Articles By Fred

“A patient approached me today regarding an article she read in the local newspaper about mercury fillings. Since this is a topical (pardon the pun) subject, how would you suggest I answer?”

Recently it was reported that a federally funded study concluded that dental fillings containing mercury-laden amalgam were unsafe. However, a joint panel of Food and Drug Administration health advisors rejected the findings of this report by a 13 to 7 vote after reviewing 34 recent research studies contained in the federal report. The advisors said that the federal report didn't clearly and objectively present the current state of knowledge about the "silver" fillings. In addition the panel stated that the report's conclusion about safety weren't reasonable, given the quality and quantity of information available. The panelists recommended further study regarding the mercury-based fillings, with emphasis on risk groups such as young children and pregnant women. And so the beat goes on.

The fate regarding the safety of mercury-based amalgam continues, and the debate of these fillings will too. In the meantime there are millions of patients whose mouths are full of “silver” fillings. What is a dentist to do?

Practicing dentists have differing opinions about how mercury based silver fillings affect one’s health and well-being. No matter what side of the track you are on regarding the safety issues of these fillings, you most likely will come across patients with questions. This article is intended not to sway anyone to one side of thinking; rather, it is designed to help the dentist and staff handle these questions or concerns should they come up.

Research and find the facts

Take the time to find pertinent information from reputable sources regarding your position on the matter. Assemble this information in a way that is easy to disseminate to people who may have questions about amalgam. Make legible copies or request reprints from periodicals, newsletters, or internet sites that provide the information.

Educate the team!

In order to make sure that everyone in the practice is on the same page, spend time discussing the issue with the relevant facts. Be open to questions from the team and create an environment that allows people to discuss the topic freely. Make certain that any questions regarding the topic are answered with fact based material, not opinions.

Objective vs. Subjective

Be aware that some may not have the same belief about amalgam restorations. In this case, if the beliefs of a team member don’t mirror that of the doctor, I’d recommend providing the team member enough time to research the subject and allow the person to arrive at an objective conclusion based on the facts, rather than a subjective opinion. If the person’s stance still varies from the doctor’s, then request the team member defer all answers to the doctor and not provide an opinion on the matter.

If there is a team member that has strong convictions and aren’t able to follow these simple instructions, ask the team member to leave the practice and find an office that agrees with his/her philosophy.

Inform before you perform!

One of the most frustrating experiences a patient has is when something happens by surprise. In other aspects of the dental office, “…wow, I didn’t know it would be that much!” happens when we don’t make specific financial arrangements with the patient prior to treatment. In the case relating to restoration materials, make sure the patient is aware of the material used in the restoration prior to starting treatment. That way there won’t be any surprises. Try something like, “Mrs. Smith, we’ll use {name of material of choice} to restore your tooth. In our (doctor, staff) experience, this has served our patients very well.”

If a question arises regarding restoration material, then you’ll have information handy to explain why the practice has selected the material of choice. Further, the entire team will present a united front regarding the issue. Without this approach, patients may become confused as to what may be best for them and won’t be reassured they are receiving the best care.

It is important to be aware that people are receiving information in the public circle and are going to have questions. They may or may not ask them openly in the dental office. When they do, it’s important to be prepared to provide an answer that is consistent across the board – from the doctor to the dental assistant to the hygienist to the front office coordinator. Backing up your position with material from reputable sources makes your position that much more respectable to patients.

The trust and confidence you have with patients goes back to how well you communicate with them. It carries even further when good factual information comes alongside. Be proactive in your approach to this customer/patient relations issue and other sensitive issues to retain patients’ trust.

I’m confused about the term “At-Will” employment. Some have said “You just can’t fire someone without good reason”, yet “At-Will” implies you can. Can you clear up the confusion?

I hear this frequently in my work, almost on a daily basis. Employment law on the local, state, and federal level is confusing to those without formal education and experience. In this article, I’ll do my best to help clear up the ambiguity and provide a few practical steps to solve the issue.

Although many states are “At-Will” states, which is defined as “both the employer and the employee can end the employment relationship at any time for any reason or for no reason without any notice”, you still need to make sure that you are not ending the relationship in violation of any local, state or federal law, act or statute. What dentists, as employers, need to be concerned about is, “How well have employee issues been documented to support personnel management decisions”?

Working with dentists on a daily basis in these matters and as a business management advisor, it is safe for me to say that dentists’ documentation, including misconduct, performance appraisals, attendance and personnel files, is not very good, at best. How do you rate? Check your employee files and ask yourself, “When something goes wrong and I have a discussion with the employee, what do I write down and where do I keep it?” (Sorry, the “It’s too busy, I’ll write it down later; I can remember” card doesn’t work as well as you may think.)

Employers tend to get themselves into trouble by not having proper documentation to support their employment decisions; dentists are not excluded from this group! The biggest reasons I find in my work are fear of confrontation, do not like doing the paperwork, lack of supervisory training and discipline procedures are just too much trouble. Sound familiar in your dental practice?

What’s even worse is that dentists who do an inadequate job of documenting employee conduct or performance are rarely disciplined themselves. Since there is little accountability, why do it? This is what you may be thinking, until a wrongful termination law suite is served and one has to defend one’s termination decision.

Consider these helpful tips to tackle this problem of support personnel management and employment termination decisions.

“If in doubt, write it out”

As the well-known writer on business management, Harvey McKay, says, “Pale ink is better than a short memory”. It is a valuable practice to keep a record of both positive and negative outcomes of employee activity. There will be examples of employee behavior to use in the performance appraisal that will present opportunities to provide positive recognition, which, by the way, is a very popular item on an employee’s “What Gives Me Job Satisfaction” list. Examples also will provide ammunition in disciplinary discussions. Another point: Judges and juries are more likely to believe contemporaneous documents than people.

There should be no surprises when conducting the performance appraisal interview. Many dentists tend to avoid the tedious preparation of a well-orchestrated performance evaluation. Employees want to know why they were rated the way they were and what made the dentist select the rating. This brings home the point of making notes during the time period between appraisals so that ratings have justification – provide examples of instances where the employee shined and did a wonderful job. This can only improve performance, as your people will feel better about themselves being recognized for having done a good job. Just as important is to use examples of when the employee didn’t do so well. When you state specifics about situations that happened, there is little room for discussion. It’s hard to fight facts.

“Three-Strikes, You’re Out!”

Use a three-step method in handling disciplinary issues. Many dentists struggle with handling discipline because it is a distasteful task. No one likes to tell someone that they are doing poorly or violating company policy. The problem however, is that if it is not addressed in a timely and proper manner, it only gets worse.

You know the scene: employee performs poorly, there isn’t time during the day treating patients to pull the employee aside and conduct a quick one-minute reprimand. Time slips away, and before you know it, you never did talk to the employee, they don’t know they did anything wrong, and it is likely they’ll do it again!

First of all, have a discussion with your employee the moment an issue arises. Sure, it’s tough, but find the first available moment to address the issue. Document your discussion. Granted, dentists may talk to their employees, but in most cases, nothing is committed to writing. Do so to avoid problems of recollection and justification later.

A good tip here is to create, on a word-processor, a verbal and written warning guide. This can be a single page that has room for two, three, or four instances, rather than one page for each individual occurrence. Include the following specific points to address. Use the basics of, “Who, What, When, Where, Why, and How” as much as possible; all of them may not apply, but the point is be thorough. In other words, describe who did it, what happened (and what was their reaction to the discussion), when and where did it happen, why did it happen, and how did it happen? Lastly, make notes on what was discussed to prevent it from happening again.

Here is an example; choose the correct way to document employee performance:

Did you get them both right? Awesome! Let’s move on.

Have the guide handy so that anytime an issue comes up and you talk to your employee, make a quick dash to the private office, pull the guide from your files, and complete the documentation. Put the filled out guide away under lock and key in the employee’s personnel file.

Okay, that’s strike one. Strike two happens and you find yourself in a position of repeating the discussion. At this point, I suggest a more formal discussion that entails a written warning that the employee will have for himself or herself. Include the date, time of discussion, what was talked about and what the consequences will be if the problem continues this document may be one page for the specific event. Have the employee sign the statement as confirmation of the discussion and that he/she has received a copy of the statement, and most important, that they understand what will happen if it crops up again.

If the problem persists and one of the consequences discussed in the written warning was termination of employment, Strike Three is termination of employment. You now have three pieces of documentation, your notes from the first discussion, the signed statement from the second meeting and the termination notice, which includes a discussion of the verbal and written warnings. This will provide proper backup for most inquiries. You always want to make sure that you have given the employee a reasonable amount of time to improve, that you have spoken with them before about the issue and that the employee has had the opportunity to present his/her side of the story.

In personnel management, as in dentistry, there is no such thing as too much documentation. Train yourself to ALWAYS write it down. This will also provide direction for future situations to ensure that the level of discipline is consistent among employees. Sometimes the things employees do wrong, as standalone items are relatively minor. But when put together, over a period of time, they become your worst nightmare. Document, document, document! It will speed up the process and reduce the chance of litigation.

In conclusion, “At-Will” employment can be confusing. Rather than taking the term literally, be reasonable and prudent when dealing with employee behavior. Prepare documentation regarding employee performance, both good and bad, and use it as a management tool to reprimand poor performance and acknowledge employees for a job well done.

Question: I wish to begin regular documentation of employee performance, both positive and negative. Where do I start and how comprehensive should the documentation be? How do I distinguish between what's inappropriate and what's trivial in terms of behavior?

As an employer, there is no such thing as too much documentation regarding employee behavior. There was a national study conducted by HRhero.com that found that one out of every three employers rated their documentation (for misconduct, attendance, performance appraisals) as "Not Very Good." The reasons for improper documentation vary, but include fear of confrontation, the process is too much trouble, too time consuming, and lack of proper training.

Documenting employee behavior is beneficial for multiple reasons, including performance appraisal reviews, and necessary disciplinary actions. Sometimes when employees do something wrong, as a stand-alone event seem insignificant, but when pieced together with continual infractions show a pattern of behavior that needs to be dealt with.

Although Arizona is an "Employment at Will" state, defined as "both the employer and the employee can end the employment relationship at any time for any reason or for no reason without any notice," it still is prudent to protect oneself through proper documentation of employee behavior. With written documentation, it is easy to produce justification for terminating an employee.

No employee behavior should be considered trivial whether negative or positive. Documentation of behavior should be done as soon as possible, and should be specific as to the details (who, what, when, where, how, time, date). It is not in the employers best interest to have an evaluation form that involves a checklist for an appraisal. Check boxes regarding behavior have been shown to be inconclusive and difficult to determine if a merit raise is warranted or if termination is needed. It is best to use long-hand evaluation forms for specific behaviors to be recognized.

Here are some examples of proper/improper documentation:

Proper: January 9, 2006; 15 minutes late to work, because of "traffic."

January 18, late to work "alarm didn't work".

January 29, 20 minutes late due to "car trouble".

 

Improper: Late to work several times this month.

Proper: August 8, 2006, 2:00pm, front office manager heard rude comments being made to patient E.B. She reported you said "Insurance is your problem, not ours. You should know better since you have been in our office before," using a harsh tone of voice. Office manager then overheard patient telling her spouse that she "felt like she just got yelled at."

 

Improper: August 8, 2006 you were rude to a patient.

 

Proper: August 22, 2006, 11:45 am, Hygienist, S.H. observed you helping out a fellow employee by cleaning her instruments for her because she was running behind.

Note: If the employer does not personally observe a behavior, have the employee that did give a written statement for the file.

When a positive behavior is exhibited, it is best to recognize the employee as soon as possible. Looking for small indicators of good performance and identifying the performance immediately is a successful way of improving future performance, especially when others in your dental team realize that you take note of these actions. Continually writing down and verbally acknowledging good behavior makes the yearly appraisal report much easier to complete and justify.

In regard to negative behavior, once it has been determined that an employee is behaving in a manner not conducive to office policy, disciplinary action must be taken. When to begin the disciplinary action depends upon each employers tolerance, and the extent of the employee's negative behaviors.

The first step in discipline is a verbal warning. An employer should have a face to face conference with the employee and state specifics regarding the behavior that is not tolerated in the office. By giving specifics, there is little wiggle room for the employee. It is difficult to fight when facts are presented. After discussing the negative behavior, set specific expectations for future performance. For example, "It is my policy for an employee to be on time. If you are late again, it will result in a written warning, and the third offense will be termination." Make note in the employee's file that there was a verbal warning regarding ___ behavior on ___date and employee was notified of the disciplinary process.

With another infraction, again have a conference detailing the specific behaviors, this time writing down the specific offense and the expectation of performance regarding the behavior. Have the employee sign this document. Include that further behavior of this kind will result in termination. This document should be dated and kept in the employee's file.

If termination is the final step with a specific employee, the employer can feel confident that the facts were presented, the employee was given a fair chance for improvement and that termination of employment was warranted.

Any given employee can affect an entire team, and your practice. The impact an employee makes, both positive and negative must be recognized and dealt with in an effective manner to keep the dentist, fellow employees and patients happy.

Our operating system crashed and we lost about a third of our patients' radiographs. To make things worse, our backup files were corrupted as well. While we are not planning on ever being faced with a patient complaint and subsequent subpoena by BODEX, we are wondering what would happen in that instance if we were unable to produce an x-ray. Would that be considered non-compliance? What proof would I have that the appropriate x-rays had ever been taken? What are the possible ramifications of having lost these radiographs?

There are two issues involved in these questions. One aspect is the information technology, or computer issues. The other is the compliance issue regarding maintenance of records.

First, let’s discuss the computer issue. Unfortunately, computers are extremely complex machines built by people with engineering and technology related degrees. The majority of employees in the dental work force don’t possess the formal education necessary to understand how they are built or how the machines operate, but they are required to use them in their day-to-day activities.

To battle this dilemma, computer manufacturers and software companies have been successful in constructing a “User Friendly” environment. That is to say, the end user of personal computers doesn’t have to posses an engineering degree or have the technological prowess to operate a computer because of GUI (pronounced, “gooey”), short for Graphical User Interface. This is the mainstay of Apple and Windows based systems that make it simple to orchestrate daily operating tasks with such a complex integration of silicon and metal. I still marvel at how something as simple as using the mouse to move the cursor arrow and double-clicking the 8:30 a.m. appointment slot in the Dentrix Appointment Book pops up a box that helps me schedule an appointment for a patient. What’s going on behind the scenes that make this stuff happen?!

Doesn’t matter, does it? It works! And it makes our jobs easier; we’re more productive; and it looks cool!

Using the computer makes our job easier, until the computer doesn’t respond to the nice commands we’ve become so accustomed to typing, the screen is black, and we realize we are witnessing a disaster in the making…our hard disk is crashing! Now, all of a sudden, our whole attitude and demeanor changes about computers. Four letter words that are outside of dental terminology and completely out of the editorial capacity of this article echo through the confines of the workspace like the roar of an avalanche in the Alps during the dead of winter.

Then, we realize we have a backup. Oh, thank goodness! All is not lost; we’ve been safeguarding our data! As your initial question states, you checked your backup and the data was corrupted. My daughter who is a sophomore in high school would probably respond with, “Bummer”. So would I.

How sad would it be if you reached down to the slot where your tape backup is placed, pull it out, and find that the tape is stuck?! You tug and pull, and it finally releases, only the tape is caught in the drive and the spool of tape is unwinding from the cassette with every inch you pull away from the box.

Okay, all kidding aside, these are big problems. For more on safeguarding computer data and dealing with computer crashes, you can go to my website, www.FredHeppner.com and click on “Articles by Fred Heppner”. Read the one titled, “How Sound Is Your Practice’s Data?”

Now, on to the maintenance of records issue. For this I have contacted known expert on dental law in Arizona, Jeff Tonner. According to Mr. Tonner, recent information from the Arizona State Board of Dental Examiners, or BODEX, indicates a new statute is now in effect, (ARS §32-1264e) that covers Maintenance of Records. Essentially, this statute now states that dental records must be kept for six years from the last date of service for adults; and three years after a juveniles 18th birthday, or six years from the juvenile’s last date of service whichever is later.

When asked about the dilemma regarding losing patient data from a computer crash and the legal issues in our original question, Jeff was very helpful and informative with his responses. Here are answers to the records questions that I trust will be helpful and useful to you.

The Board might find a person in violation if a requested record cannot be reproduced. If one can’t produce the record, x-ray or otherwise, even if the progress notes indicate the record was taken, one may be in violation due to the fact that the record can’t be produced. It’s also a matter of degree. If one can produce most of the records, but can’t produce all of it (request for records), then one may stand a better chance of being exonerated. For example, from a full set of x-rays, one is missing and the missing x-ray is the one needed for the case, then perhaps one may experience some leniency from the licensing board.

Essentially, if everything crashed, and a person had taken proper precautions, and it was a fluke that nothing was recoverable, perhaps there may be some leniency. The more comprehensive the backup plans one has, the better chance one would have to avoid possible legal entanglements if required to produce a record.

Another example would be if the backup routines were sound and reasonable. That is, the routine called for daily backups at the end of the working day, perhaps even at night before the next day, and they were done appropriately. Someone breaks and enters the dental office in the middle of the night and steals the computer and all the data. In this case, the board might be more lenient due to the fact that reasonable precautions were taken and one day’s worth of data was the only information lost.

If one requires proof that an x-ray had ever been taken, then inspect the office for the X-ray itself, a notation made in the progress notes, the ledger for a billing entry charging out for the service, an insurance claim form, or a billing statement.

The ramifications of not being able to produce a record subpoenaed by a licensing board could be Unprofessional Conduct: Failure to Maintain Records. Or, one may be in violation when the patient requests the records and one is unable to produce them. Again, the board may find that person in violation.

Another event that happens occasionally is a patient arrives at an office and brings their own records, in particular their own x-rays. When the patient leaves and requests their original x-rays, oftentimes the office gives them back to the patient without obtaining a copy of the records for their files. True, the patient owns records brought by the patient. But without records, the office may put themselves in an embarrassing situation in the future, or in a legal entanglement if a complaint is filed. To guard against this, make a duplicate immediately, and make a note in the record: “Patient brought full mouth series from Dr. Simpleton on 10/10/06. Copy made for our records”. If a copy was not made, Dr. Simpleton’s records could be subpoenaed and therefore could help in supporting the diagnosis.

It’s a tragedy when hard work is lost when a computer crashes. The uneasiness that comes along when the records are required for potential legal entanglements compounds the frustration. Be Proactive and safeguard your data, and work hard to maintain your records so that you will be prepared, just in case something happens.