters, and two books. Dianne’s new DVD on instrument sharpening is now available on her website at wattersonspeaks.com under the “Products” tab. Visit her website for information about upcoming speaking engagements. Dianne may be contacted at (336) 472-3515 or by e-mail at [email protected].