This article is the first installment of a three-part series on patient safety in dentistry. The second article will examine the importance of clinical documentation, and the third will address safe management of adverse events.
Patient safety should be the underlying foundation of everything we do as healthcare professionals. It is a goal, a culture, and a destination. Unfortunately, achieving patient safety is ambiguous and hard to measure. How will an organization know that patient safety has been achieved? Questions like this lead safety experts to look outside healthcare to other industries. High-risk industries, such as airlines and aerospace, have made significant safety gains by pursuing high reliability. High reliability includes five premises: preoccupation with failure, sensitivity to operations, reluctance to simplify, commitment to resilience, and deference to expertise.1 The first principle, preoccupation with failure, is the essence of patient safety. High reliability organizations employ teamwork, respect, and trust to ensure that everyone is situationally aware and free to speak up. Without effective communication, success is not possible.
Therapeutic Versus Nonprofessional Communication
Teamwork requires open communication. Therapeutic, or person-centered communication, embodies friendliness, genuine interest, empathy, and a desire to facilitate and support. The practice of therapeutic communication involves active listening, reflective statements, and open-ended questions to establish a patient-centered relationship. Therapeutic communication fosters trust, respect, and collaboration.
On the other hand, nonprofessional communication projects attitudes such as anger or disinterest using sarcasm and self-aggrandizement. This type of negative behavior can lead to professional liability claims, cast doubt on a dentist’s ethics, and create a hostile environment. Examples of nonprofessional communication include openly criticizing the treatment administered by another provider or berating staff in front of a patient. Nonprofessional communication is antithetical to patient care, camaraderie, and interprofessional relationships.
In clinical practice, it is helpful to examine communication from three perspectives: provider to provider, between providers and staff, and providers and staff to patients and families.
Referrals are the dental version of a handoff. In clinical care, handoffs are subject to error and may contribute to patient harm when poorly done. A small study of referrals between general dentists and specialists showed a positive correlation between communication and quality of work.2 One study found that timely referral reports significantly strengthened the relationship between the specialist and general dentist.3 Managing referrals well is necessary to improve patient safety and reduce the risk for referring and receiving providers. Patient safety experts recommend a “closed-loop” process that tracks the referral from the initial treatment to the patient seeing the specialist to the report reaching the referring provider, who then reviews the care, updates the treatment plan, and closes the loop by contacting the patient.4 The referring provider must make sure that the specialist receives complete, accurate, and timely information. While limited dental data is available, the medical literature suggests that over 100 million referrals per year occur in the U.S.5 Up to 50 percent of referrals are not completed.6 A study of referral communication found that, while 70 percent of referring physicians said they sent patient histories, less than 35 percent of specialists reported receiving them.7 Research indicates that breakdowns in the referral process contribute to 20 to 30 percent of diagnostic errors. See Table 1 for suggestions to improve referral communication.
Table 1. Improving Referral Communication
|Develop a standardized referral form.
||Collaborate with the sending provider to ensure referral communication is effective.
|Collaborate with receiving providers to ensure the information is complete and unambiguous.
||Clarify patient care responsibilities with the referring provider.
|Include appropriate diagnostic images.
||Verify appropriate site (teeth) with the patient, images, and referral form diagram.
|Send the information directly to the receiving provider.
||Verify the images are for the correct patient, up to date, and appropriately marked (laterality).
|Do not expect patients to carry the referral packet to the specialist.
||Consult with the referring office if there are questions before proceeding with treatment.
|Review the referral note promptly and update the treatment plan as necessary.
||Complete the referral note and share it with the referring provider promptly.
Consider the following elements from the Agency for Healthcare Research and Quality (AHRQ) Surveys on Patient Safety Culture® Medical Office Survey:8
Providers and staff are willing to report mistakes they observe and do not feel like their mistakes are held against them,
Providers and staff talk openly about office problems and how to prevent errors from happening,
Providers in the office are open to staff ideas about how to improve office processes, and
Staff are encouraged to express alternative viewpoints and do not find it difficult to voice disagreement.
Safety culture requires teamwork, employee comfort in speaking up, and the ability by team members to report potential risks without fear of reprisal.
Improving teamwork and communication in healthcare has been well studied. AHRQ TeamSTEPPS® is one of the most studied and successful programs because it works well in outpatient settings. TeamSTEPPS® provides simple, easy-to-use tools, such as huddles, debriefs, and structured communication. A huddle is a brief planning meeting to ensure that the team understands the next steps. Huddles often occur at the end of the day to confirm that the necessary documents and equipment are ready for the next day’s cases. Use a morning to evaluate staffing, make assignments, and discuss any pertinent patient safety issues, such as a patient who needs a translator. After an event or procedure, debrief to determine what worked well, what could have gone better, and what changes are necessary to decrease risk or improve a process.
Structured communication, which ensures complete information is shared in a meaningful way, often includes a mnemonic. SBAR stands for situation, background, assessment, and recommendation/response. SBAR was developed in hospital settings to improve telephone communication between nurses and providers. It can be very useful in a dental practice for electronic communication between staff and providers and for handoffs.
Finally, patient safety depends on team members having the courage to speak up. CUS is a simple tool to empower staff, using escalation to gain action: “I am concerned,” followed by “I am uncomfortable,” followed by “this is a safety issue.” Using the phrase safety issue must trigger a pause to evaluate and discuss the situation before moving forward. The CUS tool’s application in dentistry will require some finesse as the patient is present when these discussions are likely to occur. Consider identifying a CUS trigger word or phrase to signal the need for conversation out of patient earshot. Empower staff to CUS and thank them for their input.
For more information on TeamSTEPPS® in an office setting, visit ahrq.gov/teamstepps/officebasedcare/index.html.
Poor communication between providers and patients is frequently identified as a contributing factor in professional liability claims. The Doctors Company is a large national professional liability carrier that provides insurance to physicians and dentists. Advice for managing dissatisfied patients is the most frequently asked question by dentists calling the helpline. Poor communication and patient dissatisfaction are common contributors to medical professional liability in medicine.9 To determine if the same findings hold true in dentistry, we analyzed dental claims that closed with indemnity between 2016 and 2019 to determine if patient communication affected safety.
The findings in our study appear to support the conclusion. Of the 537 claims, approximately 50 percent (266) involved patients seeking care from another provider due to dissatisfaction with care. Transfers of care are inherently risky from a patient safety perspective and are at high risk of nonprofessional communication. Poor rapport, such as the provider making an unsympathetic response to the patient, contributed to just over 33 percent (178) of claims. Miscommunication between the provider and patient/family about expectations contributed to nearly 12 percent (63), and failure to inform the patient of an adverse event contributed to more than 3 percent (18).
An interesting 2018 study in dental communication found a difference between patient-reported experience with dentist communication and dental hygienist communication: Dentists were most frequently noted as disregarding patients’ expressed feelings, while hygienists were noted as engaging in judgmental behaviors and language.10(p1041) The authors suggest that patients may misinterpret dental hygienists’ education efforts as criticism rather than its intended purpose. Patient-reported negative communication experiences with dentists included disregarding concerns and feelings, discussing inappropriate topics, using a rude tone or sarcasm, and talking too much during the examination.10 These findings confirm that nonprofessional communication is likely occurring between providers and patients, as also evidenced in the previously discussed closed claims data.
Dental care can be expensive, and coverage tends to be less common than medical care coverage. Unexpected out-of-pocket expenses can contribute to patient anxiety—which may contribute to unrealistic expectations. Dental providers should consider being transparent in their discussions of anticipated costs and expected outcomes. Consider explaining what is involved with an expected settling-in period and advising patients what to watch for and report.
Informed consent provides an additional opportunity to foster patient-centered care, promote collaboration, and establish expectations. The essential elements of informed consent include discussion of the intended procedure, its benefits, the patient-specific risks of the planned treatment, its likelihood of success, and the potential alternatives. When discussing the likelihood of success, be honest about the probable life expectancy of the work, the limits of the material(s) used, and the reasonably expected cosmetic outcome. For multistep procedures, discuss the length of time between each step and the total expected time commitment for treatment and recovery.
Informed consent is not “informed” if the patient does not understand the discussion. It is important for dental providers to present treatment and consent discussions and forms in plain language. Plainlanguage.gov defines plain language as “communication your audience can understand the first time they read or hear it.”11 To achieve plain language, replace clinal terms with common usage, limit the use of multi-syllable words, and aim for a reading level between sixth and eighth grades. See Figure 1 for an example of dental plain language.
Figure 1. Example of Dental Plain Language
Before: A dental implant is a surgical component that interfaces with the bone of the jaw or skull to support a dental prosthesis such as a crown, bridge, denture, or facial prosthesis or to act as an orthodontic anchor. [Source: Wikipedia]
After: Dental implants are metal anchors put inside the jawbone underneath the gumline. Small posts are attached to the implants, and artificial teeth or dentures are fastened to the posts
After essential communications, such as discussions involving consent or education, use teach-back to evaluate patient understanding. Advise patients that the information provided is important, and you want to make sure you did a good job explaining. Invite patients to share their understanding of the discussion in their own words. Gently clarify and correct any misunderstandings. Show me is the procedural version of teach-back; for example, asking patients to show you how they brush their teeth and floss. Document the process and result in the patient’s dental record.
Patients with low English proficiency or hearing impairment may require the use of translators. Never use family, particularly children, to translate. Family members, who are there for support, may not have the linguistic capability to translate clinical information, and they may not be objective. Have commonly used documents translated from English into the most frequent languages spoken by patients. Use teach-back to assess patient understanding.
Sometimes patients need to be asked to leave a practice. The most common reasons for terminating the dentist-patient relationship are nonpayment of bills and aggressive or inappropriate behavior. Before dismissing a patient for nonadherent behavior, consider other options. Discharging a patient from the practice is not without risk; an improperly managed dismissal may be deemed patient abandonment by a professional review board. Meet with the patient to discuss the behavior and determine if there are any addressable barriers to compliance, such as lack of transportation, lack of childcare, or financial difficulties. Patients have the right to refuse care. Sometimes nonadherent behavior is a proxy for a patient’s lack of comfort with directly refusing the treatment plan. Dentists are often concerned about professional risk when patients are nonadherent or refuse care. Under the circumstances, much like informed consent, the dentist’s responsibility is to inform the patient of the purpose of the recommended treatment and the risks of refusing. The patient’s responsibility is to agree or refuse. If the patient refuses, determine if there is an acceptable alternative. Memorialize the discussion using an informed refusal form, and include a summary of the discussion in a progress note in the patient’s record.12
Good clinical communication improves teamwork and creates a safer environment for patients. Excellent communication engages and satisfies patients and reduces the risk of professional liability claims, even when things go wrong.
See the other articles in this series, “Patient Safety in Dentistry: Documentation” and “Patient Safety in Dentistry: Managing Adverse Events in the Practice Setting.”
Reprinted with permission from Florida Focus. December 2021, pages 11-13. Available at https://www.flagd.org/wp-content/uploads/2021/12/Florida-Focus-Dec-2021-v.10.pdf.