TDIC Liability Lifeline - Volume 2, 2023

The Dentists Insurance Company’s Risk Management Advice Line analysts provide guidance to dentists, including daily communication strategies for addressing conflicts. The conflicts may involve difficult conversations with problematic employees or noncompliant patients regarding their treatment. Dentists frequently face situations that require thoughtful communication.

When dentists speak to Risk Management analysts, often just one thing is needed to prevent or mitigate

risks: effective communication. Positive communication is a vital skill for all members of the practice team and should be included in team training. Studies show that clear communication is associated with better treatment outcomes, increases patient satisfaction, builds trust and decreases the level of patients’ complaints. Within the workplace, 86% of employees and their employers cite the lack of effective communication as the main cause for workplace failures, while

an environment that fosters positive communication increases employee retention by 4.5 times the average rate.

Advice Line analysts point out that breakdown in communication is often the underlying factor in negative online reviews, lawsuits or complaints to the dental board, OSHA and thirdparty payers. In this issue of Liability Lifeline, discover new ways to improve your communication with patients and employees.

A Case Study on Patient Communication

One important factor leading to a breakdown in communication is emotion. Negative emotions channeled into negative outcomes directly relates to the communication climate between patient and provider. For example, analysts note that during Advice Line calls, dentists often express the feeling that patient complaints are simply an attempt to avoid payment for their services. Negative emotions based on this assumption may cause the dentist to fail to investigate if there are legitimate reasons why the patient is unhappy. The patient making the complaint in consequence feels unheard and increasingly dissatisfied, building upon the negative emotions and further breaking down the communication.

In one case reported to TDIC, a minor patient developed an abscess on tooth No. 7 while undergoing orthodontic treatment. The orthodontist’s office received an unpleasant phone call from the patient’s mother who requested to speak with the dentist. She reported that her child was complaining of discomfort on a front tooth and their general dentist had provided them with a referral to an endodontist to determine the source of the patient’s symptoms. The mother believed the abscess resulted from tooth movement during the orthodontic treatment and demanded a copy of the patient’s records, including radiographs and models. In looking at the pretreatment radiographs taken two years prior, the orthodontist noted evidence of a slight periapical radiolucency on No. 7. Given this finding, the orthodontist said they would have referred the patient to an endodontist then for further evaluation. The orthodontist was uncertain whether the extent of the treatment or the treatment outcome had been impacted by the delayed referral and diagnosis. Concerned about how to communicate this finding with the mother, the orthodontist reached out to TDIC’s Risk Management Advice Line for guidance.

The Risk Management analyst reminded the orthodontist of the importance of reviewing pretreatment records prior to initiating any treatment and to establish protocols for conducting a comprehensive assessment of the

pretreatment records gathered while developing a treatment plan. To facilitate positive communication with a concerned parent, the analyst advised the orthodontist to return the mother’s phone call without any further delay to explain his findings in a transparent manner. The dentist was additionally counseled to seek permission from the patient’s mother to speak with the endodontist to determine whether the prognosis would have been different had the issue been caught two years earlier when it first appeared on the radiographs. The analyst offered the dentist de-escalation tips and reiterated the importance of listening and remaining empathetic. She alerted the dentist that the mother could potentially interpret any minimization of the patient’s symptoms or necessary treatment as being dismissive of her concerns about the prognosis for her son’s tooth.

continued on page 4

continued from page 3

A few days later, the Advice Line received a followup phone call from the orthodontist, reporting that the guidance he had received from the analyst was helpful and the conversation with the patient’s mother went much better than he anticipated. The dentist explained to the patient’s mother that he had reached out to the endodontist and the endodontist confirmed there were no changes in the prognosis or the extent of treatment needed despite the timing of diagnosing the

radiolucency. The mother seemed to be receptive of the explanation the orthodontist provided to her and was reassured that the overall prognosis for tooth No. 7 was favorable.

In this case, the orthodontist’s transparency about treatment and involvement in the treatment plan effectively communicated his concern for the well-being of the patient, diffusing a difficult situation.

A Case Study on Employee Communication

In the dental office, open communication between practice owners and staff ensures an efficient workplace, reduces employee turnover and helps mitigate potential employment-related claims. Failing to communicate office policies and expectations properly or effectively can lead to difficult situations.

In one case reported to The Dentists Insurance Company’s Risk Management Advice Line, an employee was hired as a full-time registered dental assistant. She was instructed to write down eight hours on her time card, regardless of the actual hours worked. She was also asked to report 15 minutes prior to the start of her shift for a mandatory daily huddle.

Although the employee was not happy about these requests, she complied because she needed the job. Ultimately, the employee became fed up with not being paid for the actual hours worked. After a few months, she began to record her actual hours on the time card. The payroll program used by the dentist removed any overtime entries that were not marked as approved by the dentist. The employee questioned the dentist about the missing overtime on her paycheck and was told that his office policy is not to pay overtime unless prior approval is obtained. However, he had not previously informed her of his office policy regarding overtime.

To make matters worse, the office manager changed the employee’s schedule, resulting in a reduction of hours. The manager also changed her position from RDA to DA without prior notice or any discussions with the employee. The employee contacted the office the following week and informed them that she would not be returning to work. Two months later, the office received a letter from an attorney representing the former employee, who alleged a hostile work environment and failure to pay overtime. Eventually, the case was settled through mediation for a high five-figure amount.

When communicating with employees, TDIC recommends that practice owners be clear, direct and decisive. This should begin with employee onboarding and continue through the duration of employment. A good starting point is a comprehensive and up-to-date employee manual. In addition, new employees must clearly understand the practice's vision, goals, policies and procedures.

It’s also a leadership best practice to clearly outline each employee’s role and responsibilities. Each position should have a written job description and written expectations, and these expectations should be discussed with the employee in person to ensure understanding. This establishes accountability and increases motivation and performance for each member of the team.

Communication Climates and Your Practice

Communication and behavior experts categorize interactions in terms of climate. A confirming communication climate is one in which the receiver gets a sense of their value and worth from the messenger. Conversely, a disconfirming communication climate suggests to the receiver that they are devalued and unimportant. Disconfirming climates lead to negative behavior patterns that impede communication, such as defensiveness, embarrassment and conflict, while confirming climates lead to positive behavior

patterns that support effective communication, such as honesty, appreciation and collaboration.

Defensive communication behaviors are particularly important to avoid, because as one individual becomes more defensive in a conversation, they become less able to accurately perceive the other individual’s messages. Both sent and received messages then become distorted. The opposite is also true: defense-reducing or supportive behavior fostered by a confirming climate lead to fewer distorted

Creating a Confirming Communication Climate

messages in a conversation. The resulting communication is clearer and more effective, supporting more teamwork and less conflict.

An environment in which patients feel safe, understood and willing to cooperate is one where both provider and patient can benefit. The same standard is true for interactions with dental practice owners and staff members. Learning and adopting confirming communication strategies is one of the best tools you have for reducing risk.

In 1961, communications researcher Jack Gibbs identified six patterns of behavior that create confirming communication climates. These remain the gold standard for developing positive communication skills that de-escalate conflict and foster feelings of support and cooperation. Below are examples from TDIC experts that apply to interactions within a dental practice.

• Description. Describe a behavior instead of evaluating it. A description provides detail about the person’s behaviors without passing judgement.

– Disconfirming statement: “It’s rude for you to arrive late to your appointments.”

– Confirming statement: “I’ve noticed that it’s been difficult for you to make it to your appointments.”

• Problem Orientation. Focus on the problem you are trying to solve, separating it from the person with whom you are communicating. Rather than exerting control over the other person, problem-oriented behaviors focus on finding solutions that satisfy both parties’ needs.

– Disconfirming statement: “You should floss every day.”

– Confirming statement: “Let’s talk about some ways that we could make it easier for you to remember to floss each day.”

• Spontaneity. In terms of confirming communication, Gibbs defines spontaneity as honesty or transparency. Instead of hiding an

agenda, the communicator is simply honest rather than manipulative.

– Disconfirming statement: “What are you doing on your day off?”

– Confirming statement: “Next Friday, we need extra staff members on hand to finish purging paper charts. You could earn overtime pay if you are able to come in to help.”

• Empathy. This is the action of responding to another person’s feelings by trying to understand the situation from their perspective. Being empathetic demonstrates that you value another’s opinions even if you don’t agree with them.

– Disconfirming statement: “This crown just needs to be replaced. It’s not a big deal.”

continued on page 8

Need guidance with a complex issue?

We’re here for you! The Dentists Insurance Company offers tools to navigate potential liabilities in the areas of documentation, employment, patient care, property and more. TDIC policyholders can tap into resources, guidance and education to mitigate the risks of practicing dentistry today.

Time-saving Resources

• Dentistry-specific reference guides

• Multilingual informed consent forms

• State-specific forms and templates

One-on-One Guidance

• No-cost Risk Management Advice Line

• Dedicated analysts with unique expertise

• Convenient online appointment scheduling

Ongoing Education

• C.E.-eligible live, expert-led seminars

• Convenient on-demand eLearning options

• Articles and insights on trending risk topics

Plus, policyholders can earn C.E. and lock in discounts on professional liability premiums by completing a risk management seminar.

Explore the benefits at tdicinsurance.com/RM. Scan here:

@TDICinsurance | tdicinsurance.com | CA Lic # 2361-4

Terms and conditions may apply. Visit tdicinsurance.com/Seminars for additional details.

continued from page 5

– Confirming statement: “I understand why you are angry and afraid. You didn’t expect to find out today that your crown would need to be replaced.”

• Equality. Messages of equality demonstrate that the person you are communicating with has value and worth, regardless of their amount of knowledge or expertise in a particular area. Try not to treat them differently because of age, gender, education or socioeconomic status.

– Disconfirming statement: “Since you haven’t been to dental school, you aren’t qualified to determine the best treatment.”

– Confirming statement: “I’d like to hear what you think about this. I want to make sure we find a solution that makes us both comfortable.”

• Provisionalism. Provisionalism is being flexible and allowing for other points of view. Behaviors that

demonstrate that another’s opinions matter just as much as your own include letting others speak without interruption and encouraging others to contribute to the conversation.

– Disconfirming statement: “Postponing treatment is out of the question.”

– Confirming statement: “From my perspective, addressing this tooth sooner rather than later will result in a better outcome.”

Tips for Communicating with Employees

How you communicate is often as important as what you communicate. The following tips can help:

BE AUTHENTIC. Being honest and approachable helps build relationships. Sharing personal stories, finding common ground and asking open-ended questions creates a connection with the team, thus establishing trust.

BE POSITIVE. Approaching challenges with a can-do attitude works wonders on employee morale. Letting staff know you’re in it together creates a camaraderie that leads to buy-in from the entire team. Focus on successes and learn from failures.

BE CONSISTENT. Nothing kills employee morale faster than employees who feel they are treated differently or unfairly. Maintaining consistent policies in all aspects of practice management, from dress codes to time off, ensures each staff member feels respected.

BE CONCISE. A lack of clear instructions is one of the greatest causes of lackluster performance in the dental office. Giving directives and using straightforward language illustrated with causeand-effect examples can help employees better understand instructions. Practice owners are advised to conduct regular performance evaluations and morning huddles. Employees should also be asked whether they have follow-up questions.

Nonverbal Communication and Other Considerations

While verbal interactions are at the forefront of communication, don’t forget that nonverbal behaviors impact how communication is received. Voice inflections, facial expressions and hand gestures can signal additional meaning to spoken phrases. Sarcasm, for example, is often conveyed through a specific tone of voice. Nodding your head while listening is a nonverbal acknowledgement of the speaker. Ensure that your nonverbal cues sustain the confirming climate that you are working to create through your verbal statements.

It is also important to be mindful of patients who may require additional communication, such as patients with vision or hearing impairment, patients with a learning disability, patients who do not speak English or patients with psychological issues (anxiety or phobia). Be prepared to utilize technology, interpretation services or a patient advocate to enhance communication and understanding between provider and patient.

Practicing these positive communication behaviors is the key to creating a confirming climate in your dental practice. While it can be especially difficult to remove your own emotions from a situation — particularly with a difficult patient — doing so is the first step toward confirming communication. This will help de-escalate and minimize conflict, ensuring that patients and employees are willing to communicate and work with you to create practical solutions

to problems. While not all challenges are easily or quickly resolved, your efforts to maintain positive, supportive communication behaviors can minimize the stress of a situation and improve outcomes.

Being entirely objective is not easy!

TDIC’s Risk Management experts are available to assist you and draw upon

their experience and communication strategies to optimize positive outcomes. If you need additional support or suggestions for creating a confirming communication climate in your practice, the Risk Management Advice Line analysts are a source of practical tips and suggestions for implementing new techniques and communication skills.

Endorsed by:

Alaska Dental Society

California Dental Association

Hawaii Dental Association

Idaho State Dental Association

Illinois State Dental Society

Nevada Dental Association

New Jersey Dental Association

Oregon Dental Association

Washington State Dental Association