Who is at "risk" and why

1. Eliminating the risk;
2. Eliminating activities that produce undue risk;
3. Insuring for uncontrollable risk;
4. Informed consent;
5. The establishment of standards, controls and regulations.

Patient Concerns

Assessment of Risk

Cost:	HIV, hepatitis or other serious infection of patient, staff or dentist. Dentists reputation if office is perceived as "dirty". Decline in recall appointments.
Probability:	Probability is moderate but all strata of society are aware that it is possible to "catch" an infection at a dental office.
Control:	Universal blood precautions.

Assessment of Risk

Cost:	Occasional overexposure of patient. MoH or patient complaint to College about lack of compliance with HARP (Healing Arts Radiation and Protection Act) regulations. Lengthy explanations to patient(s). Dentist's reputation.
Probability:	Risk of discovery of lack of compliance with the Act is genuine and penalties have been assigned.
Control:	Comply with legal requirements by adhering to standards.

A rising concern is the patient's perception that they are not receiving value for their money in dental care. This is a combination of the current recession, the fact that most patients feel dentists are paid too much and in some cases, feel that they are simply being "processed" through an office. The predisposing factor is the high cost of treatment and the precipitating factors can be a hygienist who begins treatment without explaining to the patient what she is about to do, or a dentist who chats to his/her staff without consideration of the patient undergoing treatment in the chair. This combination "sets the patient up" for anger and frustration if anything goes wrong with the dental product.

Assessment of Risk

Costs:	Complaints about treatment rendered (product).
Probability:	Complaints are bound to occur, but with the public attitude that dental fees are too high, any of a number of precipitating events can stimulate the perception that they did not receive value for their dollar. This trend is expected to increase unless fees fall precipitously and this is impossible due to the rising costs of dental care.
Control:	Your patients must perceive that although dental fees are high, your office provides both superior product and service. This will increase the value: cost ratio in their mind. You can't buck attitudinal trends but you can educate your patients about why the costs of dental treatment are high and demonstrate your superior service.

Patient Desires

In today's service industry it appears that good service not product superiority or low prices determine ongoing success.

Staff Concerns

If patients are concerned about infection in your office, you can be sure your staff are concerned about infections from your patients. This is a clear example of how different people see "risk" through their own eyes. You must always assess and control the risk for each major stakeholder. If you have a set of procedures and standards for infection control and your staff and you abide by them, your staff will have confidence in both your concern and in your management abilities. Staff members who are nervous about the levels of disinfection and cleanliness of the office they work in will radiate that concern to patients. Furthermore, staff move from one dentist-employer to another so your standards of sterility and cleanliness are never a secret. This can affect referrals either positively or negatively.

Assessment of Risk

Cost:	Injury to staff. Personal liability for lack of compliance with existing legislation. Personal liability to office and building.
Probability:	Chemical hazards in dental practice are rare but fire is a possiblity. As well, chemical burns or the release of chlorine gas from inappropriate use of cleaning material is possible.
Control:	Staff education, fire plan, hazardous materials data sheets and review of all chemicals and solvents in the office.

Dentists' Concerns

1. To make the operation of your practice comply with the laws that affect it;
2. To establish systems that reduce your risk of complaints and litigation;
3. To ensure that service is at or beyond patient expectations.

External Regulations

What are "standards of practice" and where do they come from? Actually, from a large number of governmental bodies and organizations that have a vested interest in maintaining the safety of their constituents. They do this by enacting regulations, by-laws or even formal laws that affect dental practice. There is a wide range of levels of authority and a wide range of requirements for compliance with the ever-growing numbers of regulations and guidelines that affect your practice.

Clinical Standards and Practice Standards

Clinical standards pertain to the dentist's technical and diagnostic abilities, the dental product itself and the wide variety of possible outcomes. The professional colleges and university faculties are the prime repositories for the scientific and technical base of standards of clinical practice, human experimentation and technology transfer.

...dentists are advised to proceed cautiously in introducing any new product or technique into their practice, especially when the results of clinical trials and other research are not available. The onus is on each member of the College to ensure that the use of any new product can be supported by a sound scientific basis that demonstrates both its safety and effectiveness for the particular patient group being treated with the protection of the public being an overriding consideration. RCDA Dispatch 7(3) 7, 1993.

"an integral part of patient care is the need for each practitioner to be confident at all times that the treatment being rendered is within his/her capability." RCDS Dispatch 9(3) 16, 1995.

The Five Main Risks

Quality Assurance Program

1. Development of practice guidelines/standards of clinical care;
2. Mandatory continuing dental education (MCDE);
3. Quality Assessment
   • Practice review
   • Dentist evaluation
   • Dentist enhancement
4. Remediation of behaviour or remarks of a sexual nature by a member towards a patient.

Process Development: Procedures and Forms

Critical Indicators:	Observable and measurable criteria that permit ongoing accurate monitoring that reflects when standards of care or service are not being met.
Clinical Indicator:	An instrument that measures a quantifiable aspect of patient care and can be used as a guide to monitor and evaluate the quality and/or appropriateness of patient care.

• Volume indicators
  • Number of patient visits per month
  • Number of emergency patients per month
• General indicators
  • Sick time utilization monthly
  • Analysis of patient questionnaire administered one week quarterly
• Operational indicators
  • Number of patient "did not shows"
  • Number of vacant appointment slots
• Outcome indicators
  • Number of repeat radiographs
  • Daily processor testing results
  • Sterilizer graph and spore test results
  • Equipment maintenance tests (surgical suctions/central oxygen supply)
• Risk indicators
  • Number of lost radiation dosimeter badges per month
  • Occurences of gloves worn outside treatment rooms
• Management indicators
  • Employee performance appraisals completed on time
  • Accounts receivable monthly review

1. The dentist is informed immediately by staff if there is a concern/complaint expressed by a patient.
2. Staff members don't get drawn into the situation by a crafty patient.
3. They deal with the concern/complaint immediately.
4. The account ledger is placed with the chart to assure that the collection process does not continue until the problem is resolved.

What are some standards that might facilitate risk management in such a situation?

1. Staff must know enough to tell the dentist if there are any potential problems. If the receptionist has dealt with a difficult person on the telephone prior to the first visit, the dentist must know this. If a patient grumbles on the way out of the office after treatment, the dentist needs to know this as well.
2. Staff must know when a conversation is getting sticky and know enough to call in the dentist.

The Need for Risk Management

Reviewing existing systems including:

• Personnel
• Office policies and procedures
• Equipment and premises
• Professional procedures
• Educating staff about practice and work habits
• Reviewing patient complaints and maintain personal involvement
• Establishing appropriate practice management procedures

Common Reasons for Litigation:

• Failure to diagnose and inform
• Failure to maintain standards of practice
• Failure to personally address legitimate patient problems
• Failure to maintain adequate records
• Failure to collect co-payment
• Faulty systems:
  • poor procedures and staff direction
  • faulty equipment and patient injury
  • privacy violations
• Providing patient (insurer) with false or misleading statement
• Provision of treatment beyond expertise
• Aggressive collections following unsuccessful treatment

Risk Management may require a critical, introspective review of all office procedures.

Recognize:

1. Murphy's Law: If anything can go wrong, it will.
2. The law of maximum bad luck: If any two things can go wrong, the worst possible thing will happen.
3. It may take a pessimist to develop a safe office protocol and policy.
4. It still requires an optimist to commence patient care!

How to minimize risk

1. Maintain clear and complete notes and records.
2. Insure that records are constantly updated (i.e. medical histories).
3. Insure a full diagnosis has been developed (i.e. avoid hurried actions for impatient patients).
4. Insure patient is made fully aware of treatment scope, alternatives and risks (i.e. informed consent).
5. Consider formal written reports to patient for complex cases (a positive practice of orthodontists for years).
6. Deal personally with patient problems and complaints (it is easy to sue someone if you are angry!).
7. Develop a formal office policy manual that deals with likely problems and allows your staff to properly handle patient problems.
8. Be available to your patients (often a simple telephone presence with a solution or acknowledgment is sufficient).
9. Develop a formal policy to protect patient privacy (i.e. do computers face away from public areas, what is on the screen for the patient to see...).
10. Insure the procedures you perform are those with which you are comfortable.
11. Periodically audit claim forms and billings.
12. Maintain records of qualification as part of employee records.
13. Employment standards, workplace safety issues (i.e. HARP, Vaccinations etc.).
14. Provide staff with clear concise direction.
15. A small dash of paranoia.

Examples

1) Insurance Related

• recognize, unless a formal contract has been signed with an insurer, you have no legal relationship with an insurer.

However

• you have a legal responsibility to render an accurate statement to your patient;
• you have a legal responsibility to attempt to collect co-payments
• you have a legal responsibility to maintain standards of practice

Case A

Several instances whereby front desk staff have fraudulently added procedure to claim and skimmed this money from receipts.

• Proceed to complaint?
• Not covered by PLP. (Professional Liability Plan - malpractice insurance term used in Ontario)
• Risk that insurer will hold you responsible for the actions of your staff (vicarious responsibility) and seek damages.

Case B

2) Care Related

Case A

• Major treatment undertaken with a few radiographs, no written estimate, no clinical notes and no indication of a discussion on scope of treatment or risks.

Classic case of failure to maintain standards - result

1. Formal complaint to College and possible loss of registration.
2. Civil action for damages - covered by PLP with deductible.

• Defence of case is difficult due to lack of notes to protect dentist.
• Lack of informed consent.
• Treatment rendered below standards of practice.

Why is Risk Management important?

• Direct cost and rise of higher insurance premium.
• Direct cost of deductibles.
• Inconvenience and lost time.
• Possibility of formal complaint.
• Possible loss of registration.
• Negative publicity and long term practice growth.
• Protects the patient and improves the standard of care.

It should also be noted that such damages or awards are not covered by professional liability insurance and I doubt whether any coverage would be obtained.

Dental Records Management

1. Records accurate and complete;
2. Records produced at or about the same time as treatment;
3. Record taking is unfailingly routine.

then the Courts have accepted the records as a factual accounting of the events described.

Hospital records, including nurses' notes, made contemporaneously by someone having a personal knowledge of the matters then being recorded and under a duty to make the entry or record should be received in evidence as prima facie proof of the facts stated therein. This should in no way preclude a party wishing to challenge the accuracy of the records or entries from doing so. Thus, where the nurses whose notes are offered in evidence are present in Court, the defendant medical practitioner who wishes to challenge the accuracy of their notes is free to call them as witnesses.

Rules for records

• Write legibly.
• Use ink only, never pencil.
• Do not use white-out, no matter how messy things get.
• The person who makes the entry must be identified.
• Date each entry, regardless of how trivial.
• Do not skip lines or leave spaces.
• Don't use short forms or initials without identifying them so that others will know what they mean.
• Note in chart any missed appointments, consents completed, release of information forms.
• Don't alter the pre-operative chart.
• Never write anything in a chart that you would not be prepared to have the patient read, explain to a court or see published in a newspaper (even ten years from now). You are somewhat protected from libel/slander in your charts by "Qualified privilege" but clearly insulting comments may be subjected to legal challenge.
• Make arrangements to purge your office records periodically but remember clinical, financial and drug records as well as diagnostic/study models must be stored 10 years from the last entry in Ontario. In the case of treatment of minors, the primary rule is 10 years from last visit but not before the minor reaches age 20. This is the age of majority, (18), plus 2 years.
• Records of a deceased dentist can be destroyed after 2 years.
• Obviously, if a case is under review the records must be maintained.
• The dentist is responsible for the physical security of the records. This means protection from environmental damage such as mildew, water and fire.
• When it comes time to destroy health records, the dentist is responsible to make sure that confidential information does not end up in public hands.
• Electronic recordkeeping is acceptable and guidelines have been written.
• Charges to patient credit cards should have the patient's actual signature as proof of authorization in case of a dispute.
• Police may secure records by presenting a Warrant for Seizure under the Coroners Act, section 16(2)(b).

Employment Law

There can be no catalogue laid down as to what is reasonable notice in particular classes of cases. The reasonableness of the notice must be decided with reference to each particular case, having regard to the character of the employment, the length of service of the servant, the age of the servant and the availability of similar employment, having regard to the experience, training and qualifications of the servant.

Conclusion

SOURCES

1.   Dental Risk and Quality Management, published by the Ontario Dental Association.

2.   Dental Records Management, published by the College of Dental Surgeons of British Columbia.

3.   Material from "The Daily Discipline", published by the Canadian Dental Protective Association.

4.   Material supplied by ExperDent Consultants Inc.

5.   Various employment law material in my office.

6.   29 years of experience in the trenches.