No employee wants to be injured at work. And no employer wants their staff to be injured at work. Guild Insurance knows that employees and employers have the best of intentions when it comes to workplace safety. Unfortunately, despite these good intentions, we see many cases where early learning workers are injured while at work,
and sometimes quite seriously. And it’s disappointing that many of these injuries could have been easily avoided.

Guild Insurance sees too many cases where an injury in an early learning centre has
occurred while the worker was performing a task in an unsafe manner. We know that in many of these cases the staff member would have been taught the right way to do things and therefore would have been aware it was incorrect. So why does this happen? Why do staff risk their physical health and wellbeing by performing tasks in an incorrect and dangerous manner?

Examples of tasks performed incorrectly

The following are some of the common actions which lead to injuries in early learning centres:

> Standing on swivel chairs instead of ladders to reach an item
> Picking up children rather than lowering to their height
> Lifting children onto a change table rather than having the child climb up steps
> Lifting something alone which is too heavy rather than asking a colleague for assistance

Training

It’s possible that one of the main reasons people perform tasks in a dangerous way is that they don’t fully appreciate the risk. They may have been taught that it’s wrong,
however they may not understand why it’s incorrect and what could go wrong. Therefore, when teaching staff about the correct way to perform tasks, it’s important to not just tell  them what to do and what not to do, but also stress the reasons why. They need to appreciate what could happen and what sort of injury they could sustain. They need to understand, for example, that when standing on a swivel chair, it can easily move causing the person to fall off. This often leads to serious arm injuries, such as fractures, as the person has landed on the ground.

Reminders

Being told something only a couple of times, maybe during formal education or at induction, isn’t always enough to enforce learning and change behaviour. People often need to be continually reminded. Early learning centres should be regularly talking about and promoting safety and correct techniques in the workplace. This could be a regular agenda item at team meetings. There could be signs around the centre to remind staff of the correct way to do things. Staff could be commended when seen doing the right thing. Don’t make education a once off.

Rushing

One of the most common reasons people don’t do things as they should is that they’re rushing and feeling they’re too busy. Too often when staff are busy at a centre, they’ll try to do things quickly and will often look for workarounds to speed up tasks. Unfortunately, this can lead to unsafe practices and injuries. Taking an extra couple of minutes to look for an appropriate ladder or ask a colleague for assistance is surely better than suffering a serious long-term injury which may prevent someone from working for weeks or even months. Similarly, scanning the room for hazards prior to entering may aid in the prevention of a trip or fall.

Lead by example

Managers and senior staff need to be sure they’re leading by example. There’s no point
telling your staff how to do things correctly and then doing it a different way yourself. And if you think you can do it quickly and get away with it, think again as someone will see you. Not only are managers risking injury by doing things the wrong way, they’re also sending the wrong message to their staff. To create a workplace culture that values safety, all staff need to do the things the right way which is the safe way.

It won’t happen to me

We’re all guilty at times of knowing what can go wrong but not really thinking it’ll happen
to us. However, Guild’s claims experience tells us these incidents and injuries happen
to anyone, including people just like you. Just because you may have cut corners with tasks in the past and nothing went wrong, doesn’t mean you’ll get away with it next time. Taking these risks just isn’t worth it, because it only takes one time where something goes wrong for a serious injury to occur.

Early learning and childcare centres are dynamic, unpredictable, ever-changing environments.  For some educators, it’s this type of environment which makes it a fantastic place to work.  However, this environment can also make it a hazardous place to work if the risks of an ever-changing environment aren’t identified and managed.

All early learning centres have processes in place to be sure the centre is tidy and orderly at the beginning of the day with all furniture and equipment where it should be.  However, this rarely lasts long and nor should it.  Through the regular activities undertaken throughout the day, many pieces of equipment can end up being left in areas which may create a hazard and lead to an injury to staff and children.  Also, it’s possible for toys, play equipment and even furniture to become damaged over time and this also creates a hazard.  The solution of course isn’t to stop the children playing and using what’s in the centre.  The solution requires all staff who work in centres to be aware of the risks within their environment and what they can do to manage them.

Constant vigilance

Working in an early learning centre requires constant vigilance from all staff.  This means staff are always looking around and scanning for risks and hazards which could lead to injuries. 

Centres have processes in place where regular inspections are carried out.  While these checks are important, they aren’t enough.  Staff need to be in a habit of being continually on the lookout for risks at all times and in all locations within a centre.

Risks aren’t always obvious

There are some risks which will be obvious and that all staff would know to look out for and rectify, such as toys being left in walkways or spilled drinks on the floor.  However, this is not the case with all risks.  Some are harder to spot and may be unexpected, such as a poorly fitted baby gate closing on a staff member.  This further emphasises the need for constant vigilance and not just looking for common risks.  It means staff should be continually asking themselves ‘What could happen?’ and thinking outside the square when answering this. 

Don’t put it off

It’s not uncommon for Guild Insurance to hear of an injury occurring in a centre due to a hazard which had previously been identified yet no action had been taken.  This lack of action may be due to other competing priorities, lack of funds or the risk may have not been taken seriously.  When a risk or hazard has been identified it’s important that it’s assessed immediately so the likelihood of an injury and the potential seriousness of that injury are both well understood.  This will assist the centre in developing an action plan for what needs to happen to reduce or eliminate that risk and how urgent this is.  Staff and children do suffer serious injuries in early learning centres which can affect them for a very long time.  Hoping the risk won’t eventuate isn’t sufficient risk management, centres need to take action.

Risk register

Creating a risk register is an important process for dealing with identified risks and being sure they don’t get forgotten about.  The risk register should contain important details about each risk including the likelihood of the risk occurring, the potential consequence if it did occur, what actions or steps are required to mitigate or reduced that risk, who is responsible for doing this and by when this action needs to occur.  This register should be made available to all staff and discussed regularly so there is constant monitoring of which risks have been actioned and which still needs actioning.

Whose job is it?

In every workplace, everyone has a responsibility to ensure it’s a safe environment for all who attend or visit.  This means that all staff, including the newest and least experienced right up to the most experienced, have a responsibility to continually be on the lookout for hazards and act on them when found.  Leaving this to someone else is not acceptable.  While some staff members may not have the ability to create the change necessary to reduce the risk, for example it’s not their responsibility to book in maintenance staff, all staff have a responsibility to at least report the hazard to someone who can take action.

To ensure staff do speak up when they see a risk or hazard, it’s important that a culture of speaking up is encouraged.  This means making all staff aware of their responsibility but also listening to and taking on board the concerns raised by staff. 

Regular safety discussions

To encourage and support staff to continually think about safety and identify risks, regular safety conversations in the workplace can be very beneficial.  This can be done in a number of ways such as having safety as an agenda item at staff meetings or by including staff in discussions about how identified risks will be actioned.  This continual conversation encourages safe thinking to become how people do their job, not an addition to it.

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Early learning centres are dynamic, continually changing environments.  This is important so children are stimulated and always learning.  However, this also presents challenges and potential risks for both children and staff which need to be managed.

Guild Insurance has over 25 years’ experience insuring early learning centres; this means we understand your industry.  The following information provides examples of common incidents, which lead to insurance claims reported to Guild.  Following this are risk mitigation tips for running a safer early learning centre.

Case examples:

• A child scaled a 6ft high fence, with the assistance of nearby play equipment, and left the centre.The child was intending to go after his parent who had just dropped him off.The child was found by a member of the public on a busy road about a hundred metres from the centre, fortunately unharmed.
• A child was climbing up some play equipment when she lost her footing and slipped.As she fell, she bumped her mouth on the equipment, fracturing her tooth and splitting her lip.
• A child was running outside and tripped over some play equipment.As she landed, she fractured her wrist.
• A child was closing a door not realising there was a child on the other side of the door.This child’s finger was caught in the closing door and the tip of his finger was amputated.
• Following complaints about an employee’s unprofessional conduct towards children, the employer investigated the matter and subsequently decided to terminate the employee. The employee then lodged an unfair dismissal claim with Fair Work Australia.

Tips to mitigate risks

Identify and act on hazards

There are many hazards in an early learning centre which could lead to children suffering an injury or experiencing an incident which could lead to harm.  Staff need to be continually vigilant looking for these hazards.  And this applies to all staff, this isn’t a job just for senior staff.  All staff have a responsibility to maintain a safe environment and this means staff should be encouraged to speak up if they see something which concerns them. 

When hazards are identified, it’s important they’re acted on immediately.  It’s not uncommon for Guild to see cases where identified hazards are put on the back-burner due to a lack of funds or time to address it.  This isn’t ok.  All centres need to have a process for how identified hazards are reported and recorded, with the person responsible for ensuring it’s rectified clearly noted.  This person needs to have an appreciation for what could go wrong if the matter isn’t addressed and ensure the required focus and urgency is applied.  It’s also important to have a maintenance budget to allow the centre to deal with unexpected yet urgent maintenance issues.  Waiting till more money becomes available could be more costly in the long term if there’s a serious incident.

Ensure there is appropriate supervision

All centres would be aware of the required levels of supervision and ratios for their centre.  However, supervision is about much more than numbers.  Staff need to understand what they need to be looking at and for when supervising children.  They need to know where to place themselves.  They need to be sure their attention is on the children and not allow themselves to be distracted.

Adequate supervision assists in several ways.  It means potential risks may be detected before there’s a serious incident.  Take the earlier case of the child using play equipment to climb the fence.  Not only should appropriate supervision have meant the child was seen climbing over the fence, but it’s possible that staff may have seen children attempting this on previous occasions.  This risk could have been dealt with by moving equipment away from the fence.  Appropriate supervision also means that if there’s an incident, such as a child has fallen and injured themselves, staff will be able to respond quickly and provide an accurate report of what occurred.

Create a safe place of employment

All staff want to work in an environment where they feel safe and valued.  Unfortunately, Guild sees many varied cases where staff claim they’ve been treated unfairly.  This may be because they’ve not been provided their full entitlements, such as salary or leave, or they may feel they’ve been bullied or not given promotional opportunities.

Managers and directors within early learning centres need to be sure their focus isn’t solely on the children but also on their staff, remembering that staff play a crucial role in the success of any business.  There needs to be open conversations and clear expectations regarding how staff are to treat and interact with each.  Managers need to also be sure their expectations in terms of behaviour and work performance is clear.

It’s important to create a workplace where staff feel comfortable speaking with mangers if they have any issues or concerns.  Too often we see cases where the managers are quite surprised a staff member has lodged a formal complaint as they were unaware of how the staff member was feeling.  It’s much easier and quicker to deal with an issue in its early stages.

Understand employment law

Employment related disputes are an ongoing theme in early learning claims reported to Guild.  These claims indicate that some employers may not be aware of their obligations and the laws governing them as an employer.  There are laws surrounding salaries and awards, leave entitlements and terminating employment.  Employers can’t simply do as they please, no matter how their employee behaves, which unfortunately it seems they sometimes do. 

The following two websites contain a great deal of easy to follow information to assist employers, and employees, understand their obligations.

• fairwork.gov.au (Fair Work Ombudsman)
• fwc.gov.au (Fair Work Commission)

If you find yourself in a difficult situation regarding an employment matter and you hold a Guild Insurance Early Learning Business Insurance policy, you’re entitled to two (2) hours of free legal advice under the policy.  This advice can assist you to deal with a matter correctly and fairly while it’s still in its early stage which may prevent the situation escalating into a more serious legal matter.

Don’t think it won’t happen to you

It’s easy to read cases such as those at the start of this article and think that wouldn’t happen to you and your centre.  However, Guild’s claims suggest these incidents can happen to anyone.  Thinking you don’t face these risks can actually put you at an increased risk.  This is because when risks and hazards aren’t taken seriously, the necessary risk mitigation strategies are likely to not be implemented.  Therefore, acknowledge what could happen, and do what you need to do to prevent this.

Avoiding big problems for little people

Many allied health practitioners across the country are already using telehealth to provide care for their patients during the COVID-19 pandemic. However, there are some additional risks and limitations associated with delivering health services via telehealth which practitioners need to be mindful of.

Using telehealth to deliver allied health services to patients during the pandemic? AHPRA releases new guidance for all health practitioners.

As part of the national health response to the COVID-19 pandemic, many registered health practitioners are electing to use ‘telehealth’ to deliver health services to their patients.  The Australian Government has demonstrated support for this initiative by rolling out new temporary Medicare Benefit Scheme (MBS) ‘telehealth’ item numbers, several of which apply to the provision of allied health services (including those which form part of chronic disease management[1]). 

In an effort to support practitioners who wish to use telehealth to service their patients going forward, AHPRA has recently released new guidance (https://www.ahpra.gov.au/News/COVID-19/Workforce-resources/Telehealth-guidance-for-practitioners.aspx) which sets the expectations for all health practitioners delivering health services using videoconferencing or telephone solutions[2].  The key message is that a service may only be provided by telehealth where it is safe and clinically appropriate to do so.[3]  

Critically, the limitations around the use of a telehealth consultation to provide a particular health service need to be at the forefront of practitioners’ minds and on a case by case basis.  For example, practitioners ought to consider whether this a consultation which, if conducted face-to-face, would add no further value than if conducted over the telephone?  Or, is this a consultation which requires a physical examination in order to properly diagnose the presenting complaint? If it is the latter, in our view it will not be sufficient to simply tell the patient about the limitations of a telehealth consultation and rely on this disclosure defensively without conducting the necessary examination. If required, further arrangements ought to be made to provide full and appropriate clinical care. This may mean arranging for an in-person consultation/examination for the patient with a colleague if you are unable to conduct it yourself. 

So how do you perform a consultation via ‘telehealth’? While neither AHPRA nor the Department of Health has been prescriptive about the type of software or technology practitioners need to use to deliver telehealth services, the Department has made clear that videoconferencing services are the preferable substitute for a face-to-face consultation.  AHPRA has said that either videoconferencing or telephone is suitable.  However, both organisations have warned practitioners to ensure that their chosen software meets both their clinical requirements and satisfies privacy laws[4].  The MBS Online website refers providers to the Australian Cyber Security Centre website (https://www.cyber.gov.au/publications/web-conferencing-security) for information on how to select a web conferencing solution.

Although the Australian Government has provided several new MBS telehealth item numbers for the provision of some allied health services, the items are very specific, and should be reviewed carefully as rebates may not be claimable if the service does not have an equivalent telehealth item number.  In addition, practitioners need to be mindful that the MBS items specify whether they are to be used for videoconferencing or telephone-only services – we recommend reviewing the schedule to ensure the correct number is used for billing purposes. 

While it is a legislative requirement that some medical practitioners must bulk bill the new telehealth services for certain patients (including those who are more vulnerable to COVID-19), these requirements do not apply to allied health practitioners as of 20 April 2020.   Allied health practitioners may employ their usual billing practices for delivering services via telehealth. That being said, it is expected that practitioners will obtain informed financial consent from patients prior to providing any telehealth service, including providing details about the practitioner’s fees and any out-of-pocket costs. 

Patient privacy is another key issue that allied health practitioners need to consider when using telehealth to conduct consultations.  AHPRA guides practitioners to confirm the identity of the patient at each consultation, which may be more challenging if telephone is used (as opposed to videoconferencing), or if the patient is a new patient for the practitioner.  Also consider the location and surrounds in which the telehealth consultation is conducted - if it is not at the practitioner’s usual practice site (for example, because the practitioner is conducting consultations from home), consider what measures need to be implemented to protect patient privacy during the consultation.

Finally, all registered health practitioners who intend to use telehealth to conduct patient consultations ought to ensure that they have appropriate professional indemnity insurance arrangements in place for all aspects of their practice, including telehealth consultations. We encourage practitioners to contact their professional indemnity insurer about their intentions to use telehealth, and confirm that the appropriate coverage is in order.

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Operating a business during the COVID-19 pandemic has presented many challenges. Unfortunately, many businesses closed for a period of time while others worked on reduced hours. And for others, staying open meant finding new ways of doing so, such as by providing virtual services. As the world starts to consider how to move out of pandemic restrictions, it’s important for all business owners to carefully consider the approach they’ll take and the associated risks. The fallout of COVID-19 is likely to be with us for some time, so we all need to be careful to not become complacent and make changes too quickly.

Government requirements

Firstly, all business owners need to be sure they’re keeping up to date with and adhering to government requirements and regulations. This can at times be challenging as the federal government is making recommendations, yet all state and territory governments are moving at different paces in terms of lifting restrictions. All business owners need to take responsibility for being sure they understand what they can and can’t yet do regarding their operations. Information about this can be found on the following websites:

Australian Federal Government - www.australia.gov.au 

ACT - www.covid19.act.gov.au

New South Wales - www.nsw.gov.au/covid-19

Northern Territory - www.coronavirus.nt.gov.au

Queensland - www.covid19.qld.gov.au

South Australia - www.covid-19.sa.gov.au

Tasmania - www.coronavirus.tas.gov.au

Victoria - www.vic.gov.au/coronavirus-covid-19-restrictions-victoria

Western Australia - www.wa.gov.au/government/covid-19-coronavirus

Business owners may also wish to seek guidance and clarification from their professional association.

Gradual changes

While it’s understandable that business owners want to get back to how things were pre-pandemic, it’s advisable that changes aren’t made too quickly. Rushing could see changes being made which aren’t allowed or aren’t safe if they haven’t been carefully considered. It could also result in staff not understanding the changes and not adhering to them as they should. It’s important to remember we may not continue transitioning out of restrictions. Unfortunately restrictions could at any time be wound back which is another reason why a planned and measured approach is ideal.

All changes should be communicated to clients. This means they’ll feel reassured and trust that your business is continuing to operate safely. It also helps your clients understand what you expect from them to maintain this safety. This communication can be done in a variety of ways, such as by simply posting notices around the premises or sending email updates.

What works for you?

Not all businesses and business owners are the same and therefore how they provide services during the period of restrictions and how they transition out of these will, and should, differ. You should consider the following when planning to transition out of restrictions:

> Is the current way of working successful? If the changes you’ve made to the business during the restriction period have worked well for you, you may feel less urgency than others to move away from these.t of

> Does the service you provide require contact with others? The services provided by some professionals requires them to come into close contact with their clients, whereas other services can be offered from more of a distance. When thinking about making changes to your services, you need to carefully consider how close this will require you to be to your clients and if this is something you think you can do safely.

> Are your clients high risk in relation to COVID-19? If your clients are at an increased risk, possibly due to their age or health condition, this should be seriously considered when assessing how the business provides its services.

> Are you, or someone you live with, high risk? It’s not just the health of your clients you need to consider when making decisions about how to run your business. You also need to consider your health and that of those you live with. Remember, this is a highly contagious virus which can have devastating consequences; please don’t risk your or another person’s health.

Insurance cover

All business owners and professionals need to be sure they have insurance to cover them for what they do. During the period of restrictions, when some professionals changed the way they were working this led to changes in their insurance cover. Therefore, as you come out of restrictions and again change the way you provide services, you need to be sure your insurance covers those services as well as the hours you’ll be operating and the estimated income.

Trust your instinct

There are unfortunately cases of clients pleading with business owners to open when they aren’t ready and even when in breach of government restrictions. This puts unfair pressure on business owners to do the wrong thing to keep their clients happy. Of course one of the core functions of running a business is to keep clients happy and satisfied, after all they keep you in business. However this can’t be done when it’s potentially detrimental to the health of you or others. When making changes to come out of restrictions, ensure these are planned, well thought through and explained to your clients. If they do try to convince you otherwise, reiterate your reasons to them and don’t allow yourself to be convinced to do something you know isn’t appropriate.

In summary…

As more and more businesses are coming out of their restrictions and returning to their usual services, it can be very tempting to follow suit. However, please be sure no changes are made without careful consideration and planning, as the risks are too great.

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Guild Insurance sees many insurance claims which have come about due to poor maintenance of a property.  In too many of these cases, the poor state of the building or its grounds is obvious and it’s quite surprising, as well as disappointing, that repairs haven’t been carried out before an incident has occurred.

What can go wrong?

There are a range of incidents which can occur due to poor maintenance of a property.  Staff can be injured leading to a worker’s compensation claim as well as staff being absent from work for an extended period.  Visitors to the premises, such as customers, clients or contractors, can also suffer injuries leading to public liability claims.  As well as the insurance claims which need to be managed, there’s the added stress of knowing that someone has been injured while at your premises.  Some of these injuries can be very serious and life changing.  Unfortunately, the hazards which lead to these injuries are often not viewed as seriously as they should be.  Yet with appropriate property maintenance many of these injuries could be avoided.

Case 1

A client entered a building and tripped over an edge of carpet which was ripped and curled up.  The client sustained a fractured wrist when they landed.

Case 2

An awning out the front of a building was old and worn out.  During heavy winds it broke off from the building and hit a person walking past at the time.

Case 3

While walking through the carpark of a premises, a staff member has tripped on a large crack in the asphalt which had caused the surface to be uneven.  They fractured their ankle as they fell.

Case 4

Poor maintenance doesn’t just lead to people suffering injuries, it can also lead to further damage to the property.  An old deteriorating roof collapsed when hit by heavy rain as it no longer had the strength to support the weight of this rainfall.  This led to excessive water damage within the building.

Property maintenance tips

• Have a documented maintenance program in place.This requires a schedule for regularly checking the property to identify hazards as well as details on what needs to be serviced, repaired or replaced and when.
• Be aware of the out-of-sight, out-of-mind hazards.Many properties have roofs, guttering and downpipes in poor condition due to a lack of maintenance as no one has thought to get up on the roof and inspect it.Include the less obvious hazards in the maintenance program.
• Have a maintenance budget.Some maintenance work can be planned, other work will come up unexpectedly when something breaks down.You need to be able to find money to fix hazards when identified.
• Be sure to use qualified tradespeople to undertaken maintenance work.While it can be tempting to undertake some DIY and save money, the risk of things not being maintained or repaired correctly will not be worth the savings in the long term.
• If you’re a tenant, be aware of what you’re responsible for maintaining and what’s the responsibility of the landlord.Not all tenancy agreements are the same, so you need to be across the details of your agreement.
• Don’t wait to undertake maintenance till a more convenient time.There are many cases of injuries occurring due to hazards which had been identified but not yet acted upon, usually due to costs, time or not acknowledging the risk of the hazard.
• All staff have a responsibility to create and maintain a safe workspace. Some hazards will be identified through regular property inspections, however, you can’t rely solely on these inspections.Therefore, encourage all staff to continually be on the lookout for hazards and to speak up when they see something.
• Don’t think it won’t happen to you and your property.These incidents are a lot more common that many people realise.

Property maintenance and injuries

In recent years, with the continual growth in social media, online fitness options have grown dramatically. And now with restrictions on how and where people can exercise due to COVID-19 this demand is increasing.

Offering personal training sessions in a virtual online manner is a fantastic idea. It means clients can conveniently keep exercising at a time when people have more limitations. It also means personal trainers can keep their business operating and bringing in an income. However, running a personal training business online isn’t the same as running one where you’re physically present, and this means there are new challenges and risks which need to be managed. While some of what has always been expected of you will stay the same, there will be some additional requirements and considerations.

Meeting your requirements

As a personal trainer, there are professional obligations you need to meet, regardless of how you’re operating your business. When running virtual online PT sessions, you need to be sure you’re still complying with Fitness Australia’s Code of Ethics and Scope of Practice for Australian Registered Exercise Professionals. Also, all online virtual training
needs to adhere to Fitness Australia’s Online Virtual Personal Training recommendations.

You also need to be sure you’re keeping up to date and complying with the COVID-19 restrictions put in place by Federal, State and Local governments. Restrictions are changing frequently, and each State and Territory may vary, so it’s imperative fitness providers remain aware of their requirements.

Client selection

Online personal training sessions won’t suit all clients. Therefore, your process for selecting clients who you’ll train in this manner is very important.

Firstly, all clients should complete the Australian adult pre-exercise screening system tool which can be accessed via Fitness Australia’s website. Fitness Australia recommends that only those clients who are determined to be low risk should be trained online; the challenges of managing high risk clients remotely is too great. Online training may also not be suitable for clients who are new to personal training and the types of exercises you’ll be prescribing, so you’ll want to find out a bit about their exercise history.

You need to be sure the client has the equipment and space necessary to undergo online virtual training, beyond the obvious of having the necessary technology to connect and a reliable internet connection. You’ll need to discuss devices with them. The small screen of a phone is most likely not going to be suitable, particularly when you want them to see you demonstrating the correct technique. A laptop or tablet would be more ideal.

You also need to discuss the location where the client will be using, given many won’t be designed for fitness sessions, and assist them to do a risk assessment of that location to be sure it’s safe and ideal. This requires considering the physical layout of the premises such as furniture and flooring, but also other potential distractions and risks such as children or pets being present. You need to work with each client and their set up to make it as safe as possible. If you don’t think it’s safe, you need to reconsider if you’ll train them in this manner.

Program development

As a personal trainer, your program development and exercise selection are always incredibly important to ensure the program is suitable for that individual client and their goals and expectations. When creating an online training program, there are additional factors which need to be considered.

You need to be sure you’re still having regular conversations with the client to understand what they want to achieve with their training and how they’re progressing with the program over time. Given it will be harder for you to observe how the client is going with their training, you may want to set up additional times to talk.

When selecting exercises, keep in mind that it’s going to be challenging to demonstrate the correct technique as well as check the technique of the client. Therefore, it’s worth considering selecting exercises which are less challenging from a technique perspective and easier to explain. For inexperienced clients, exercises which have a high injury rate when performed incorrectly, such as deadlifts, might be best to avoid. During a virtual online session, you’ll need to be sure you can see what the client is doing so you can check and correct their technique. So, when setting the exercises, plan how you want the client to be positioned so you’re able to watch them. Also, be prepared to spend more time than usual explaining exercises and you may have to repeat yourself a few times.

When developing the program, you need to decide what you’ll charge the client; your usual fees may change for an online program. Always be sure you’re upfront and clear with clients regarding fees; having this information in writing will assist this.

Record keeping

It’s important that personal trainers keep detailed records of their training sessions with clients, whether they’re done in person or online. These records mean trainers don’t need to rely on their memory to know what the client did in previous sessions and provides evidence of the client’s progression. Unfortunately, Guild’s experience in managing claims against personal trainers has shown that many trainers keep minimal records. Be sure when conducting online training sessions, you’re taking notes which include, but isn’t limited to:

• Exercises performed (include sets, reps, weights etc)
• Difficulty the client experienced with the exercises
• Pain, discomfort or injuries experienced
• Exercise prescribed for the client to undertake in their own time
• Referrals, such as to a health or allied health practitioner

Privacy

You have a professional obligation to take reasonable and appropriate steps to protect the privacy and confidentiality of your clients. Therefore, when conducting an online training session, be sure it’s done in a private setting where no one in the background can hear or see what’s happening. Many forms of online communication, such as video conferences, have a recording function. Training sessions shouldn’t be recorded simply because they can. They should only be recorded if there’s an identified need for it and if the client has given their consent.

What to do in the case of an emergency?

While it may not seem likely, you need to be prepared and have a plan for what you’ll do if your client experiences an incident or emergency during one of your sessions. All incidents, even the small ones, need an incident form completed. This acts as the history and record of what happened and your response to it. You also need to think about how you’ll assess the severity of the incident given you aren’t there. If the client is injured, it’s best to err on the side of caution and recommend they seek medical attention even if they don’t think it’s necessary. If the client is severely injured, you may need to call an ambulance for them. To be able to seek the assistance they may need, you should be sure you know the address of where they’re exercising.

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Published in conjunction with Fitness Australia.

It might be surprising to know that telehealth has been occurring for about 100 years now; there’s evidence of radios being used in the 1920s to provide clinical advice to people in remote locations. The way telehealth is conducted or provided has changed greatly over the years as the technology which supports it has changed and developed.

What is telehealth

Telehealth is providing health services remotely with the use of technology. There are many forms of technology which assist this such as phone calls, teleconference calls and sharing of images and videos.

There are many reasons why telehealth is used, however, they primarily boil down to the patient and practitioner not able to physically be in the same place. This may be because of geographical remoteness. Age or disability can prevent patients from travelling to their practitioner. And now social distancing requirements to reduce the spread of COVID-19 is making face to face appointments difficult and potentially unsafe. Therefore, telehealth is very beneficial, however it isn’t without risk. And these risks need to be considered and managed before this service is offered.

Is it right for you?

All business owners want to stay ahead of their competitors and provide the best service possible to their clients. However, this can mean at times business owners leap into something new too quickly without proper consideration and assessment.

Telehealth isn’t ideal for all health practitioners. Before you start offering telehealth services, do some research that will help you assess if it’s right for your business, your patients and the services you provide. Consider the pros and cons; think about how it’ll benefit your business but also consider the risks and challenges it’ll create.

You should consider developing an implementation plan to assist you in working through a range of factors to consider, such as:

• Which services will suit telehealth, which won’t?
• Who’ll assist with providing and supporting the technology required?
• How will this new process be communicated with patients?
• How will patients be assisted if they have difficulty with the technology, or simply
  don’t want to use it?
• Will the process be phased in gradually?
• How will it be evaluated?

Invest to do it well

The old saying ‘if something’s worth doing it’s worth doing well’ really does apply to implementing telehealth practices. When technology works well, it’s fantastic, when it doesn’t, it can cause a huge amount of frustration and time wasting. It’s therefore important that health practices don’t rush into implementing telehealth practices. It’s worth taking the time to ensure the tools and technology used are suitable for that individual practice. It’s also recommended that time is spent training all staff to be sure they understand how to use the new technology and what’s required of them with this change. Investing both time and money at the beginning will benefit the practice, practitioners and patients in the long term.

Some things stay the same

Much of what you already do, and what you’re required to do, as a health practitioner won’t change when using telehealth.

• Communication – communication is always incredibly important for all health practitioners. However, it needs additional focus when consulting via telehealth. Practitioners may find they need to spend longer having conversations and should consider what questions they’ll ask the patient to be sure information has been understood.

• Record keeping – you need to keep detailed and accurate records of all consultations and communications with patients, and this includes when using telehealth. It’s not just about actual consultations, even details about phone conversations with patients need to be recorded. If a consultation takes place via telehealth, make a note of this in the clinical record including the type of technology needed.

• Informed consent – you need to ensure patients give their informed consent prior to treatment. Providing signed informed consent is a bit harder when consultations take place remotely, yet this can still be done in some cases. However verbal consent is sufficient. But remember, informed consent can only be given when the patient has been informed about the treatment, so sending a form to be signed to a patient before there has been any discussion or consultation isn’t appropriate. Also, verbal informed consent must be noted in the clinical record.

• Privacy – you have a professional obligation to maintain the privacy and confidentiality of your patients. Therefore, when conducting a telehealth consultation, be sure it’s done in a private setting where no one in the background can hear or see what’s happening. Many forms of online communication, such as teleconferences, have a recording function. Consultations shouldn’t be recorded simply because they can. They should only be recorded if there’s a clear and specific reason for it and if the patient has given their consent.

• Duty of care – health practitioners have a duty of care to all patients they treat. If a patient is being treated using telehealth and has never met the practitioner prior to this, this doesn’t change anything in terms of the practitioner’s duty of care to that patient.

• Clinical decision making – Incorrect diagnosis is one of the greatest risks with telehealth, yet telehealth is no excuse for mistakes being made. If you don’t have the information needed to make a diagnosis or provide/recommend treatment, you must to find a way to get this additional information. Practitioners may want to consider if their assessment processes alter when using telehealth. Practitioners should also be sure they don’t allow the patient, or the treatment circumstances, convince them to provide treatment or advice that goes against their better judgement.

• Practice within scope – when consulting using telehealth, the need to keep within your recognised scope of practice, and refer when the situation is outside of this, is no different.

• Funding schemes – some funding schemes, such as private health insurers and Medicare, provide cover for telehealth, for some forms of treatment. As the treating practitioner, it’s your responsibility to be sure you’re meeting the requirements of the various funding providers and don’t claim for items which aren’t permitted.

• Regulatory requirements – in addition to the above, any other requirements set by regulatory bodies need to be adhered to. This includes keeping on top of government advice and restrictions relating to COVID-19

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The Coronavirus pandemic has challenged us all personally and professionally, as we live through never before seen challenges. Many professionals and businesses alike are struggling with the ever-changing landscape as they navigate business continuity in a way which is safe for them, their staff and their customers and also complies with changing government restrictions and requirements.

You don’t have to be powerless through this uncertainty, and the key to continue to thrive as we move into the new normal is robust communication with your customers. Clear, concise and relevant  communication with your customers is vital in the coming weeks and months to ensure continued engagement.

As Guild Insurance works across multiple industries, our experience of working with thousands of professionals and their customers puts us in the unique position to understand what customers need from you. We have compiled some information to assist you in developing email communication with your customers.

Please note that this information is generic and should be used as a guide. All businesses are unique and how they’re responding to COVID-19 is also unique. Therefore, you need to create your communication to suit your individual circumstances.

Start your email with an introduction to the situation

E.g. We face challenging times ahead as we navigate through a continually changing
environment caused by the impact of the Coronavirus pandemic. Here at (business
name),we are focused on staying healthy and continue to review our health and safety
processes, so we can keep our doors open to our customers when they need us. A key part of this is to ensure we change our operational practices to maintain compliance
with evolving government recommendations and restrictions and reduce the risks to our
staff and visiting customers. We’re therefore contacting you keep you informed of what
we are doing here at (business name).

Now inform your clients of what you’re doing to avoid the spread of infection in your business

E.g. At (business name), the health of our clients and staff is our number one priority.
Therefore, on top of our usual cleaning and hygiene processes, we’re implemented the
following steps.

• All clients will be asked to wash their hands when they enter the premises
• Hand sanitiser is readily available, and we insist all staff and visitors use it regularly
• We’re asking all clients to wait outside the building, where there is space to maintain
  the recommended distance, rather than in our waiting room which doesn’t allow for
  social distancing. We’ll call you when you should come in for your appointment.
• We are regularly cleaning and sanitising all high touch areas such as doorknobs and counters.
• We will no longer accept cash and will only accept card payments.

Let your clients know if anything about the service you usually provide has changed

• Is there a service no longer available, have modifications been made, is there something new you’re now doing?
• Are you offering services remotely?
• Have opening and closing hours changed?
• Will your usual cancellation policy alter to encourage people to not attend if unwell
• Will you be offering any financial assistance or support to customers who may be experiencing financial hardship?
• Will you offer refunds if people have paid upfront and are no longer able to participate/attend?

E.g. Our usual cancellation policy requires 24 hours’ notice or a late cancellation/no show fee of $40 is charged. However, we are currently waiving this notification period until further notice. This fee will not be charged provided you call us to let us know you can’t attend. Therefore, if you feel that on the day of your appointment you have flu like
symptoms and shouldn’t attend our practice, please give us a call and don’t come in.

Finish with a reminder asking people to not attend your business if they have any concerns about displaying COVID-19 symptoms

E.g. We understand everyone wants to get on with life and do the things they are used
to doing. However, for the time being it may not be possible, and we must do what we can to flatten the curve. At (business name) we’re committed to doing our part to minimise the spread of COVID-19. Therefore, if you are experiencing any flu like symptoms, please consider others and stay home, do not visit our practice. We’re keen to see you again soon, however only when you’re feeling well

As we all do our best to minimise the spread of COVID-19, one of the tragic outcomes is that many businesses need to close their doors for a period of time. This is never a decision made lightly as the ramifications are enormous. There are many factors to consider when doing this, such as how staff will be looked after during this time, if services can be provided online and how to communicate the closure with clients.

Another important consideration should be the protection of the property from which you operate your business. Sadly, vacant buildings can lead to an increase in thefts and burglaries as a lot of crime is opportunistic. Thieves will know that many businesses have closed only temporarily and therefore the buildings may not be empty, there may still be items worth stealing inside.

The following are some tips to consider if you are temporarily closing the physical premises of your business:

• While you want to inform your clients about the change to the business, placing a sign on the front of the building may not be the most ideal way, especially if this will be easily visible for those walking past. If you do want to place information on the building about a
  closure, don’t indicate this is potentially long term or indefinite, simply provide details for clients to contact you.

• Redirect mail to a home or post-office box and place a ‘no junk mail’ sign on the building’s letterbox. A messy overflowing letterbox is a sure sign no one has been frequenting the premises.

• Use a timer to have the lights turn on and off at certain periods of the day, creating a look of someone being in.

• Electronic Security Alarms should be kept operational where fitted.

• Consider which appliances can be turned off as many appliances continue to use power even when they aren’t being used. Items to consider turning off include hot water tanks, televisions, microwaves and computers. However, be sure to think about what you’re turning off before you quickly switch off all power; for example, fridges and freezers, unless empty, should be kept on.

• It’s important to conduct regular external inspections of your property to check the condition, ensuring that it’s safe and there are no signs of attempted entry or vandalism. Where possible, visit your property fortnightly, however, be sure you’re complying with government COVID-19 restrictions when doing this. Maintain the external appearance by removing any rubbish and mail and keep lawns and gardens trimmed.

• Clear out your gutters. A build-up of leaves and other debris creates a fire hazard as well as a risk of an overflow of water entering the roof space during a storm.

• If you have a good relationship with your neighbours, let them know about your closure and be sure they have your contact details. That way if anything goes wrong or they notice anything suspicious, they can let you know.

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What is Evidence Based Practice?

The best known and most widely accepted definition of Evidence-Based Practice (EBP) was suggested by David Sackett back in the 1990s; ‘Evidence based medicine is the integration of best research evidence with clinical expertise and patient values.

Similarly, the American Dental Association defines Evidence Base Dentistry (EBD) as: ‘An approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence relating to the patient’s oral and medical condition and history, with the dentist’s clinical expertise and the patient’s treatment needs and preferences.’

The Australian Dental Association’s policy on Evidence Based Dentistry encourages the concept behind EBD, supports the need for ongoing dental research and emphasises that the need for dental care must be determined by the treating dentist in consultation with the patient.

Click here for the Australian Dental Association policy.

There are five steps in the EBD process that the clinician should consider when reviewing a clinical intervention:

> Ask the Question: Define a clinically relevant and focused question where the evidence may promote the oral health of patients.

> The Search for Information: Access and acquire available evidence, systematically conduct searches of all studies, grade the strength of the evidence used, and identify gaps in the evidence.

> The Appraisal: Critically appraise the information accessed, evidence for validity with an understanding of the research methods.

> The Application: Use the results and act on them to provide treatment in practice. Apply the results of the evidence to patient care or practice in consideration of patients’ preferences, values and circumstances. Ultimately the patient makes the final treatment decision; by using this framework dental professionals can ensure that patients will be provided with treatment options based on sound evidence.

> The Evaluation: Assess the health care outcomes following the EBD process.

EBD is not about developing new knowledge or validating existing knowledge. It’s about translating the evidence and applying it to clinical decision-making. The purpose of EBD is to use the best evidence available to make patient-care decisions. Most of the best evidence stems from research, but EBD goes beyond research  use and includes clinical expertise as well as patient preferences and values. The use of EBD takes into consideration that sometimes the best evidence is that of opinion leaders and experts, even though no definitive 6 results from research results exists.

Applying Evidence Based Practice to everyday clinical situations

One way of making synthesised evidence usable in practice is to present recommendations for best practice in clinical guidelines.

Clinical guidelines are systematically developed statements to assist health professional and patient decisions about appropriate health care for specific circumstances. They are used to translate evidence into actionable recommendations that can be applied to clinical situations. The Institute of Medicine defines clinical guidelines as ‘systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances’, and well developed guidelines will have gone through at least the first three stages of the five stage evidence-based process.

An important consideration is that Clinical Guidelines are fossilised at the time of publication and evidence is rapidly evolving, usually outstripping the rate of updating of guidelines. An example of this is the Therapeutic Guidelines second edition published in 2012 and superseded by version three in December 2019.

Using research to inform treatment planning can seem daunting for clinicians who have used alternative techniques that have worked adequately throughout their careers. In dentistry, many procedures are accepted and carried-out on patients without having a strong evidence base.

It has been suggested that these procedures should be called ‘dogmas’ as they are based on beliefs that are accepted as being true even when this has not been supported by evidence. Once formed, ‘dogmas’ can allow clinicians to fall into the routine of carrying out and accepting procedures as a ‘gold standard’ without questioning alternatives which may provide better outcomes for the patient.

One example of how a dogma has been challenged is the concept of a shortened dental arch. When a shortened dental arch is considered for a patient, the patient’s functional needs and preferences must be taken into account and the patient must be informed of teeth that do not need replacing.

Another example of dogma is that some orthopaedic surgeons insist that their patients require antibiotic cover when their patients are undergoing dental treatment (particularly extractions) following joint replacement surgery despite there being no evidence to support this and the prescribing of prophylactic antibiotics for patients with pre-existing joint prosthesis is not recommended (Therapeutic guidelines Oral and Dental 2019).

Unfortunately changes like this take time to be accepted in practice.

Guidelines are tools, not rules. Clinicians still need to think for themselves and individualise care, not simply follow dogmatic principles and processes in a blinkered fashion.

Clinicians should support the concept of evidence-based dental care using credible scientific data, in conjunction with the requirement to have patient-centred treatment and base a treatment plan on accepted evidence, with patient input into the plan through a thorough informed consent process.

References

1. Kudray, G, Walmsley A D, -Evidence Based dentistry in Everyday Practice- Dental Update-December 2016.

2. Innes N.P., Schwendicke F., Lamont T.-How we create, and improve the evidence base-BDJ No 12 -2016.

3. Evidence Based dentistry: Managing information for Better practice-Derek Richards, Jan Clarkson, Deborah Mathews, Rick Niederman.

4. Therapeutic Guidelines Oral and Dental Version 3.

5. ADA Inc Policy statement.

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By: Dr Errol Kilov
BDS ADEC Grad Cert Dent FADI MRACDS (GDP) FRACDS (GDP) FPFA FICD

How likely am I to receive a complaint?

Dental practice differs from many other health professions, with practitioners undertaking multiple high-risk surgical procedures on a daily basis, working predominantly in private practice. These characteristics may place dental practitioners at an increased risk of complaints as well as certain forms of legal and regulatory action when compared with practitioners from other health professions.

AHPRA regulates health practitioners across 15 specialisations. Practitioners from these professions must have professional indemnity insurance (PII) arrangements that comply with the relevant registration standard, for all aspects of their practice.

A recent study shows that dental practitioners have the highest rate of complaints among fourteen health professions. The study showed that approximately 1 in 23 dental practitioners have a complaint lodged against them each year. Any practitioner facing a complaint has various options when it comes to responding to their complaint, including AHPRA, or the Health Complaints Commissioner (HCC). Often the complaint is accompanied by a request for a refund or a request for a compensation. The HCC often encourages people to attempt to resolve their complaints directly with the practitioner, and can act as an intermediary in the process – further information can be accessed at ww.hcc.vic.gov.au/public/our-process.

What’s the potential impact if I receive a complaint?

Unfavourable outcomes or experiences during dental treatment may result in complaints against dental practitioners. Not only can adverse events in a dental setting lead to litigation and disciplinary action, complaints against dental practitioners are also known to contribute to stress and have ramifications across the entire dental practice. An AHPRA notification may result in conditions of registration, and/or requirements for further training and education at the practitioner’s own expense.

What should I do if I receive a complaint?

Reporting incidents early enables support to be provided to a member by Guild Insurance, and for the implementation of management strategies to mitigate adverse outcomes. Timely notification enables the best outcome for the practitioner, the patient, and the profession. In the case of Guild insured ADA members, the member will be assisted by one the Community Relations Officers (CROs) or Peer Advisors through their state branch.

It is crucial to understand that if a practitioner is aware of an incident or notification of a potential claim, the practitioner has a contractual obligation to notify their insurer. Failure to report can mean that seemingly minor incidents can escalate out of control, incurring significant costs, and potentially compromising the indemnity provided by the insurance policy.

If the patient directs their complaint directly to the practitioner, the practitioner is then provided with the opportunity to respond to and manage the complaint with the help and guidance from the state branch and this can reduce the time and stress involved in resolving a complaint as well as reducing the risk of the complaint escalating.

What are my options regarding resolving the complaint?

A complaint does not mean that the dentist has ‘done something wrong’. Often a complaint is the result of a miscommunication and differing expectations.The possible decision to refund or provide compensation is a carefully considered option based on risk assessment conducted in collaboration with the insurer. A practitioner may decide not to agree to the patient’s request for a refund or financial compensation, and the complainant may seek alternative pathways for their complaint, such as HCC or AHPRA.

The decision to refund, or not, is best made by the practitioner in collaboration with the indemnifier. Considerations include what is best for the patient’s welfare, the practitioner’s peace of mind, as well as the best interests of the long-term reputation of the practice.

Certainly, there are times when a commercial decision is not appropriate. It is not being advocated that the practitioner should resist defending the principle or accede to a patient’s demands at the first hint of dissatisfaction. Each matter needs to be assessed on its merits and seeking advice is an appropriate approach to help in reaching a decision. A refund is not in any way an admission of liability, it’s purely a gesture of goodwill.

One of the services provided by the CROs and Peer Advisors is to discuss the risks involved in the decision making and the possible outcomes bearing in mind that effective and appropriate complaint management strategies can prevent escalation of the matter.

If a decision is made to refund, it’s important that the appropriate documentation is drawn up which may include a letter of offer and/or a Deed of Release, and your branch can assist with this process including assessing whether it is appropriate to claim under the indemnity policy.

Bibliography

1. Hopcraft MS, Sanduja D. An analysis of complaints against Victorian dental care providers 2000-2004. Aust Dent J 2006; 51:290–296.

2. Thomas LA, Tibble H, Too LS, Hopcraft MS, Bismarck MM - Complaints about dental practitioners: an analysis of 6 years of complaints about
dentists, dental prosthetists, oral health therapists, dental therapists and dental hygienists in Australia. Aust Dent J 2018; 63: 285–293.

3. Australian Dento-Legal Review-Guild-2013-2014 and 2007.

4. AHPRA

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We know, insurance can be tricky to understand. Unfortunately, it’s not as clear as 1s and 0s when working out what cover you need to ensure you’re meeting your professional and contractual requirements. That's why our partner Guild Insurance has provided some insight into the importance of having the right insurance policy by developing common scenarios based on claims trends for the IT consultant profession below:

Scenario one – Expectations can be hard to meet

Despite best efforts, sometimes things don’t end the way intended. Whether that’s due to expectation management, perceived skill or capability, or it's just a bad day, there's a range of reasons that an employer can feel they've been left exposed, feeling vulnerable or worse, have experienced a financial loss. In this case, they may seek retribution by way of seeking compensatory damages.

Scenario two – Differences in scope of work after commencement of contract

It is not uncommon for claims to arise due to cost variation involving a contract. The variation could occur for a range of reasons, including but not limited to the contract taking longer than initially planned, or the discovery that the project is far larger and more complicated than first anticipated. If this results in a dispute of work/cost, things can and often do get messy if not communicated well.

Scenario three – Mistakes in high risk industries

Developing software for aerospace applications can come with challenges. Even the smallest mistake in this sector could have enormous consequences. Like the aerospace industry, segments such as health, utilities, medical or defence, among others, can come with significant risk if an accident occurs, and can result in major claims.

Scenario four – Proof of insurance and maintaining cover

Employers may ask for evidence of professional indemnity and public liability insurance as a condition for working for them. However, it is imperative to maintain your professional indemnity insurance policy after the contract ends, as claims may arise days, weeks, months even years after the services were performed. If you don't have a current policy, then you may be left exposed for claims or allegations made against you.

The ITPA partners with Guild Insurance to ensure the unique needs of your profession are covered. And they do this by providing a policy that bundles professional indemnity, products and public liability all in one.

To learn more about the features and benefits of Guild Insurance’s IT consultant policy, visit guildinsurance.com.au or call 1800 810 213.

Disclaimer

Implants: a step in the tooth life cycle, not the end.

Media and consumer interest have heightened demand and expectations for implants as a solution to tooth loss. As a result there are an increasing number of implants being placed but, with less than satisfactory treatment planning and case assessment there are also increasing complaints about failures. When an implant fails it usually means that the super structure also fails, making any substantiated claims costly to the PI insurer and therefore to everyone via increased premiums. By not adequately assessing and planning cases dentists are not acting to protect their own interests or those of the profession.

 Emerging issues in implant complaints:

There are two emerging issues (leaving aside the issue of implants placed overseas for another article): firstly, patient driven treatment, where the patient refuses a removable option yet is biologically unsuitable for fixtures, can lead to placement of implants without adequate risk analysis and therefore a higher risk of failure. Secondly, a number of practitioners and most patients believe the treatment to be permanent and at low risk of failure. This is not the case according to dental literature.

Failure risks can be considered as restorative and surgical/periodontal. The prosthetic part of the treatment must be governed by first principles of occlusion and load, and because of the ease of machined components it is more predictable and if the occlusion is right, there is less risk of mechanical failure that conventional crowns and bridges. When implants fail, they are less amenable to treatment than natural teeth. There is reference in the literature to “failing” and “ailing” implants and it is recognised that there will always be implants which fail in the short term, but with time it is expected [and demonstrated in the literature] there will be more biological and technical issues resulting in increasing loss of implants.

Risk of failure

It appears that an increasing number of implants are being placed with no heed to the biological risks of failure. There is already (as well as emerging) published literature on this point but many dentists continue to place implants in cases which, given evidence based research, are at high risk of failure. As dentists we are used considering a risk hierarchy of factors for periodontal disease and caries. There are also risk factors to be considered when planning implants. There is well regarded literature which shows increasing loss or failure over time, and some cases of “spontaneous” failure with no known risk factors.

Emphasis in many planning cases is on the type of fixture and restoration and not on basic triage of suitability. In overlooking this foundation of treatment planning the result is increasing failures, complaints and therefore costs to the profession and the insurer.

High risk factors for peri-implantitis are:

1. Present active periodontal disease
2. History of past periodontal disease
3. Poor oral hygiene
4. Smoking (evidence showing it is less ranking than with periodontitis but still significant)
5. A small amount of literature identifies osteoporosis and Diabetes as risk factors but there is not enough evidence to rank them.

In summary

Every dentist should know the limitations and complications which arise from implant placement and advise the patients of these. The dentist should conduct a risk assessment on the likelihood of failure and add this to the general discussion of implant treatment. Expectations of patients should be aligned with this risk profile prior to embarking on treatment.

Although this is a now ageing article, I recommend the excellent review article by Drs Gary Greenstein and John Cavallaro: JADA 145(8) August 2014. In this article they cite the following recommendations to help reduce failures.

1. Treat any periodontal or peri-implant pathosis before implant placement
2. Fully assess medical history
3. Make sure there is adequate bone height and width: if not augment
4. Follow strict surgical protocol
5. Construct a proper super structure
6. Instruct patients in good oral hygiene and the absolute necessity for maintenance
7. Over engineer cases where parafunction is obvious

Performing  and recording a risk analysis and then informing  patients of any heightened risk of failure is good risk management for you, not to do so is potentially negligent and can give rise to a basis for an expensive claim, usually involving a costly remedial treatment plan. Disregard for considering evidence based research would also result in a potential unprofessional conduct finding if the matter was taken to AHPRA, as would practicing beyond the scope of an individual’s formal training.

Dr Eryn Agnew

Community Relations Manager/ Professional Consultant

Dental Implants - Success or Failure pdf

Chiropractors regularly deal with challenging situations and are continually required to make difficult decisions.  However, these decisions don’t always relate solely to the clinical care they’re providing their patients.  Unfortunately, sometimes chiropractors will face other difficult situations with their patients and knowing how to manage these isn’t always easy or obvious.

The information below highlights three challenging scenarios, which are not uncommon in chiropractic, with tips on how they could be managed.

Patient requesting specific treatment

Some patients will attend their chiropractic appointment with what they believe is an understanding of their condition and how they should be treated.  These patients will often request, maybe even demand, a particular type of treatment.  This information may be based on how they’ve been treated by a chiropractor in the past.  Sometimes it will be based on information non-clinically trained people, such as friends, have shared with them or even information they’ve read online.

Chiropractors must be sure all patients are assessed thoroughly regardless of what the patient tells them about their condition; the chiropractor as the health professional needs to be sure.  Following the assessment, the chiropractor may determine that the treatment being requested isn’t appropriate for that patient based on their current clinical situation. 

When the treatment the patient has requested isn’t ideal for them, they may not be happy with the decision to not provide this.  This requires the chiropractor to explain to the patient what treatment is recommended and why.  Chiropractors must be sure they don’t allow themselves to be coerced into providing treatment against their better judgement and they need to be sure all treatment they provide is clinically justified.  If there is a poor outcome following treatment and the choice of treatment is questioned, stating that the patient demanded that treatment isn’t a justification for it being provided.

In many cases, the patient will accept the chiropractor’s treatment recommendation.  However, chiropractors need to be prepared for the possibility that some patients won’t agree with this recommendation and may leave the appointment disappointed.  Unfortunately, it’s not possible to please all patients. 

If the situation above occurs, it’s vital that the patient’s request is noted in the clinical record so there is a full history not just of what treatment was provided but of all conversations regarding the treatment.

Patients seeing multiple practitioners

Some patients will choose to visit multiple practitioners for the one condition.  A common reason for this that they aren’t satisfied with the treatment outcome from one practitioner, so they try others hoping for a different result.  They may choose to see different chiropractors, or they might see different types of practitioners such as osteopaths and physiotherapists as well as a chiropractor.

In most cases, a patient seeking a different opinion shouldn’t be cause for concern.  However sometimes a patient who has seen numerous practitioners and has been unhappy with them all may be a patient who’s difficult to please and chiropractors should be mindful of how they manage this situation.

In cases where a patient presents criticising the treatment provided by another practitioner, it’s important that chiropractor doesn’t also criticise this treatment.  The chiropractor doesn’t have the full story of how the patient presented to the other practitioners, what treatment was provided and why.  Criticising the work of other practitioners is not only unprofessional, it can also encourage, even if unintended, the patient to make a formal complaint about that practitioner.

Quite often patients are unhappy with their treatment outcome due to them having unrealistic expectations.  Assisting a patient to form realistic expectations about treatment requires effective communication before treatment starts.  Therefore, be sure that with all patients the likely and realistic treatment outcomes are discussed with them prior to any treatment being performed.  And this conversation needs to be had using language they’ll understand so avoid clinical jargon.

If a chiropractor has a very uneasy feeling about a patient due to it appearing difficult to meet their needs, the chiropractor can decline to provide treatment.  However, the chiropractor needs to acknowledge that not providing treatment could upset the patient.  Therefore, this discussion needs to be planned and worded in a way unlikely to cause offence.  Exactly what is said will vary depending on the situation, however it would be reasonable to let the patient know that due to the patient not getting benefit from previous treatment similar to what would be provided, the chiropractor may not be the most appropriate person to provide further treatment.  The patient could be advised to see another health professional such as a medical practitioner.

Blurred boundaries

The relationship between a patient and chiropractor is a professional relationship.  However, at times the behaviour of patients and chiropractors can blur the boundaries of this relationship and it can start to seem more of a personal relationship which isn’t appropriate.

Chiropractors need to remember that their patients are just that, patients.  They aren’t friends and shouldn’t become friends.  There are a couple of simple rules to follow to avoid this change of relationship.

Chiropractors should avoid socialising with patients.  Sometimes a chiropractor will treat a patient and their family for many years which leads to them getting to know each other quite well.  This can lead to chiropractors being invited to family birthdays and other events.  While it may seem impolite to decline these invitations, accepting them can complicate the professional relationship. 

With the continually increasing use of social media, there can be a temptation to connect on social media with a large number of people.  If a chiropractor has a professional social media account, only used for professional communications, it’s okay to connect with patients through this account.  However, chiropractors shouldn’t connect with patients on a personal social media account.

Chatting to patients during consultations is a great way to seem more personable and make patients feel relaxed.  However, if there is too much personal chatting the chiropractor is possibly not spending enough time discussing the treatment being provided.  Also, there have been occasions when personal conversations have been misinterpreted by the patient and they’ve felt uncomfortable with the chiropractor discussing information not related to treatment.

Unfortunately, keeping clear boundaries can be a little challenging for those chiropractors practicing and living in small towns or communities where many people know each other.  In these situations, the chiropractor needs to ensure that if they are treating someone they know, they maintain their professional standards during consultations and not treat these patients differently to others. 

Managing difficult chiropractic situations

Managing complaints in dentistry

There has been a steady increase in errors reported to Guild Insurance involving the wrong route of administration.  These errors occur when a pharmacist dispenses a medication that has been manufactured for administration via a different route.  For example, the pharmacist dispensed ear drops instead of eye drops, or the patient was prescribed injections, but was given tablets.  Errors also include pharmacists directing customers to take the correct medication, but via the wrong route.  For example, a customer was prescribed oral capsules, but the pharmacist labelled the medication to be used as a suppository.

These errors can and do happen, even to experienced pharmacists who’ve never made a mistake before.  They can happen to you and they can have serious consequences for you and your customers.

Cases

An infant was prescribed Egozite scalp lotion to treat a skin condition.  On the same script, it was recommended her parents also obtain Infacol drops to help treat infant colic.  However, during the dispensing process, the labels were transposed and as a result, the Egozite lotion was given orally and the Infacol drops used topically.

 A pharmacist inadvertently dispensed Ciloxan ear drops instead of Ciloxan eye drops.  While the customer didn’t suffer harm, the same error with a different medication may have resulted in serious consequences.

Reduce the risk of dispensing errors        

• Adhere to the PDL ‘Guide to good dispensing’ every time.Don’t be coerced into rushing or cutting corners.When errors occur, pharmacists often say “if only I’d taken the time to…”
• Display posters or reminders in the dispensary to promote compliance with dispensing procedures.
• Use barcode scanning every time.
• Seek help if you are feeling intimidated or uneasy about contacting the prescriber to clarify a script.
• Consider placing flags or warnings in the dispensing basket when handling a script for a different route of administration.For example, a simple card stating ‘RISK WARNING – injection’ could reduce the chance of you automatically selecting an oral dose.
• Make use of the safety features available in your dispensing software.Set up different alerts to remind people to perform certain tasks.Likewise, make use of advanced scanning features that automatically print a barcode on the dispensing label.
• Promote a culture where all staff are confident to point out risky practices when they occur.
• Reducing distractions when a pharmacist is dispensing is everyone’s responsibility.Agree to strict rules for minimising interruptions and distractions in your pharmacy.
• When handing medications to a customer, point out all warnings and directions on the label and packaging.This not only helps with counselling but serves as a final check against any dispensing error.

Dispensing errors – wrong route of administration

There are an increasing number of dental services available which are direct to the consumer, meaning the consumer hasn’t consulted directly with a registered dental practitioner.  While the convenience of these services is obvious, they aren’t without risk for both the consumer and any registered dental practitioner involved.

These direct services are available for several dental treatment areas such as orthodontic aligners, splints and sleep appliances.  These services can be initiated by the consumer creating their own impression using materials and information provided to them.  In other cases, the patient may have a digital scan carried out by the service provider at a designated location (shopfront or pharmacy), often by someone who is not a registered dental practitioner.  Following this, a treatment plan is developed and the device(s) required will then be provided to the patient for use.  Some of these services also offer mechanisms for remote supervision of treatment progress by a dental professional.

One of the concerns with this type of treatment model is that other dental issues, not directly related to the appliance, may not be detected due to the patient not being regularly assessed and treated in-person by an appropriately registered dental practitioner.  There are also concerns about how patient suitability (or standard of care case selection) is determined.  While some companies providing these services do have a process of assessing the suitability of the appliance for each patient, this is often done by the patient completing an online assessment form themselves; therefore, there is no assessment for suitability by a registered dental practitioner.

There may be occasions where a dentist, who isn’t involved in this treatment model, has a patient ask them about their views on it or asks them for support in completing forms required to purchase one of these devices.  Dentists should be aware that if they provide clinical advice, they are involved in the treatment.  It’s therefore recommended that dentists contact their ADA Peer Advisor (NSW/ACT) or Community Relations Officer (Victoria, South Australia and Tasmania) if they find themselves in this situation so they can obtain advice on how to best manage this situation.

Dentists who choose to participate in these treatment models need to understand and appreciate their level of responsibility and possible liability.  Regardless of whether or not a dentist has seen or consulted with the patient themselves directly, involvement in design of such appliances or other aspects of their provision and use may be deemed by regulatory bodies to be provision of a dental service.  Registered practitioners, when providing a dental service, must ensure their professional obligations are always being met. 

If a consumer is dissatisfied with the outcomes of their treatment and they’re aware of a registered dental practitioner who was involved in their treatment in some capacity, they have the same rights as other patients to formally complain to regulatory authorities or make civil claims about the treatment provided by this practitioner.  To defend against allegations of wrong-doing, this practitioner would need to show that:

• the treatment and/or advice they provided was to the professional standard expected;
• they are appropriately qualified and experienced to be providing that treatment and/or advice;
• the treatment and/or advice was clinically justified;
• the patient was aware of the risks, expected outcomes and limitations of the treatment; and
• detailed clinical records have been maintained, showing exactly what was done and why.