Disaster Preparedness for Your Dental Practice

By Julie Brightwell, JD, RN, Director, Healthcare System Patient Safety, The Doctors Company

Recently, hurricanes, floods and fires nationwide have highlighted the importance of planning for disasters. Hurricane and flood damage in Texas and Florida left practices without power for days or even weeks. Wildfires in California forced several dentists to quickly relocate their practices ― some permanently ― and to move scheduled procedures to different facilities. Is your practice prepared for this type of situation?

A disaster can overwhelm a dental practice, with damage that can include shattered windows, flood debris, power outages, disrupted telephone systems, computer and system outages, unsafe drinking water, destroyed dental records, medication exposure to temperature and humidity extremes, contaminated instruments and building structure failure.

Disaster preparedness requires a continuous cycle of planning, organizing, training, equipping, rehearsing and evaluating. Dentists are critical participants in disaster preparedness, ensuring that patient care and critical services are not interrupted.

Plan Ahead Now
Before the next disaster strikes, make sure your practice has a plan in place. A checklist, ordered by priority and customized to specific types of disasters, can provide the framework for a comprehensive plan. The checklist should include these elements:

  • A full-circle call tree that outlines who contacts whom.
  • Instructions for setting up instant messaging technology that enables staff to communicate without a wireless network or cellular data connection.
  • A Certificate of Insurance for your dental malpractice coverage, or instructions for contacting your agent or insurer directly to obtain proof of coverage. This document will be necessary if you are forced to temporarily relocate your practice or procedures.
  • Steps to follow upon returning from evacuation.

When Disaster Strikes
Planning today makes accomplishing the following tasks more feasible during a disaster:

Communication

  • Contact staff immediately to determine realistic time frames to return to work.
  • Notify external vendors and business associates of your practice interruption and targeted resumption of operation.
  • Implement staff briefings at the beginning and end of each day.
  • Create temporary phone, fax and answering services.
  • Establish patient telephone triage.
  • Implement temporary controls to ensure HIPAA compliance.

Computers and systems

  • Contact computer service vendors to ensure integrity and recovery.
  • Verify insurance coverage for repair or replacement costs and losses.
  • Evaluate applicable warranties and consider an information technology restoration service contract.
  • Inventory and document hardware and software.
  • Document the type and extent of both lost electronic and paper data.
  • Ensure data backup and periodically test compliance.
  • Re-establish filing systems and internal programs.

Dental records

  • Determine the extent of damage to, or loss of, patient records and filing systems.
  • Attempt to restore all damaged charts and document inventory findings.
  • Notify the state dental board for specific guidance pertaining to lost or damaged records.
  • Document all efforts to restore and protect existing records.
  • Reconstruct lost charts at the next patient encounter.
  • Contact your insurance carrier for restorative services and/or claim procedures.
  • Re-establish a filing system and temporary storage if necessary.
  • Obtain legal guidance for patient notification during recovery efforts.
  • Contemporaneously date and initial all late entries and duplicate information in context of recovery efforts.

In addition, create an inventory of all equipment and medications that may have been exposed to water or extremes in temperature. Repair, replace or discard damaged items appropriately.

Once your plan is in place, regularly re-evaluate its steps and update all contact information. Practice and rehearse the plan’s protocols. An effective disaster preparedness plan will help keep your practice focused on delivering care during an emergency.

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.

Reprinted with permission. ©2017 The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

Is Your Patient a Victim of Human Trafficking?

By Amy Wasdin, RN, CPHRM, Patient Safety Risk Manager II, The Doctors Company

Most health care providers are aware of their role and responsibility to identify and report victims of child abuse, elder neglect and domestic violence. However, there is another type of abuse that is on the rise and reported in every state throughout the nation. In 2016, human trafficking cases reported in the United States rose by more than 36 percent from 2015, according to the National Human Trafficking Hotline statistics.

Human trafficking occurs when a trafficker exploits another individual with force, fraud or coercion to make him or her perform labor or sexual acts. Victims can be any age (adults or minors), any gender, and from any cultural or ethnic group. The trafficker, or abuser, might be a stranger, family member or friend. This criminal industry is extremely profitable, generating billions of dollars worldwide. Lack of awareness and misconceptions by health care providers allow opportunities for identification of the victims to go unnoticed and unreported.

Victims of abuse rarely find opportunities to interact with other persons without approval from the abuser. A visit to a physician or dental practice may provide a rare opportunity for a patient to receive the help that he or she desperately needs. Research published in the Annals of Health Law in 2014 revealed that 87.8 percent of trafficking survivors reported that they were seen by a health care provider during their trafficking situation.

Human trafficking victims commonly are seen in medical and dental practices with the following conditions:

  • trauma such as broken bones, bruises, scars, burn marks or missing teeth
  • poor dental hygiene
  • pregnancy
  • gynecological trauma or multiple sexually transmitted infections (STIs)
  • anxiety, depression or insomnia

Victims usually are afraid to seek help for a variety of reasons that usually stem from fear, shame or language barriers. Health care providers and their staff should be trained to recognize the signs of human trafficking and know what steps to take.

Red flags to look for from the victim include:

  • fearful demeanor
  • depressed or flat affect
  • submissive to his or her partner or relative
  • poor physical health
  • suspicious tattoos or branding
  • lack of control with personal identification or finances
  • not allowed to speak for himself/herself
  • reluctant or unable to verify address or contact information
  • inconsistency with any information provided (medical, social, family, etc.)

Victims may be fearful and untrusting of their environment, so it is best not to directly ask an individual if they are a victim of human trafficking. Instead, the Department of Health and Human Services recommend questions such as the following:

  • Has anyone threatened you or your family?
  • Can you leave your job or home if you want to?
  • Are there locks on your doors and windows to keep you from leaving?
  • Do you have to get permission to eat, sleep or use the restroom?
  • Has someone taken your personal documents or identification?

Human trafficking is a federal crime and violators who are prosecuted receive prison sentences. The Trafficking Victims Protection Act was enacted in 2000 and provides tools to address human trafficking on a national and worldwide level. Many states also have laws and penalties for human trafficking.

If you suspect that a patient is a victim of human trafficking, please call the National Human Trafficking Hotline at 888.373.7888 or go to https://humantraffickinghotline.org/report-trafficking to report online. The hotline is not a law enforcement or investigative agency, but will take any possible steps to aid the victim and could result in a report to law enforcement.

Health care providers should follow state laws regarding mandatory reporting to provide notification of patient abuse or neglect situations. Unless calling the authorities is mandatory, it is recommended that you do not do so without the patient’s permission.

For resources and information on assessment tools, go to the National Human Trafficking Hotline’s Resources for Service Providers or Centers for Disease Control and Prevention.

 

Reprinted with permission. ©2017 The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

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.

Providing Dental Services in the Hospital Setting

By Amy Wasdin, RN, CPHRM, Patient Safety Risk Manager II, The Doctors Company

Lack of familiarity with hospital systems can pose serious risk management implications.

Patients present to an acute care facility for a variety of reasons, such as emergency care, admission for ongoing treatment, surgical procedures and specialized nursing care. Unfortunately, appropriate dental care often is overlooked or not identified as a priority at the beginning of a patient’s course of hospitalization.

Good dental care is an important component to maintain overall health and well-being. When unchecked and untreated, bacteria that forms on teeth often can lead to more serious health problems. Poor oral care has been known to contribute to cardiovascular disease and respiratory infections, as well as other serious health conditions.

Dentists and oral surgeons often are credentialed and included in a hospital’s medical staff roster to provide dental services to emergency department patients and inpatients when needed. Providing dental care for a hospitalized patient is uncommon, and dentists and oral surgeons are not routinely consulted to provide dental services.

Because of the infrequency of providing dental care in the hospital setting, many dentists are unfamiliar with hospital and medical staff requirements that apply to the providers who examine and treat inpatients. The lack of familiarity with hospital systems and medical staff rules can pose serious risk management implications for the dental care provider.

Risk Management Strategies

  • Be wary of “curbside consultations” in which informal collaboration may find its way into the medical record. Consulting dentists have been sued by patients that they neither met nor examined because of inaccurate documentation by other providers in the medical record. If you are asked for input on a specific patient situation, it may be best to request a formal consultation so that you can document your thoughts and opinions in your own words.
  • Communicate clearly with other providers on the expectations regarding your involvement in patient care. Once you become a part of the care team, the lines often get blurred among providers regarding who is responsible for each aspect of care. Key information often can get lost in the transitions of care that occur in a hospital among caregivers. Clarify your role in the record, and communicate with other providers when there is confusion or cause for concern.
  • Familiarize yourself with the medical record beforehand — ask for training. Electronic medical records (EMRs) present unique nuances and special challenges to a user who is unfamiliar with the system. There may be templates or designated sections for your documentation. The EMR may not be easily navigated, so it is helpful to take the time to learn the various sections that you will need to use. It can be a powerful tool for provider collaboration if you know where to look for information.
  • Understand your documentation requirements. How often are you required to document your care of the patient? When does your documentation need to be finalized and available in the medical record? What do you need to include in your consultation notes? This information should be provided at the time of your appointment to the medical staff.
  • Request updates and revisions to processes and systems. Hospitals regularly update and revise facility operations as well as clinical policies and processes. Make sure that you periodically request updated information regarding any facility or patient care-related changes. Notice of physical plant changes may prove extremely helpful to you when you need to locate your patient to provide dental services. Notice of process changes will help you fulfill your obligation as a medical staff member to follow current policies and procedures.
  • Have a go-to person to contact for assistance when needed. Despite taking appropriate steps to be prepared to care for your patient, there are always unexpected challenges that may occur. Get to know your medical staff department coordinator or the facility risk manager. They can prove to be great resources when you need quick access to information. Also, if you can’t find someone for assistance after regular hours, reach out to the hospital administrator on call who will connect you with someone who can assist you.

 

Reprinted with permission. ©2017 The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

Referral and Negligent Referral in a Dental Practice

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.

 

Reprinted with permission. ©2017 The Doctors Company. For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

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.