The Basics on Bonus Plans
Getting Staff to Produce the Quantity you Need and Want

It is very wise to have a bonus plan for staff in operation in your office. If you reward staff for increasing their production and the production of the practice, they will naturally want to continue to do that, and the whole staff will tend to operate much more as a team.

In structuring a bonus plan, the simpler you can make it for yourself and your staff, the better. Bear in mind that you want the staff working as a team and that there are several areas of concern. Consider the following:

The best bonus plans are ones that get the entire staff working together towards increased viability for the whole practice, while rewarding their own increased production. A plan that gives staff bonuses when the practice is not viable is a loser for the doctor/owner. At the same time, not providing bonuses to staff for their increased production when the practice is getting more and more viable provides no incentive or reward for the staff and will lead to a less cohesive and productive group. So, you have to put together a system that takes into account the major statistics of the practice, the viability of the practice, and the individual production of the staff members.

Certainly, you want higher production statistics, but if you pay bonuses only on increased production, you could be painting yourself into a corner if the collections do not keep up with the production. You could be paying bonuses out of your own pocket!

At the same time, generally, only one person is handling collections. But even so, a team effort can come into play in this area. Staff members who do not formally have anything to do with collections can still be of assistance by not overburdening the person in charge of collections with other matters. The staff can offer to help out with getting statements out. If appropriate, the staff can offer to perform other helpful functions (as time allows) so that the person in charge of collections can handle financial matters. All staff should be cognizant of relaying important financial related information to the accounts manager if they become aware of a situation that could affect the financial area. Additionally, the better service a patient/client receives, the easier it is to collect payment. All staff can contribute to collections by doing their own jobs well.

If the staff is focused only on production statistics, they may not focus an appropriate amount of attention on promoting new patients/clients in the practice. New patients/clients coming into the practice is one of the prime factors involved in your being able to generate more production and collections. The new patient/client area ties in closely with the growth and viability of the practice. All staff can be responsible for the inflow of new patients/clients into the practice by their own promotion from their job area, as well as outside of the practice.

The point becomes self-evident. The staff must be focused on all of the above and working as a team to keep all of those statistics going up. The practice will grow, and they will be rewarded for their contribution to that growth. At the same time, the practice’s viability must be looked at.

The following is a very simple and effective bonus plan suggestion:

  1. For starters you must confront the viability status of the practice. Determine what the break even point of the practice is – what it honestly costs to operate. Don’t forget reserves too! It is advisable to confer with a consultant on this as he/she will be able to help you determine whether or not you have considered all factors. As you are determining this figure, take into consideration the fact that the practice does have variable expenses, so you will want to average those figures in. Work them in on the high side to ensure that you’re not cutting yourself short.
  2. Once you have determined what the baseline viability figure of the practice is, you will know exactly how much you must bring into the practice to keep the doors open and operate in a solvent fashion. Remember, it is better to figure high than to cut yourself short. You now know that anything above that figure can be used for giving bonuses to the staff.
  3. You would now take a percentage of the amount that is above and beyond this figure to be used as a staff bonus fund. This could be anywhere from 15% – 20%. Of that percentage, you would figure what percentage each staff member would be paid as a bonus. This could be based upon seniority of position (the office manager would probably be bonused more than the receptionist), years of service, etc. Each individual staff member would be eligible for their share of the bonus amount based upon whether they have met their own individual production quotas. In this way, the staff are being rewarded for helping to make the practice solvent and viable and for their own production that contributed to the solvency level of the practice.

SAMPLE: Cost of operation is $20,000. Production target is set at $24,000. Collection target is $22,000. A New Patient/Client target would also be set to keep staff focused on all three areas. If all three targets are met, the staff bonus plan operates for the month.

Let us say that the Production target is met, the collections are at $22,000 and the New Patient/Client target is met. The staff would then qualify for their bonuses.

You would take the amount collected over the baseline viability figure which in this case is $2000. Let’s say that you are putting 20% into the bonus plan which, in this case, would be $400. Let’s also say that you have four full-time staff, and you work out that the office manager gets 30% and each other staff member gets 23.3% if they made their own production targets. So, the office manager would get a $120.00 bonus, and the rest of the staff would get a $93.20 bonus. That is a very nice incentive for the staff and allows the owner to get a nice bonus as well.

It is suggested that the percentage amount that goes to bonuses be based upon the present viability of the practice. If you are just starting this and don’t have much in reserves and are just covering your bills, you would put a smaller percentage toward the bonuses and use the rest to pay off bills and build reserves. As you build more reserves and get debts paid off, you become more and more viable and can thus afford to put a higher percentage toward the staff bonuses.

The effectiveness of this bonus plan lies in the fact that each staff member knows that they need to reach established targets to qualify for bonuses. They also know that the more they produce, the more bonuses they will get and that nobody wins unless they and the practice all win. Thus they will want to push the statistics up and the practice will expand due to the focus and teamwork of the staff. Everybody wins!

We are now offering a no cost, no obligation 1 hour phone consultation for practice owners that have questions about private practice bonuses systems. Schedule a 1 hour complimentary call with one of our research experts now!

Claims Against Dental Amalgam Lack Scientific Evidence

PANEL REPORT FINDS HEALTH CLAIMS AGAINST
DENTAL AMALGAM LACK SCIENTIFIC EVIDENCE

The American Dental Association recently announced that a review of seven years worth of scientific studies concludes there is insufficient evidence “of a link between dental mercury and health problems, except in rare instances of allergic reactions,” according to a report released today by the Life Sciences Research Office, Inc. (LSRO) in Bethesda, Maryland.

Established in 1962, LSRO is a non-profit, independent organization with a worldwide network of experts that studies issues in biomedicine, healthcare, nutrition, food safety and the environment.

LSRO conducted the independent scientific review of dental amalgam at the request of a work group made up of representatives from the National Institutes of Health, Centers for Disease Control and Prevention, Food and Drug Administration and the U.S. Public Health Service. The report, Review and Analysis of the Literature on the Potential Adverse Health Effects of Dental Amalgam, updates and reaches the same conclusion as two earlier reviews by the U.S. Dept. of Health and Human Services of the dental material, which is an alloy made of silver, copper, tin and zinc, bound by elemental mercury. The silver-colored material is widely used to fill dental cavities.

“This report further substantiates the American Dental Association’s position that dental amalgam is a safe, effective material to fill cavities, based on science and clinical experience,” said Dr. James B. Bramson, ADA executive director. “Countless people’s teeth have been saved by using amalgam, which is one of the most durable and affordable cavity filling materials available, especially for large cavities in the back teeth where chewing forces are the greatest.”

The LSRO report was based on a review of nearly a thousand papers from peer-reviewed scientific literature along with public comments submitted to the Federal Register and involved a multidisciplinary panel of experts in fields such as toxicology, allergy, pediatrics, epidemiology and pathology.

The American Dental Association is the nation’s largest dental association, representing more than 149,000 members.

Successful Treatment for Canine Spinal Injuries

Lab tests have shown that an injection of a liquid polymer known as polyethylene glycol (PEG), if administered within 72 hours of serious spinal injury, can prevent most dogs from suffering permanent spinal damage. Even when the spine is initially damaged to the point of paralysis, the PEG solution prevents the nerve cells from rupturing irrevocably, enabling them to heal themselves.

“Nearly 75 percent of the dogs we treated with PEG were able to resume a normal life,” said Richard Borgens, director of the Center for Paralysis Research in Purdue’s School of Veterinary Medicine. “Some healed so well that they could go on as though nothing had happened.”

The research, performed at Purdue, Indiana University-Purdue University Indianapolis, and Texas A&M University, appears in the December issue of the Journal of Neurotrauma.

In the study, 19 paraplegic dogs between 2 and 8 years of age were treated with a PEG injection within 72 hours of their injury as an addition to the standard veterinary therapy for spinal injury. This standard treatment includes injection of steroids, physical rehabilitation with swimming, and surgical removal of any offending chips of bone remaining in the spinal area after injury. This group of 19 was compared with a second group of 24 dogs that received only the standard treatment.

“The control group was taken from historical cases of dog injury that were similar to those in the 19 dogs we treated,” Borgens said. “We didn’t want to tell any owners who walked in with injured dogs that their pets were not going to receive something that might help. So we looked at the results that the standard treatment had on dogs that had suffered similar injuries in the past.”

After treatment, the dogs’ improvement was measured based on criteria including desire to move, deep and superficial pain perception, and transmission of electrical impulses through the nerve tissue.

“More than half of the dogs in this study were standing or walking within two weeks of treatment,” Borgens said. “In most cases, you could usually notice positive signs within three to five days.”

Another 16 dogs were injected with a different substance called P-188, a mixture of 80 percent PEG along with other chemicals, which also was thought to have potential as a treatment.

“However, dogs treated with the P-188 mixture did not perform as well as those treated with PEG,” Borgens said.

Trauma to nerve cells causes their membranes to weaken and even rupture. Though the cells may survive, this membrane damage causes them to lose the ability to produce and carry nerve impulses along their membranes from one cell to the next.

“Worse yet, chemicals seeping out of the dying spinal cord cells send a ‘suicide signal’ to other nearby cells, causing a chain reaction that kills off more cells than the initial injury did,” Borgens said. “Until now, the end result has been irreparable damage to the spinal cord, causing partial or complete paralysis to the victim.”

PEG is able to intervene in this process by repairing the initial membrane damage. It has been known for decades that two cells that touch each other can become one big cell if PEG is added to the fluid they live in. Because of this surprising ability, PEG is sometimes called a “fusogen.”

About five years ago, Borgens and his partner, Riyi Shi, found that they could actually fuse hundreds to thousands of severed nerve fibers of the guinea pig spinal cord with only a two-minute PEG treatment. This observation led to developing the polymer as a repair agent that would mend the broken membranes of nerve cells after traumatic injury.

Though PEG’s action as a fusogen has been known prior to their work, the exact mechanism that occurs at the membrane to fuse or mend it is still poorly understood. Borgens said that many membrane specialists believe it has much to do with the ability of PEG to quickly and dramatically remove water from the cell membrane that floods into the cell after suffering damage. This makes it difficult for the cellular membrane to heal on its own.

“Imagine children blowing bubbles with wands, the kind with a small round hole at the end,” Borgens said. “The polymer acts like a soap film that covers the hole and draws the water away. In the PEG-sealed membrane, the fatty oils that form the center of the membrane can mix again, free of the water that had likely repelled them. Once PEG dissolves away from the area, water molecules once again help to induce and preserve the restructured membrane.”

In spite of the fact that the exact mechanism is yet to be completely understood, Borgens said it is known that PEG has been both injected and ingested by humans as a component of other medicines and is completely safe. Curiously, PEG only covers damaged cells and tissues when injected into the blood stream and is not found in healthy or undamaged tissues nearby. These facts paved the way for clinical testing on paraplegic dogs at Purdue’s School of Veterinary Medicine by Dr. Peter Laverty and his colleagues, and on paralyzed dogs at a partner institution, the Texas A&M College of Veterinary Medicine, by neurologists Joan Coates and Robert Bergman. These efforts could mean relief for many dogs that are prone to spinal injury.

“Certain dog breeds can easily injure their backs simply by jumping off a couch,” Borgens said. “Up to this point, little could be done for dogs or humans with such injuries – even with immediate attention and the highest standard of care. Decompression surgery and injections of steroids, like methyl prednisone, have done little.”

However, with Borgens’ and Shi’s discovery of PEG’s effects on crushed spinal cord tissue, a new and safe therapy may be even closer to human trials since naturally injured dogs responded so well to it.

“In most dogs, we found a PEG injection within 36 hours can restore sensitivity and even mobility within three weeks,” Borgens said. “These results are unprecedented in paralysis research.”

While such news should be inspiring for pet owners, Borgens strongly cautions those who think a cure for human paralysis is right around the corner.

“There are significant differences between canine and human spinal cords that must be addressed before this treatment can be applied to people,” Borgens said. “In dogs, for example, some of the control of walking actually takes place in the spine, while in humans all of this control resides in our brains. Additionally, PEG cannot just be used off the shelf – it must have a high level of purity for it to be effective. This is very promising research, but it won’t be available in your hospital for some time.”

On the other hand, once these issues are ironed out, Borgens said the next step would be human trials.

“We do not anticipate this treatment to have any significant effect on people who have suffered from spinal injuries in the past,” he said. “But once it is refined, we hope it will prevent future spinal injuries from paralyzing victims permanently. I would like a supply of PEG to become standard on every ambulance.”

Funding for this research has been provided by grants from the National Institutes of Health, the state of Indiana and the Mari Hulman-George Endowment.

Purdue’s Center for Paralysis Research was established in 1987 to both develop and test promising methods of treatment for spinal cord injuries.

In addition to work with PEG, the center has a number of other ongoing research projects. Borgens also oversees work with oscillating field stimulators, devices that stimulate growth of spinal cord tissue by means of electrical fields. The center also is working with another druglike ingested substance called 4-aminopyridine, which has shown potential in reversing the injury-induced loss of nerve potentials in damaged nerve fibers.

New NIH Cataract Study

NEW NIH STUDY LINKS LEAD EXPOSURE WITH
INCREASED RISK OF CATARACT

Results from a new study show that lifetime lead exposure may increase the risk of developing cataracts. Researchers found that men with high levels of lead in the tibia, the larger of the two leg bones below the knee, had a 2.5-fold increased risk for cataract, the leading cause of blindness and visual impairment.

“These results suggest that reducing exposure of the public to lead and lead compounds could lead to a significant decrease in the overall incidence of cataract,” said Kenneth Olden, Ph.D., director of the National Institute of Environmental Health Sciences.

The National Institute of Environmental Health Sciences, one of the National Institutes of Health, provided support to researchers at the Harvard School of Public Health and Brigham and Women’s Hospital for the nine-year study, which is also focusing on lead’s contribution to hypertension and impairment of kidney and cognitive function. The findings on risk of cataract are published in the December 8th issue of the Journal of the American Medical Association.

Lead is found in lead-based paint, contaminated soil, household dust, drinking water, lead crystal, and lead-glazed pottery. Following exposure to lead, the compound circulates in the bloodstream and eventually concentrates in the bone.

The Harvard researchers tested whether bone lead levels measured in both the tibia and patella, also known as the kneecap, were associated with cataract in an ongoing study of men taken from the Boston area.

“Given the strong association between tibia lead and cataract in men, we estimate that lead exposure plays a significant role in approximately 42 percent of all cataracts in this population,” said Debra Schaumberg, Sc.D., assistant professor of medicine and ophthalmology at Harvard Medical School and lead author of the study. “While lead in both the tibia and patella was associated with an increased risk of cataract, tibia lead was the best predictor of cataract in the study sample.”

According to Schaumberg, cataracts develop as a result of cumulative injury to the crystalline lens of the eye. “Lead can enter the lens, resulting in gradual injury to certain proteins present in the epithelial cells, and this eventually results in a cataract,” she said.

The Harvard researchers are among the first to use bone lead in studying the effect of lifetime lead exposure on disease risk. “The best biological marker for estimating a person’s cumulative exposure to lead is provided by skeletal lead,” said Dr. Howard Hu, professor of occupational and environmental medicine at the Harvard School of Public Health and co-author of the study.

“Since blood lead levels reflect only recent exposures, they are not likely to predict the development of age-related diseases such as cataract, which take many years to develop.”
Cataracts, a clouding of the lens resulting in a partial loss of vision, are very common in older people. By age 80, more than half of all Americans either have a cataract or have had cataract surgery. Other risk factors for cataract include diabetes, smoking, long-term alcohol consumption, and prolonged exposure to ultraviolet sunlight.

“The prevention of age-related cataract remains an important public health goal,” said Schaumberg, “In addition to the obvious problems of reduced vision, the visual disability associated with cataracts can have a significant impact on the risk of falls, fractures, quality of life, and possibly even mortality.”

Vets Keep Close Watch on Canine Disease

Veterinarians Keep Close Watch on Potentially Deadly Canine Disease

– New Website Profiles the Latest Info on Recent Outbreak of Leptospirosis –

From Boston and Buffalo, to Chicago, Denver, Houston and San Diego, veterinarians across the country are keeping a close watch on the recent outbreak of leptospirosis, a potentially deadly canine disease that has already killed several dogs this summer.

Leptospirosis thrives in water sources and is commonly found after periods of heavy rain. Animals that come into contact with water sources that have been contaminated with urine of infected wildlife are most at risk.

A new website, www.dvmvac.org, profiles the latest information on the outbreak of Leptospirosis. The site, which educates veterinarians and pet owners about the important role vaccines play in the health of animals, also features break-through research on canine and feline vaccine development and helps to clarify the debate regarding annual and extended vaccination schedules.

“For many diseases such as Leptospirosis, vaccines remain the single most important element of a pet’s preventative healthcare program,” said well-known vaccine expert Dr. John Ellis, Professor of Veterinary Microbiology at the University of Saskatchewan’s Western College of Veterinary Medicine, “The site, www.dvmvac.org, answers questions by members of the veterinary profession and the pet-owning public about vaccine efficacy and safety.”

Lyme disease expert, Dr. Steve Levy stated that Lyme is another disease that requires annual vaccination. Levy said, “Annual vaccinations play a critical role in maintaining the immunity necessary to break the Lyme disease cycle. This site is an important new tool to expand our reach as veterinarians and further public awareness about the use of vaccines in dogs and cats.”

Other advisory board members for www.dvmvac.org include:

  • Steven Krakowka, DVM, Ph.D., Dipl. ACVP, Ohio State University
  • Gary Norsworthy, DVM, Dipl., ABVP, San Antonio, TX
  • James Evermann, MS, Ph.D., Washington State University
  • Dr. Margret Casal, Assistant Professor of Medical Genetics, University of PennsylvaniaIn addition to interviews with veterinary academia and testimonials from practicing veterinarians,www.dvmvac.org offers information for both veterinarians and pet owners.The section for veterinarians includes topics on:
  • Safety, efficacy and duration of immunity of vaccines
  • Killed vs. modified-live vaccines
  • Sarcomas
  • The role adjuvants play in vaccine efficacyThe pet owner section features information on:
  • Facts about vaccination
  • Disease risk factors
  • Canine and feline diseases controlled by vaccinationThe new vaccine website is currently funded through an educational grant by Fort Dodge Animal Health, based out of Overland Park, Kan.

 

Survey of Optometrists

SURVEY OF OPTOMETRISTS SHOWS FINANCES AND STAFF AS MAJOR PROBLEMS AFFECTING GROWTH

In the second in a series of articles addressing surveys The Practice Solution Magazine has conducted on the optometry, veterinary and dentistry professions, we are releasing the results of the optometry survey. Our surveys are conducted one-on-one by our trained survey team with doctors all across the United States and Canada.

The benefit of doing these surveys on the phone, rather than by questionnaire, is the ability to get all the questions answered in detail. This makes the The Practice Solution Magazine survey a bit more unique as a thorough analysis can be done of the responses.

A wide diversity of practitioners was surveyed. This ranged from doctors just starting out to doctors who have practiced for over 40 years. Fifty seven percent of those surveyed are in solo practices. Seventy two percent of those surveyed have less than five staff members.

Our survey of optometrists clearly showed that staff and financial problems are what doctors consider the primary barriers affecting the expansion and viability of optometric practices. Nearly three quarters of the doctors surveyed believed those were their most serious problems. As discussed below, these two key problems are only the outward symptoms of a much more basic underlying factor.

These problems have resulted in time consumption and lost efficiency amongst 41% of respondents while 26% felt it directly affected their bottom line. Twenty two percent believed that it resulted in stress and an overworked environment

Most of the doctors surveyed stated they didn’t learn enough in graduate school to run a practice and one hundred percent wanted more business courses to be taught in graduate school. This is indicative of the overall responses that show staff issues and finances are the key problem areas.

This also addresses the true underlying reason why the great majority of our respondents experience these financial and staff management problems. Without proper business training, it is completely expected that doctors, on the whole, would be unable to truly manage staff or finances appropriately. And, thus, the above symptoms of this lack of training are so strongly evident. One doesn’t expect an untrained lay person to be able to perform the duties of a trained doctor. Likewise then, why should a person trained to be a doctor, but never trained in business management, be expected to be competent and conversant with all the issues and problems with running a business – which is what a healthcare practice is.

To rectify not gaining an adequate education in school, seventy five percent said they attend seminars, business courses, lectures and other forms of continuing education (CE). We’ve found that many doctors spend a tremendous amount of time pursuing the education they needed to receive in school.

One disturbing figure was that over one quarter of those surveyed forgo all training and attempt to learn the business side solely by trial and error. That one out of every four doctors surveyed are “managing by chance” is cause for concern. While not true in every case, a lack of pursuit of some form of practice management education is a significant contributing factor in the struggle and sometimes failure of so many practices and businesses in the first few years of operation.

The Practice Solution Magazine has already started a new evolution of surveys for optometrists and we plan on releasing the results of that in the coming year.

From The Editor’s Desk

They say that change is good. If that’s true, then The Practice Solution Magazine will take a nice step forward this year with the changes we have underway

First of all, let me introduce myself. My name is Matthew Bratschi and I’ve recently accepted the position of Managing Editor for The Practice Solution Magazine.

We’ll be regularly contacting our readers to find out what they liked best about the magazine and areas that could be fine-tuned.

We’ll be adding regular features to the magazine including profiles on doctors and businessmen that are outstanding in their fields. A FAQ (frequently asked questions) page will be added as well as an e-mail “hotline” to me for direct communication.

The purpose of The Practice Solution Magazine is to provide an information source on practice and small business management issues that fills an existing need amongst healthcare and business professionals.

Previously, The Practice Solution Magazine has concentrated solely on members of the healthcare profession. This year we will branch out somewhat into general small business, although healthcare will remain our primary focus. There are, simply, common management problems in all small businesses – i.e. staff management, financial management, getting new patients/customers, etc. With the proper management education there are solutions to all of these problems, no matter the type of business one operates.

As many of you know, surveys are the crux of The Practice Solution Magazine. This issue spotlights recent surveys conducted on optometrists all over the country. There is some fascinating information that was uncovered that applies to all industries. This is something that we are finding out in our ongoing surveys of practitioners in the fifty States and Canada. Apparently, there are universal truths.

The article that explains the results of the survey is the first in a series of articles outlining issues that YOU have said are the biggest problems in your practices and businesses. Our next issue will address the results of our surveys with veterinarians and the following issue will highlight the results of our surveys with dentists.

I look forward to making The Practice Solution Magazine your first stop for industry news and interaction. It’s great to be here!

Matthew Bratschi
Managing Editor
The Practice Solution Magazine

Publishers Note: Happy New Year!

Happy New Year!

Some changes have occurred within The Practice Solution Magazine over this past quarter. I have moved on to the official publisher position for The Practice Solution Magazine and we have recruited a new managing editor to handle the day-to-day activities.

Our new managing editor, Matthew Bratschi, is a transplant from Washington, DC where he worked in public relations for 14 years. Most recently, Bratschi was president of the Northern Virginia PR firm, Creative Professional Resources. He is also an experienced writer, media analyst and interviewer.

We look forward to seeing him implement his visions for the expansion of The Practice Solution Magazine.

Our plans for the coming year include a change in design for the website and a broader marketing of the Forums section to engage readers in broader debate about questions of practice management. We will also be adding to our base of articles and providing additional resources for you to use.

I want to thank you very much for your continued readership of The Practice Solution Magazine. If you have any questions regarding the format or content of our magazine, please send me e-mail. I look forward to your responses.

As always, if you are having management problems with your healthcare practice or small business, don’t get frustrated – contact us and we can help in some way.

Sincerely,

Ken DeRouchie
Publisher,

The Practice Solution Magazine

Guest Column: By Dr. Barry Levy DDS

DENTISTRY AT RISK:
COMPLYING TO MINIMUM
STANDARDS OF INFECTION CONTROL

By: Dr. Barry Levy DDS

If you are not aware of, or are not complying with minimum standards of infection control, you can be in for a rude awakening. While the below article addresses cases litigated in California, it is important for dentists across the country to understand many precedents are set in California and can affect how you practice dentistry in your home state.

Recently the California Dental Board cited section 1005 of the California Profession and Business code in a disciplinary action against a dentist (Section 1005 defines “minimum standards” of infection control to be followed while practicing). Because of the dentist’s failure to follow the minimum standards of infection control the board hearing was being used to determine if this dentist would be able to continue to practice dentistry. Penalties could range from fines, to suspension, to revocation of one’s license. It is easy to see the impact that the failure to follow minimum standards of infection control could have on your life should a problem arise and the board decides to investigate how you practice.

A recent malpractice case was brought against two dentists, because of a post-operative infection following an extraction. This case should drive home this concern and show how critical the language in the dental code is.

A large law firm was handling this case for the patient. After a year of negotiations the firm told the patient that they were dropping the case because they could not link the treatment to the post-operative infection. The judge allowed the patient time to find a new attorney. The new attorney took the case and, even with no way to link the infection to the treatment, won a settlement.

So why did the dentists’ lawyers settle this case after getting a law firm to drop out?

The lawyers for the dentists settled this case rather than risk trial, because the liability was too great. It was impossible to defend the position that a post-operative infection was not the dentists’ responsibility when they failed to follow the minimum standards of infection control when treating this patient.

A dentist cannot afford to litigate when he has FAILED to follow minimum standards of infection control and his patient winds up with a post-operative infection. A jury would hear the failure to follow the minimum standards as proof of negligence. A dentist could not argue that he didn’t know the code. Ignorance of the law is no excuse. And, in California, a course in infection control must be taken in order to renew one’s license.

Of particular importance is the language of the code section that states, “Sterile gloves shall be worn in connection with surgical procedures involving soft tissue and bone.” That can be taken to include periodontal treatment, extractions, endodontic treatment and, indeed, almost all of dentistry. Sterile gloves are not the medical exam gloves that are currently being used.

Should a complaint be filed, or legal action pursued against a dentist, the failure to follow the minimum standards are easily proven, and worse, could be shown to be occurring on an ongoing basis. In the civil case, the deposition of the dentist took about 20 minutes. The settlement was large.

The questions were very simple. “What size glove do you wear? Do all of your staff wear gloves? Do these gloves come in boxes of 100? Are you familiar with code section 1005?”

The answers of “large”, “yes”, “yes” and “no” were all that was needed to show the negligence. There were no questions directed to how the patient was treated, or what was done, or to try and link the treatment to the infection. These simple questions and unambiguous answers locked this dentist into negligence by failing to follow the code section.

The continued and ongoing failure to properly follow minimum standards of infection control could change a simple act of negligence into continuous acts of negligence.

My experience with the California Dental Board is that one act of negligence is treated very differently than continued acts of negligence.

If a dentist wasn’t using “sterile gloves” for one patient, the odds are very high that a thorough investigation would prove that all patients were at similar risk. The lone act of negligence would immediately become continued negligence.

But because of recent court action the stakes have risen even higher. It is bad enough to be sued in civil court, and facing a dental board investigation is a horrendous experience, but the precedent has been set so that criminal proceedings could be brought against you.

Should dentists fail to follow the minimum standards of infection control, and should they treat children, they will have met the minimum letter of the law that could see them charged with felony child endangerment (penal code 273 (a) a). This was the precedent that was set in the Dr. Ford case.

The Dr. Ford case involved sedation of a 15 year-old patient, who suffered a heart attack and brain damage in the dental office. This injury to the patient was deemed by a lawyer in the Attorney General’s office to be a criminal act. In the preliminary hearing, the judge, having heard the evidence, ruled that placing a child in a situation where there is a probability of harm, EVEN if no harm occurs, and knowing the consequences of your action rises to the letter of the law for criminal prosecution. There are now some lawyers who believe that an informed consent form is proof that the letter of the law for prosecution has been met.

Dr. Ford was exonerated of all charges against her, but the precedent had been set. It becomes easy to see that failing to follow the minimum standards of infection control could easily meet the letter of the law as applied in the Dr. Ford case, not to mention negligence, defined in black and white.

If you fail to follow “Minimum Standards” of infection control you have definitely placed your patient in a situation where there is a probability of harm, even if no harm has occurred and you are aware of the consequences of your action.

When the state was prosecuting Dr. Ford they argued that guidelines were not followed. They didn’t argue that minimum standards had been violated, because in this case the minimum standards weren’t. Having an unsatisfactory result when not following guidelines can be argued, and argued successfully, by showing that the standard of care in the community was met. Failing to follow a minimum standard can never be argued in that manner and, indeed, the standard of care in the community would be irrelevant in your defense.

AMALGAM RISK PRECEDENT:

We can throw in the interesting aspect of dental amalgam just to show how this can be applied as well, once a precedent is set. While the American Dental Association continues to argue that amalgam is perfectly safe, some dentists in California settled a lawsuit involving amalgam restorations.

In this lawsuit the dentists paid a settlement, and the settlement stated that the use of amalgam poses a health risk to the patient. The settlement even included the language that the use of amalgam in children under age six is contraindicated.

So using amalgam could cause a problem as the precedent has been set that placing a child in a situation where there is a probability of harm, even if none occurs, and knowing the risks can be viewed as rising to the letter of the law for criminal prosecution.

Pending federal legislation even cites the California settlement in the language of that bill. Certain consumer groups have gone on record to state that the use of amalgam should be a criminal act. It would not be a far leap that at some time in the future a test case might be filed. To say that this could never happen is what the profession had said in the Dr. Ford case.

But once the precedent is set, the argument that it could never happen can no longer be used.

What we are finding is that small, very vocal groups of consumer advocates are pushing legislation that can be very harmful for the way you practice and for your fiscal health. The problem is that once these groups get the legislation passed, the precedent is set and you may find that you have to follow these regulations in order to practice in a manner that mitigates possible civil, board or even criminal action.

Intelligent and learned dentists may argue that some of the precautions are not really necessary. When the new regulations are defined as minimum standards for the care of the patient, when certain materials are defined as potentially harmful, and when precedent has been set by cases that have been tried, your ability to defend yourself becomes more difficult if not impossible, should a problem occur.

I hope that this brief article that started out with the issue of infection control, has been informative. These situations can have a profound effect on you should a complaint or lawsuit ever be initiated against you. We are entering a new era for dentists, and it is becoming increasingly more important that you are aware and practicing within the letter of the law.

I strongly believe that the dental profession must take strong steps to regulate and protect their profession. When dentists get so involved that they don’t, then others make the rules and regulations that you must follow.

And because time is money, I want to finish with the cost to you should the California regulations come to apply to your state.

If you have to change one box of gloves each week to sterile gloves to comply with the minimum standards of infection control, the cost is over $3000/year. A busy practice using 5-10 boxes a week would be looking at an increase in cost of $15-30,000/year for sterile gloves.

(Dr. Levy has served as an expert on several cases, and is on the California Board of Dental Examiners panel of expert witnesses to assist in investigations)