ADAVB submission re National Safety and Quality Framework · Dental Ethics Manual, 2007, p.20) Any Code of Ethics, such as ADA’s Code, can only be a guide to personal judgment

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ADAVB SUBMISSION IN RESPONSE TO: Discussion Paper on achieving the directions established in

the proposed National Safety and Quality Framework INTRODUCTION The Australian Dental Association Victorian Branch Inc. (ADAVB) welcomes the opportunity to comment on the ‘Discussion Paper on achieving the directions established in the proposed National Safety and Quality Framework’ (‘the Framework’). The ADA operates as a federation and ordinarily the ADA Inc. (the federal body) responds to Commonwealth initiatives and issues. In this case, where safety and quality measures are in some cases being transferred from a State jurisdiction to a new national scheme, we feel it is helpful for separate submissions to be made. The ADA Inc is working in partnership with QIP to develop practice accreditation standards which are consistent with the principles established by the Commission. Representing over 90% of registered dentists in Victoria, the ADAVB is the peak professional body for dentists, and has a long history of acting in the public interest as well as representing our members. The ADAVB mission statement reads:

“The ADAVB is an association of dentists committed to advancing the art, science and ethics of dentistry, the care of the oral health of all Victorians, and the professional lives of its members.”

We highlight the ethical and community dimensions here because health professions are sometimes characterised (unfairly we believe) as being simply ‘vested interests’. Our view of professional obligation continues to place patient welfare first, and that means we hold strong views about the way regulations and guidelines need to be framed to protect public health and safety. In seeking to achieve the above mission, the ADAVB provides a number of services which we believe offer public benefit: o Guidelines are published on a wide range of matters affecting the quality

and safety of dental care infection control, drugs and poisons, radiation safety, therapeutics, electrical safety, and waste management, amongst

ADAVB submission re National Safety and Quality Framework Sept. ‘09

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others. Both the ADAVB and ADA Inc. provide professional and industry standards.

o Assistance is provided to hospitals and other Government funded agencies with the credentialling of dentists seeking to work in these facilities – an important safety and quality mechanism. Guidelines on credentialling and defining the scope of practice of dental personnel were prepared by the ADAVB to assist Directors of Medical Services in understanding the application of these processes to dental service providers.

o The ADAVB offers a conciliation service to assist patients to resolve disputes with dentists over treatment.

o Member services include newsletters which, amongst other matters, advise on regulatory compliance and emerging issues regarding the safety and quality of dental care.

o In partnership with the Melbourne Dental School, the ADAVB offers a world class continuing professional development program, designed to keep members up to date with clinical and scientific developments and to continuously improve the quality and safety of the treatment they provide.

o Members are kept informed of issues, developments, and clinical matters through Group meetings held across the State. Members in remote areas access information electronically through the Branch website and email messages.

o Sponsorship of student visits to rural areas to promote better distribution of the oral health workforce is another example of a community service provided by the ADAVB. This further demonstrates the Branch’s continuing support for regional dentistry.

o Extensive support is provided to overseas trained dentists seeking to complete examinations to become registrable in Australia. The ADAVB has almost 300 members in this category. Their free membership entitles them to library facilities, professional development, and mentoring and personal support. These candidates have no other form of organised support – certainly none from Government agencies, despite skilled migration programs having enticed them to come to Australia.

o New graduates are assisted to understand their entitlements as employees entering the workforce, and ethical practice is promoted from their commencement.

No Government agency could or would cover all of these functions, which are provided by the ADAVB and funded chiefly by members. The value of these roles and functions for the community has not been measured, and we have therefore welcomed the recent commencement of a Productivity Commission research study into the contribution of the not for profit sector.


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Organisations representing health professions are sometimes undeservedly described as ‘professional unions’ or ‘medieval guilds’ as if they only serve the interests of their members and provide no discernable benefit to the community. Of course professional associations are intended to provide member benefits, and this is a key function. However the long tradition of health professional bodies is also to serve the health interests of the community, and to promote the welfare of the patients before the welfare of members. The notion of the ‘social contract’ is alive and well in the health professions, offering significant benefits to the community, although these are often unseen and unheralded. Our membership spans both the private and public sectors. This fact, and our commitment to a Code of Ethical Conduct, means that we are bound to address a diverse set of concerns, including those of public dental patients and the agencies that are provided with insufficient resources to meet demand for public dental services. The ADAVB has advocated for public dental services for many years, and has demonstrated its commitment to improve the oral and general health of the Victoria community. In mentioning the ADA Code of Ethics, we note that it has long been recognised, that “the ethics of a profession are not imposed by legislation but self-inflicted and voluntarily accepted for the purpose of establishing and maintaining an honourable pattern of behaviour recognised by both its members and the community it serves”. (Seear, J. Law and Ethics in Dentistry, 1975, p.103) The Dental Ethics Manual, published by the World Dental Federation (FDI) in 2007, notes: “... ethics should not be confused with law. One difference between the two is that laws can differ significantly from one country to another while ethics is generally applicable across national boundaries. In addition, ethics quite often prescribes higher standards of behaviour than does the law, and occasionally situations may arise where the two conflict. In such circumstances dentists must use their own best judgement whether to comply with the law or follow ethical principles. Where unjust laws conflict with ethical principles, dentists should work individually and collectively to change the laws. (FDI World Dental Federation, Dental Ethics Manual, 2007, p.20) Any Code of Ethics, such as ADA’s Code, can only be a guide to personal judgment. The principles and values that are enshrined in the Code need to be absorbed and lived by the professional in order to have the desired force and effect. When faced with an ethical dilemma, no-one resorts to reading the guidelines in order to make their decision. They make the choice between all possible responses according to an inner compass – the product of a lifetime of experiences and learnings about right and wrong; about what works and what constitutes a mistake.


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Recognition of the importance of this ‘ownership’ issue would be most helpful when Governments are dealing with professional groups such as dentists. The ADA supports the regulation of professional conduct and the protection of public health and safety, and we are pleased to support a nationally consistent approach to these matters. This applies to the Commission’s work on the Framework as much as it does to the National Registration and Accreditation Scheme which is being implemented in parallel with the Framework. Our comments below on the Framework elements and strategies are therefore aimed at improving the effectiveness of the proposed approach rather than opposing the initiative. In general the ADAVB considers the Framework to be quite reasonable, with sound concepts and ideas. A few points raise concerns, and these are generally informed by the view that office-based practice cannot be asked to meet the same standards as acute facilities or, for that matter, as community health centres with their access to extra administrative personnel to address red tape requirements. Some points will be argued against, while other issues raised by the Framework lend strong support to our arguments against certain reforms being advocated in other places e.g. the National Health and Hospitals Reform Commission and the National Health Workforce Taskforce. 1. Patient focused. Members of the ADA commit to adhere to ethical principles which place the safety and welfare of patients as a central priority. The following extracts have been in place for many years and provide the basis on which the dental profession is pleased to declare that it is strongly in favour of a patient centred approach to dental care. “1 Introduction The ADA Inc. has established these Principles of Ethical Dental Practice as a guide to the obligations and conduct of Members of the Association. In addition, each State Branch of ADA Inc. has established its Code of Ethics, the observance of which is a mandatory condition of membership. These Codes of Ethics are complementary to State and Territory statutory requirements. 2 Obligations Towards Patients 2.1 “,The primary responsibility of dentists is the health, welfare and safety of

their patients. 2.2 Dentists should perform treatment only within areas of their competence.

If appropriate, referral for advice or treatment to other professional colleagues should be arranged.

2.3 Dentists must accept full responsibility for all treatment undertaken by themselves and, as permitted by law, by allied dental personnel acting under their supervision and direction.


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2.4 No service or treatment shall be delegated to a person who is not qualified or is not permitted by the Laws of the Commonwealth, State or Territory to undertake that service or treatment.

2.5 Records that are comprehensive, accurate and respectful must be created and safeguarded for all patients.

2.6 Confidentiality and privacy with respect to both clinical and non-clinical information must be maintained except where the Laws of the Commonwealth, State or Territory dictate otherwise. It should be recognised that patients have the right to access their personal records and/or receive copies of them. Care should also be exercised to make certain that the issuing or transferring of personal records can only occur with the proper authority of the patient concerned. It is the obligation of dentists to ensure that allied dental personnel under their supervision observe that same confidentiality.

2.7 Dentists should ensure that they provide patients with clear information about their dental condition and proposed treatment options so that patients are then able to make decisions that lead to informed consent for a particular option, without which it should not proceed.”

Strategy 1.1: Develop service models which improve access to health care for patients. Access is primarily an issue to the extent it affects timeliness, otherwise it is not ordinarily a safety and quality issue at all. Of course, if a person does not receive treatment in a timely manner, in the case of some diseases and conditions their safety will be at risk. The issue of access to care under the banner of Safety and Quality must not be used as a rationale for workforce modification. Appropriately trained providers must be in place to meet the treatment needs of the public. Incentive schemes to ensure that well trained practitioners choose to work in regional Australia are the key. Establishment of regional university dental courses is already occurring on the assumption that this will help to attract practitioners willing to make a commitment to provide services to rural communities. Such an approach would be required regardless of whether the practitioners are dentists or ancillary dental personnel. Expanding the scope of duties of ancillary providers to the point where they are permitted to do the same things as fully qualified dentists would clearly be illogical and uneconomic. If they are to be permitted to do all things dental then why are we spending vast resources on 5 and 7 year degree courses when this could all be done via a three year degree? Dentistry is not that simple. The safety and welfare of Australian dental patients requires that complex care is only provided by fully trained dentists. This means that ancillary personnel must have certain restrictions on the care they provide and are trained to do.


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Strategy 1.2: Increase health literacy We support health literacy and recognise that many patients are now much better informed about their condition and the types of treatment which might be offered to them. However, we also recognise that professional knowledge about diseases and their management has increased greatly in recent years. Access to basic information about health conditions and treatment options is widely available online. However, the complexity of factors that need to be taken into account when determining a treatment plan or in providing a health service can sometimes be forgotten, and the sophisticated blend of competencies required for optimal delivery of health services can be overlooked. In our view, it would be unreasonable to expect lay people to fully understand some of the concepts and issues pertaining to anatomy, the aetiology of disease and the multiplicity of factors that need to be taken into account in making clinical judgments about complex care. Necessarily, the description of the diagnosis and proposed treatment plan will be simplified for all non-trained patients. The ADA has worked with MiTEC to prepare a wide range of patient information brochures about dental conditions and treatment, designed to improve the dental health literacy of patients attending for dental care (see attached). Strategy 1.3: Involve patients so that they can make decisions about their care

and plan their lives. We also support this strategy to ensure that the decisions regarding the treatments which are in the patient’s best interests are made jointly by the patient and the practitioner. The ADA advocates partnerships between patients and providers aimed at achieving optimal health outcomes. We would also support greater recognition of the important contribution made by the patient in determining their own health outcomes. Self-managed care, supported by caring professionals, is an appropriate way of thinking and talking about dental and oral health, where most diseases and conditions are entirely preventable. The ADAVB is concerned that "c. Providing patients with written records of consultations" could be misinterpreted, in that patients might be led to believe that they can have immediate access to records about their treatment. This would be logistically problematic for the many practices that still use paper records. The itemisation of accounts will usually provide the summary of treatment completed and this will generally be sufficient to inform patients.


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Professional Indemnity Insurers have long made it clear to practitioners that they must keep original records of their treatment and that without good records they cannot have a good defence in the case of an action being brought against them, whether the matter is justified or not. For dentists in Victoria, the Code of Practice governing dental records also makes it clear that the dentist must maintain original comprehensive and contemporaneous records. Failure to do so would be considered unprofessional conduct. The following extracts from the DPBV Code of Practice on Dental Records describe the obligations of registered Victorian dental care providers:

“13. Dental health practitioners have a professional and legal responsibility to: (a) keep the information they collect and record about patients confidential; (b) retain, transfer, dispose of, correct and provide access to dental records in accordance with the requirements of the laws of the state and commonwealth; (c) assist patients to make well informed decisions about treatment procedures and not to force treatment on them without their consent. 14. In order to practise in a professionally responsible manner practitioners, while exercising their professional judgement in each particular situation, must maintain their dental records at a standard that satisfies the purpose of this code.”

Patients are being told via the NHHRC report that they should own their records, as if the records are created in the practice and then handed to the patient for safe-keeping. This has the potential to mislead the public about the way in which the records must be created and held. The records that are required to be maintained under the Dental Records Code of Practice highlight the need for the records to be meaningful to another dentist rather than a lay person. Making it a requirement that the records all be expressed in terms able to be understood by any patient would actually be impossible to achieve. Even if the requirement were to be that they had to be understandable by a person with English as their first language, it would impose an onerous burden in time and administrative resources so that far fewer patients could be seen each day. This would reduce access to care and so conflict with the earlier Strategy seeking to promote access. Strategy 1.4: Provide care that is culturally safe The ADAVB is pleased to support culturally sensitive treatment of all members of the community.


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Strategy 1.5: Enhance continuity of care We recognise that patients with chronic conditions, acute and aged care patients all have a treating team and complex care needs. Such patients need effective care management, and this requires good communication between treating practitioners. Patients moving from one location to another also need copies of their record made available (for a fee if these records are extensive) or reference by other practitioners. Strategy 1.6: Minimise risks at handover We support effective communications when a patient is transferred from the care of one dentist to another, and where they have been referred to specialists. Strategy 1.7: Provide case management for complex care See comments under Strategy 1.5 above. Strategy 1.8: Facilitate patient-centred service models. Most dentists would consider that their care is already patient-centred, and if changes in practitioner behaviour are sought, then educational programs will be required to explain why such change is necessary and to demonstrate how it can be integrated into the practitioner’s treatment model. Strategy 1.9: Promote healthcare rights Please refer to our comments under Strategy 1.3 above. Strategy 1.10: Inform and support patients who are harmed during health care. The ADAVB supports open disclosure, however the wording of the following statement is of concern. "b. Providing compensation that equitably and consistently meets the

financial needs of patients who have been harmed while receiving health care and that does not rely solely on patients’ ability to prove that an error was made."

This statement is too open to interpretation. It really is not relevant to the notion of safety and quality and so we query whether it belongs in the framework. It may be more appropriate under the national registration legislation.


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2. Driven by information.

Strategy 2.1: Reduce unjustified variation in standards of care Naturally, we support all registered providers meeting minimum standards of safety and quality. Care will be required however, in the interpretation of these standards to avoid ‘treatment by numbers’. Every patient presents differently. Even where the same treatment plan might be recorded, the actual delivery of that care will vary enormously according to differences in age, oral anatomy, budget, general health, and a multitude of other factors. Clinical pathways that assume a one size fits all approach simply don’t work in the real world, and so standards need to be defined in a flexible manner recognising the rich variety of circumstances under which dental care will be provided – from a state of the art clinic to an open air outreach clinic. Strategy 2.2: Collect and use data to support safety and quality The ADA is working in partnership with the Cooperative Research Centre for Oral Health Science (CRC-OHS) located at the Melbourne Dental School to host a Dental Practice Based Research Network (DPBRN), and this venture may be helpful in collecting and analysing certain safety and quality data. Strategy 2.3: Learn from patients’ and carers’ experiences The ADAVB would be pleased to promote activities by which to enhance learning from the experiences of patients and carers. Strategy 2.4: Encourage and apply research that will improve safety and quality See also our comments under Strategy 2.2 above. Strategy 2.5: Continually monitor the effects of healthcare interventions See also our comments under Strategy 2.2 above.


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3. Organised for safety. Strategy 3.1: Clinicians recognise their responsibilities for safety Some aspects of this are refuted by the survey released by the Economist this year where it was found that medical personnel resent increased paper work and administrative roles. Strategy 3.2: Managers recognise their responsibilities for safety Most dental practices are run by self-employed dentists and they do not have dedicated managers in the way that acute care facilities do. Dentists have always recognised their responsibilities for safe treatment of their patients. The majority of dental treatment is delivered in community based office practices and many of the quality and safety issues identified considered significant in hospitals are expensive and cumbersome. They are not suitable or applicable to the office practice setting. Strategy 3.3: Governments recognise their responsibilities for safety We strongly support this point and note that with their preoccupation with cost containment and rationing of care, Governments are at risk of jeopardising patients’ welfare. Where they are tempted to permit lesser trained or untrained personnel to provide care, say in response to shortages of higher trained operatives in rural areas, they expose patients to the risk of harm. Strategy 3.4: Restructure funding models to support comprehensive, appropriate

care This strategy is supported. Strategy 3.5: Support and implement e-health Currently State registration boards publish codes of practice describing the obligations of registered persons with regard to the practice of dentistry. This is due to become nationally regulated from 1 July 2010. Dental records requirements are amongst the matters on which codes have been published, and the examples quoted below are derived from the Code published by the Dental Practice Board of Victoria (DPBV) (see also http://www.dentprac.vic.gov.au/codes.asp?doc=6). The DPBV Code of Practice on Dental Records (C003 – 2007) makes the following statements about the purposes of dental records:

http://www.dentprac.vic.gov.au/codes.asp?doc=6�


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“7. Good dental records facilitate high-quality, comprehensive care by making detailed and relevant patient information (both current and historical) readily available to treating practitioners. 8. Accurate dental records assist in the efficient and complete delivery of care in the event of another practitioner assuming that patient’s treatment. Records also provide a means of continuity in documentation and patient care. 9. Dental records are useful for forensic purposes and can play an important role in the identification of deceased and missing persons. 10. Dental records can provide a repository of valuable information for teaching, education and research. 11. Dental records form the basis for retrieval of treatment details in the case of a dispute or the requirement to provide evidence.”

What records? The DPBV Code of Practice on Dental Records lists the following as key contents of dental records that should be maintained by registered dental care providers:

“Patient details (a) Identifying details of the patient. (b) Completed and up to date medical history. Clinical details (c) For each appointment clear documentation describing: (i) the date of visit (ii) the identifying details of the dental health practitioner providing the treatment (iii) information about the type of examination conducted (iv) the presenting complaint (v) relevant history (vi) clinical findings and observations (vii) diagnosis (viii) treatment plans and alternatives (ix) patient consent (x) all procedures carried out (xi) instrument tracking information (batch control identification), where relevant (xii) drugs prescribed or administered or other therapeutic agents used (name, quantity, dose, instructions). (d) Unusual sequelae to treatment. (e) Radiographs and other relevant diagnostic data. Other details (f) All referrals to and from other practitioners. (g) Any relevant communication with or about the patient.


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(h) Details of anyone contributing to the dental record. (i) Estimates or quotations of fees.”

Use of information by other healthcare providers In our view, there may be particular benefit in being able to share medical history and medication details between healthcare providers, as in many cases patients do not recall all of the relevant details of their medical history and medication regimes, and this can lead to complications in the delivery of future care. There are limits to the usefulness of information created by dentists for other health care providers. The records created by dentists are not customarily written in plain English, as efficient and appropriate annotation of the records requires use of the specialised language of the field in which the treatment is provided. Specialised terms, codes and symbols have evolved for good reason to explain very precise concepts and aspects of care, and each health field, and indeed each sub-field within each field, has its own unique professional language necessary for effective record keeping, and communication between practitioners within that field. For efficiency, convenience and clarity, each field has developed over many years a system of abbreviations and codes or mnemonics, which allow complex ideas to be conveyed in shorthand form. The facility with which contemporaneous records can be created is a product of such shorthand annotation systems, and care must be taken to ensure that these efficiencies are not compromised by superimposing a new requirement that the records must be made in a form that a lay person can understand. It should continue to be the case that the record is a professional reference, to which the patient is entitled to have access and an explanation if they desire it. Information about medical history, allergies and adverse drug reactions, and medications prescribed are all helpful to treating practitioners, but it may not be helpful to a medical practitioner to know that a patient has received a [insert an example of an appropriately arcane but common place dental treatment or endodontic status or dmft / DMFT here]. The question is, how will other healthcare providers make use of dental records, if at all? Will they know how to read the records and without dental training, will they have any understanding of the significance of the information they are reading?


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If the information in health records is now meant to form part of some broader quality control regime, then much wider discussion will be required about the types of data being recorded and the ways in which it will be accessed and interpreted. The pooling of de-identified data may offer some insights into benchmarks, however a great deal of research will be required to test the methods that will produce meaningful data, and subsequently much education will also be required so that practitioners can make best use of the benchmarks made available. The claimed efficiencies in resource use have not been proven in a dental setting. The cost of IT infrastructure training and support will also need to be taken into account in an office based practice environment where there is no IT Department to sort out the technical hitches that can bring a service to its knees. The security arrangements that will ensure no breaches of privacy occur if health information is available online will need to be very robust, and hacker-proof. Defence grade measures will be required. We reiterate our comments about the need for agreement on the purposes to which patient health data will be put. ADA supports patient access to copies of their health records, which are owned and held by treating practitioners, but we have not seen sufficient information on the proposed benchmarking arrangements to be able to support those purposes at this time. The mechanisms by which practitioners will be supported to “get out of paper” need to be sensitive to the culture and clinical requirements of each field. Work done in large acute medical settings like hospitals, or even large primary care settings such as Community Health Centres, may have only limited application to office based dental practice, with already stretched administrative capacity. The recent discussion paper from NEHTA on healthcare identifiers cannot be considered in isolation from the NHHRC recommendations for patient owned records, and yet there does not appear to have been any effective coordination between the two initiatives. This undermines the credibility of both ventures, and will naturally lead to uncertainty and loss of engagement by health professions. Confused motives and purposes are not likely to win support and cooperation. The following media comment also demonstrates health and safety risks which could ironically be created by too hasty a roll-out of e-Health measures, without adequate training and support.


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“Hospital patients' lives could be put at risk from overdoses or wrong medication, experts warned, if the ambitious timetable for the Government's e-Health plans mean computer-generated prescriptions are introduced without adequate training and support for staff. Their comments come after a Federal Government commission found electronic prescribing had doubled the rate of medication errors at a large hospital because of poorly designed software that automatically filled out scripts to the maximum dose and ordered unnecessary repeat courses. The findings fly in the face of the widely espoused benefits of electronic prescribing - that it would cut errors by alerting doctors to possible side-effects and allergies and reduce reliance on handwriting.”

Source: Sydney Morning Herald ‘$1.8b program puts patients at risk’, Louise Hall, Health Reporter, August 20, 2009

Strategy 3.6: Design facilities, equipment and work processes for safety This is readily supported, and the dental profession prides itself on high standards of treatment facilities and work processes. As noted above, the ADA is developing dental standards for practice accreditation in partnership with QIP, and the new accreditation arrangements are due to be rolled out in 2010. Strategy 3.7: Take action to prevent or minimise harm from healthcare errors The ADAVB strongly supports this strategy and has a long history of assisting members to develop effective clinical risk management strategies. ENQUIRIES Mr Garry Pearson, ADAVB CEO [email protected] Ph 03 8825 4600

mailto:[email protected]�


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Documents

ADAVB submission re National Safety and Quality Framework · Dental Ethics Manual, 2007, p.20) Any Code of Ethics, such as ADA’s Code, can only be a guide to personal judgment