September 2016

Inadequate Supervision of Mobile Dental Clinic Results in Professional Liability Exposure

Mario Catalano, DDS, MAGD

Background

Many dentists at some point in their careers will be called on to supervise the work of other dental care providers. Although this may sound like a perfunctory duty compared to the complexities of rendering clinical dental care, this case from the Northwest illustrates how improper supervision can result in a poor patient outcome and professional liability exposure.

Case Discussion

Dr. N, a dentist new to practice after completing an Advanced Education in General Dentistry (AEGD) residency, accepted a position at a hospital-based dental facility in a small city. As a requirement for its state funding, the facility ran an outreach clinic about 20 miles from the hospital. Dr. N worked 20 hours a week in each facility.

About 9 months into Dr. N's employment, the state health department awarded the hospital a grant to purchase a mobile dental unit to serve additional clients. The hospital decided to use the mobile unit to visit schools where dental staff could perform dental examinations, prophylaxis, and fluoride treatments as well as apply sealants on students in grades K–4. In an effort to maximize profitability, the hospital hired a dental hygienist, who also was new to practice, to provide the basic dental services for the mobile unit. The hospital also hired a dental assistant and a driver.

As part of his duties, Dr. N was asked to equip and oversee the operation of the mobile unit. He trained the mobile unit staff on equipment use, and, shortly thereafter, they began to serve the community. Because state law required supervision of the dental staff, Dr. N agreed to provide general supervision, with the understanding that the mobile unit staff would refer all treatment questions to the hospital clinic.

About 15 months after the mobile dental unit began operating, Dr. N received a call from a dentist in the outlying community. The dentist had seen a patient who had previously had X-rays, a dental examination, and sealants done by the dental staff in the mobile unit. However, it appeared that sealants were applied over lesions on teeth 3 and 14. Because the teeth were painful, the dentist obtained new radiographs, which indicated that both teeth required root canal therapy. The dentist asked Dr. N why these lesions were not detected and treated earlier since they were visible on the original X-rays obtained by the mobile unit dental staff (how the dentist knew this is not clear).

A subsequent investigation revealed that the hygienist failed to note the possible decay, failed to refer the patient to Dr. N, and sealed over the lesions. The investigation also revealed that Dr. N had no protocol in place to monitor the work of the hygienist. The child's parents were irate and filed suit against the hygienist, Dr. N, and the hospital.

After 9 months of discovery, the case was settled with a payment in the midrange (between $20,000 and $50,000). Because the hospital provided professional liability insurance coverage for both Dr. N and the hygienist, liability was not allocated to the individual parties.

 


 

Risk Management Considerations

Theodore Passineau, JD, HRM, RPLU, CPHRM, FASHRM

When patients are injured while receiving healthcare, weakness in the design or administration of the healthcare delivery process often is a major factor. That certainly appears to be true in this unfortunate case, which resulted in an avoidable adverse outcome.

The problems in this case began with an apparent lack of knowledge or appreciation of the patient safety challenges inherent in mobile healthcare treatment of any sort. When healthcare is delivered outside of the facility setting, challenges can occur with:

  • Properly screening patients (to ensure they are appropriate candidates for the delivery system)
  • Gathering adequate health histories for patients
  • Finding opportunities to provide aftercare instructions and, in many cases, hygiene counseling
  • Providing adequate follow-up care for patients

Although this particular case did not provide extensive details regarding the exact circumstances of care, we know that young children were being treated in a mobile environment. This makes it very likely that at least some of the aforementioned challenges occurred on a daily basis. Further, it does not appear likely that the hospital administration adequately understood the environment of care.

Another risk factor in this case was the collective inexperience of the dental hygienist who was rendering the care and the dentist who was supervising her. Both were new to practice, and they should have been mentored and monitored by an experienced clinician. New practitioners (in any field), early in their practice, often "don't know what they don't know."

Dr. N was criticized for not having a review protocol in place to monitor the activities and performance of the dental hygienist. However, if a proper review protocol had been in place to monitor Dr. N, his supervisor likely would have recognized that Dr. N wasn't adequately supervising the hygienist. Young dentists should welcome any available mentoring and review of their work. Unfortunately, many hard lessons are learned through mistakes; learning these lessons through the counsel of a seasoned provider can greatly help inexperienced practitioners.

Although it does not appear to be a factor in this case, in many states, when a dentist is formally supervising a mid-level provider — especially an advanced practice provider, who generally offers more sophisticated services — a supervision agreement between the doctor and the provider is required. The dentist should be aware of any state requirements related to supervision agreements; if a requirement is in place, the supervision agreement must be properly executed and renewed at the mandated intervals.

The final point to consider in this case is the issue of professional liability insurance coverage. With some malpractice policies, the dentist is covered for his/her delivery of dental services to patients, not for supervision of other providers' delivery of those services. Any dentist who is called on to supervise another provider should verify that he/she has adequate professional liability insurance coverage so that everyone involved in patient care services is protected from a liability standpoint.

Conclusion

Although the modern dentist is asked to "wear many hats," a clear understanding about respective roles and reporting relationships within a practice or organization is imperative. Well-defined roles and reporting structures can help minimize confusion and the risk of suboptimal outcomes. Additionally, understanding all regulatory requirements that apply to supervision arrangements is essential, as is verifying that the proper professional liability protection is in place.

Question

What are the best steps a dentist can take to be sure he/she is properly monitoring the care that other providers under his/her supervision are rendering?

 

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