communication – Beyond the Bite

Who’s Zooming Who?

by Florida Dental AssociationApril 2, 2020April 2, 2020Leave a comment

By Larry Darnell, FDA Director of Information Systems

The title refers to an Aretha Franklin song and the first time I heard it, I struggled to understand what that even means (it refers to checking someone out). Now it has a new meaning. I remember just a month ago, the FDA Board of Trustees had their first Zoom video call. It seemed like such a novelty then — almost like watching a Brady Bunch intro with squares of talking heads. Little did we know then that this novel way of communicating would now become the standard for so many of us.

In the last month, so much has changed thanks to COVID-19 and our response to it. The saving grace for us is that our technology is up to the task in most cases. My daughter needed to see a doctor for a minor illness. Thanks to telehealth, she “saw” the doctor and got a prescription called in the same day. My wife is a teacher and she has at least weekly and sometimes daily video interaction with her students via technology. I’ve even attended church services virtually through Facebook Live. A different world indeed.

This year, we had a few employees at the FDA who could work remotely. Now, everyone is setup with that ability. It’s a challenge to work remotely, but at least we have that option. There are a few things to remember in this new Zoom Age we’re in now.

First, remember to communicate with others. While social distancing may be around for a while, communication is still essential. I admit, despite my technology background, I like face-to-face communications better. There are so many obvious physical and non-verbal cues you can pick up on in person that are missed when the contact is virtual. However, we have to now relearn the art of communicating intent through texts, emails, phone calls and even through video sessions. Communication now is intentional and likely requires more effort, but do not cease to do it. When communication ceases, people are left to doubt, question and become fearful. Be honest, kind and as positive as you can be.

Secondly, get to those projects that have been “when I get around to it” things. For me, that means clean up my email inbox, organize our shared company file system and review our websites. I do these when they become emergencies, but seldom think of them when other things are happening. It allows you to stay productive and prepare for the time when we’re able to return to our new normal.

And lastly, do not lose your spirit of volunteerism. Dentists are caring and giving people. It saddens me that the Florida Mission of Mercy was postponed, but it was the only option. There are so many other ways you can volunteer. People still have needs. I’m helping my wife’s teacher friends with technology. I’m advising churches who are forced to go online how best to do it. I am assisting my daughters’ friends who now take all college classes online. I’m using my gifts to benefit others. I’ve always wanted to help others, and I’m not going to let COVID-19 stop me from doing just that.

Referral and Negligent Referral in a Dental Practice

by Florida Dental AssociationJune 29, 2017June 29, 2017Leave a comment

By Kim Hathaway, RN, CPHRM, Patient Safety Risk Manager, The Doctors Company

Failure to diagnose and failure to refer are common issues seen in dental claims.

Dental practice claims alleging failure to refer, or failure or delay in diagnosis may arise from a general dentist’s lack of referral to a specialist. On occasion, patients have asserted their general dentist referred them to a specialist who provided substandard care and that the referral itself was negligent. Dentists referring care outside their background, experience or training must take care to avoid liability issues associated with referrals.

Case Study
During a routine prophylaxis visit, a middle-aged male reported a mass under his tongue, which his general dentist evaluated as an aphthous ulcer (benign and non-contagious). Several months later, another provider biopsied the mass and diagnosed Stage IV squamous cell carcinoma. Surgery and radiation treatment were undertaken, and plastic surgery was required. The patient alleged dental negligence and failure to refer to a specialist. The defendant dentist claimed that the patient had been told to follow up with his primary care physician (PCP) or an oral surgeon.

There was no documentation of a formal referral to a specialist or PCP, nor was there documentation of the dentist’s observations or referral recommendation. The adverse result in this case may have been avoided or the impact lessened if the dentist had documented his observation, evaluation and testing to demonstrate a low suspicion of cancer, or if there had been a documented referral with follow-up on the referral.

Clinical Comfort Level
When specialists are unavailable, or the necessary care takes a patient outside of his or her local community, the patient may ask you to provide the treatment. Treatment that is outside your training or experience may increase the risk of injury to the patient. The risk generally lessens if the treatment is undertaken by a specialist. In addition, the patient cannot waive your professional duty by consenting to a negligent act. If the patient is injured, you will be judged against the standard of care for that specialty.

Do not let the patient pressure you into a treatment plan beyond your comfort level. It is important that you know your own and your staff’s limitations. Explain that the referral is the best treatment plan for the patient. Discuss that choosing no treatment may result in an adverse outcome, disability or death. Spend more time helping the patient find the necessary specialist and clearly document your discussions with and counseling of the patient. If the patient refuses specialty care, carefully document an “informed refusal.” Consider terminating the patient from your practice if after thorough counselling the patient continues to refuse your recommendations.

The American Dental Association’s General Guidelines for Referring Dental Patients notes: “In some situations, a dentist could be held legally responsible for treatment performed by specialist or consulting dentists. Therefore, referring dentists should independently assess the qualifications of participating specialist or consulting dentists as it relates to specific patient needs.” Vicarious liability is a concern if you refer a patient to a specialist who lacks skill or judgment.

Patient safety is the primary focus when making a referral. Familiarize yourself with the specialists’ communication skills, clinical judgement and competence. Explore complaints or evidence of poor care provided by the specialist. Find another provider in the community if a pattern of poor care develops. Consult with colleagues before recommending a specialist who you do not know well. Solicit feedback from both the specialist and the patient.

Communication
Effective communication is critical to a successful referral. Explain to the patient why the referral is needed for a particular treatment or condition and that you will remain the general dentist. Let the patient know what to expect from the specialist and the treatment, and reassure the patient that you will remain in contact with everyone to ensure the best possible outcome. Schedule the appointment while the patient is still in your office. If the patient needs to reschedule or cancel, the patient may; however, your staff has facilitated the referral.

Proactively avoid miscommunication between the dentist and specialist by providing a formal written referral. Always document the details of phone referrals followed by a written referral after the call. Referral letters should include the following information:

patient demographics and identification
date of the referral and last date the referral may take place
evaluation and treatment completed to date
copies of diagnostics performed, including information about when it was collected
diagnosis and prognosis
desired evaluation or care the specialist is requested to complete
your plan for after-care following the specialist’s intervention
a request for a consultation report and ongoing status reports

Tracking
Tracking patient referrals and return visits is essential to efficient patient care. A centralized and uniform tracking process should be kept separate from the patient’s record. The tracking should cover the timeframe from the patient’s referral to the return visit to the general dentist. Have your staff make this return appointment at the time they make the specialist appointment to avoid missed attempts to follow up. The tracking system should provide a reminder or task to move the process along or documentation for why it has not progressed. If the referral is not completed in a timely manner, the process should include contacting the patient and specialist to facilitate care.

Documentation
Carefully document the referral process. In the event of a claim resulting from the referral and treatment, documentation is the best evidence. Documentation of the evaluation, treatment and discussions with the patient that lead to the referral is critical. Copies of written communications and evidence of verbal communication, including phone messages with both the patient and specialist, must be kept in the patient record. Refusal or nonadherence to care must be recorded, with evidence of efforts to overcome the refusal or nonadherence. Finally, if the patient fails to seek specialist care despite your efforts, carefully document the events that lead to a decision to withdraw from further treatment of the patient. This decision should be followed by a properly executed letter terminating the dentist-patient relationship.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

Good Communication Improves Patient Care

by Florida Dental AssociationJune 15, 2017June 16, 2017Leave a comment

Donald Wood, CRNA, CPHRM, Patient Safety/Risk Manager, The Doctors Company

Multiple studies have shown that communication challenges can cause health care errors and complications. Dentists regularly provide care to patients who require a health care team with several medical specialties. In these circumstances, dental care provided to a patient requires effective communication among all team members and the patient.

Case Study
A patient presented to a dentist for a scheduled procedure. As the patient was being prepared for the procedure, the patient inquired about the use of an antibiotic. The patient explained that he had undergone joint replacement surgery, and his orthopedic surgeon had instructed the patient that an antibiotic should be provided prior to any dental work. The dentist explained to the patient that current guidelines don’t support the concept of administering antibiotics prior to a dental procedure and was reluctant to prescribe an antibiotic. The patient wanted to discuss the dentist’s explanation with his orthopedic surgeon. He cancelled the procedure and left without being treated.

When a patient’s medical history reveals a prior surgery, the need for collaboration between the dentist and any previous treating physician may warrant a discussion. In this case, an orthopedic surgeon performed the joint replacement. The 2013 clinical practice guideline published jointly by the American Association of Orthopaedic Surgeons and the American Dental Association (ADA), further clarified by the 2014 guideline from the ADA Council on Scientific Affairs, does not specify the need for antibiotic prophylaxis for patients with a prior joint replacement surgery. However, many variables should be considered. The guidelines report that a patient with a medical history of osteomyelitis, acquired immunodeficiency, or drugs or disease that suppress the immune system may require antibiotic prophylaxis before dental procedures.

Effective collaboration, in this situation, includes notifying the orthopedic physician about the need for the dental procedure, the extensiveness of the procedure and inquiring about the need for pre-operative antibiotics based on the patient’s orthopedic history. This collaborative process should begin as soon as a need for a dental procedure is determined.

A similar situation may arise with patients on antithrombotic therapy. This therapy requires a collaborative approach with the physician prescribing the medication. Although the number of antithrombotic medications was relatively limited in the past, several new medications have been approved. These new medications are noteworthy in that for some, there is no testing for therapeutic effect and some have no antidote or reversal agent. To reduce the risk of excessive bleeding, it may be necessary for a patient who is undergoing antithrombotic therapy to temporarily cease taking the medication for several days. As a part of the communication process, the dentist and prescribing physician should determine when the patient can safely resume taking their medication. Documentation in the dental record should indicate the patient’s understanding of when to stop the antithrombotic medication and when to resume taking it. With effective communication among the dentist, treating physician and patient, the overall impact on the patient’s health can be minimized.

Risk Management Strategies
Clear, concise communication can be enhanced by implementing the Situation-Background-Assessment-Recommendation technique. This technique can help a dentist organize communication and present specific details while collaborating with a patient’s previous physician. The following is an example:

Situation: A 58-year-old patient with pain, cold sensitivity and advanced periodontal disease.
Background: History of total knee replacements in 2010 and 2015.
Assessment: Patient needs to have four teeth extracted, bone grafting and preparation for implants.
Recommendation: Assess the need and timing of any antibiotic therapy that may be necessary prior to this procedure. If indicated, provide the patient with a prescription for the antibiotic.

Track these requests in a log or other format to determine if a response was received prior to the procedure. Follow up to ensure that communication among the dentist, prior specialists and patient is successful.

References:
Jevsevar D, Abt E. The new AAOS-ADA clinical practice guideline on prevention of orthopaedic implant infection in patients undergoing dental procedures, J Am Acad Orthop Surg 2013; 21: 195-197. http://www.aaos.org/Research/guidelines/PUDP/dentaleditorial.pdf.

Sollecity T, Abt E, Lockhart P, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints. J Am Dent Assoc. 2015; 146(1); 11-16 e8. http://jada.ada.org/article/S0002-8177(14)00019-1/fulltext#sec3.

SBAR technique for communication: A situational briefing model. Institute for Health care Improvement website. http://www.ihi.org/resources/Pages/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.aspx. Accessed February 16, 2017.