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GettinG better all the time

The Dental Complaints Resolution Service has been in operation for half a decade now and is becoming better and more respected every year.

It is wonderful to see that 2016 has been perhaps the most successful yet for the Dental Complaints Resolution Service (DCRS)

Not only has the reported settlement rate increase, but we also saw the involvement for the first time of a dedicated dental adviser, Dr Maurice Fitzgerald. Dr Fitzgerald has been a great addition to the Service and his wise counsel is valued not only by our facilitator, Mr Michael Kilcoyne, but by the Irish Dental Association also.

A model for others

The successful establishment and continued operation of this Service reflects great credit on the dental profession and we know that a number of other professions are studying our Service closely, and considering adopting a similar approach Along with the decision to display professional fees, the dental profession deserves credit for adopting a proactive approach to dealing with the new realities facing all professions in today ’s more consumerist society

It is also refreshing to see that greater suppor t from the dental profession is being repor ted by Mr Kilcoyne, which is testimony to the increased familiarity and confidence in the Service among dentists and practice staff It remains a voluntary service, so the level of engagement by dentists and patients shows that the basis for the service’s operation – being free, voluntary, timely and not requiring legal representation – is intrinsic to its positive standing

The key lesson highlighted by Mr Kilcoyne – the need to deal with a problem and engage with the other par ty, is vital for dentists and patients Complaints can be regarded as nuisances, even where they are legitimate, but nobody has anything to lose by availing of this Service where they cannot resolve disagreements directly in the first place

Changes

We can all learn from careful reading of this report and the case studies which are featured In revamping our website, www dentalcomplaints ie, we hope to make these case studies more prominent and easier to access That way all can reach a better understanding of the type of complaints the Service considers and see examples of successful settlements

Finally, we wish to thank all those who have engaged with the scheme, to the facilitator, Mr Michael Kilcoyne and his adviser Dr Maurice Fitzgerald, to the Dental Council and to Dental Protection also who have been extremely suppor tive of the Service

Robin Foyle, Fintan Hourihan, President CEO

Irish Dental Association

DENTAL PROTEC TION STATEMENT

G R E AT E X P EC TAT I O N S

Dr Raj Rattan, Dental Director of Dental Protection, says it is impor tant for dentists to manage patient expectations carefully to avoid complaints.

Our lives are enriched by our daily experiences Our response to these experiences is largely determined by our expectations – a surprise is only a surprise because we have no expectation about the event or occurrence. Other responses, such as making a complaint, arise when expectations are not met. The expectation disconfirmation theory can help the dental team to understand patient satisfaction in relation to expectations and outcomes.

The concept is best illustrated by the following sequence:

1 When a patient visits a practice or a dentist, they do so with preset level of expectation In the case of existing patients, prior experience of the service will influence these expectations In the case of new patients, the experience of friends and family (or whoever else has recommended the service) will play a part For others, the expectations may be set by words and images that appear on websites and marketing literature

2 These expectations are the standard against which the dental team and the practice will be judged

3 When expectations are met, confirmation occurs

4 Disconfirmation arises when there is a difference between expectation and outcome

5 If the outcome is better than expected, there is positive disconfirmation and this leads to satisfaction Negative disconfirmation arises when the outcome is below the preset level of expectation and may lead to a complaint Simple disconfirmation is the term used to describe a situation where the expectation meets the outcome; it is neither better nor worse

Complimenting and complaining behaviours are determined by this outcome Clinical practice continues to advance and improvements in techniques and materials allow clinicians to raise the bar when it comes to setting standards Where there is competition in the market amongst providers of ser vices, adver tising and marketing materials are one method of differentiation It is all too easy to over-promote the benefits

of care and influence expectation levels such that they cannot be met

The adage “first impressions count” is also relevant here The practice environment itself contributes to expectation levels It has been described as the ser vice-scape of business It also impacts on the perceptions of quality, expectations and per formance Interestingly, cleanliness is cited as the area of the ser vice-scape that received the most complaints in the wider business world

The power of expectation Case study

A patient attended for the removal of lower impacted third molars Af ter the removal of one tooth, his dentist called him in the evening to make sure he was comfor table and that there were no post-operative issues

The call was not expected and he expressed his gratitude for the care he was shown Two weeks later, the same dentist removed a molar on the other side and, on this occasion, did not call him as a local postgraduate meeting had overrun and there was no oppor tunity to telephone On his return to the practice some days later for a review appointment, the patient commented that he was surprised not to receive a call on the second occasion

In a matter of two weeks the patient’s baseline expectations had changed and he had crossed from the positive to the negative side of the disconfirmation continuum It is a reminder on the impor tance of setting realistic expectations that can be met consistently At first glance, the mantra of under promise and over deliver offers a solution

But lowering expectations also potentially lowers the appeal of the ser vice or product, especially in a competitive market It is a matter of striking a balance Some leading researchers in the field suggest that there are three types of expectation:

1 The desired ser vice – a level that the patient hopes to receive

2 Adequate ser vice – this is the minimum tolerable level because patients will have recognised that the desired ser vice is not always achievable

3 Predicted ser vice – the level of ser vice a patient thinks they are likely to receive on the basis of probability

The gap between one and two is the so-called “ zone of tolerance” and the predicted ser vice is likely to lie within that zone It is a zone in which the dental team can per form in comfor t It is only when the experience falls outside the zone of comfor t that a patient demonstrates complaint behaviours The extent of the tolerance is contextual It varies amongst patients and may var y at different times in the same patient, depending on what else is happening in their life

Patient satisfaction

Patient satisfaction is a mental state and a multi‐dimensional construct affected by many variables It influences positive patient behaviours such as loyalty

Dissatisfaction has the opposite effect Many studies have shown that patient satisfaction is determined by subjective and objective experiences and their dentist’s interpersonal and communication skills

The “communication of care and attention” has been cited as the most

influential factor in maintaining patient loyalty

Dentists should focus on and develop effective communication skills before, during and af ter treatment sessions by involving patients in treatment decisions For example, according to one study, patients who received more preparator y information and knowledge had superior post-operative pain control and satisfaction af ter undergoing third-molar extraction than patients who did not

To avoid complaints, we must focus on the human and psychological aspects of the dentist/patient relationship and adapt our communications to better manage patient expectations within the expectancy–disconfirmation paradigm It is also wor th paying attention to the ser vice-scape as it is the antecedent to the experience itself and can mould patient perceptions

Dr Raj Rattan MBE BDS MFGDP

FACILITATOR’ S REPORT

A MO R E E F F I C I E N T S E RV I C E

The DCRS is building on our experience and what we’ve learned over the past five years and is now solving a higher percentage of cases than before.

The Dental Complaints Resolution Service (DCRS) is now in its fifth year and provides a credible and less stressful complaints resolution alternative to the Dental Council or the courts for dentists and patients. In 2016, the Service resolved a higher percentage of complaints than in 2015. The Service resolved 58 of the 102 complaints accepted as of December 31, 2016, compared to 44 out of 134 in 2015.

In recent years, the Service has enlisted the assistance of an independent dental adviser, Dr Maurice Fitzgerald, who helps with the more dentally-complex cases His advice has proved invaluable and the Service speaks at length with him discussing cases and teasing out issues The Service takes on each case from a conflict resolution viewpoint, whereas Dr Fitzgerald approaches them dentally, and this allows for a much broader examination of complaints. This has benefitted both complainants and dentists. The Service is getting more well known and dentists are seeing that it is something which can assist rather than punish them, as it provides a fair and impartial way to get beyond the problems they face with patients that can’t be resolved in house

Advantages

A number of people contacted the Service trying to find out how to make a complaint in 2016 The first thing the Service does is try its best to not deal with a complaint at all Firstly, when contacted with a complaint, the DCRS insists that the patient contact the dentist directly to try to sort things out that way This alone often leads to amicable resolutions, without the need for outside intervention When a patient contacts the Service, their complaint is considered and, following that, it is accepted or not Sometimes the patient has a valid complaint and sometimes they don’t Another advantage of the Service is that it is free for patients and IDA members, and at ¤90 for non-members, is a pittance compared to the legal costs incurred in any court The Service received 477 phone calls and 758 emails and letters last year Many times,

there was no follow-up after this initial contact as people were told to try to sort things out directly with their dentist or that there was no basis to the complaint Some 36% of telephone queries did not materialise into written complaints, which are necessary for a complaint to be accepted A total of 19 complaints could not be accepted by the Service as they related to issues outside of its remit This represents a significant increase on 2015, when there were only ten complaints of this type, which include work done under medical card schemes or dental work performed outside the Republic of Ireland One case from Northern Ireland was referred to the UK dental complaints service In 69% of cases, the complaints were about dentists who are members of the IDA, the same proportion as 2015 Up to December 31, 2016, 58 cases were resolved, representing a 57% resolution rate last year, compared to 33% in 2015

The remaining 44 cases have either been resolved since the end of the year or remain unresolved for different reasons Sometimes complaints are not followed up by the patient In other cases, the patient and dentist manage to sor t things out between themselves The Ser vice is sometimes waiting for the dentist to respond to a complaint

In 69% o f c ases, the com pla ints were a bout d en tists who a re members of the IDA, th e s ame propor tion as 2015 Up to D ecember 31, 2016, 58 cases were res olved, representin g a 57% resolution rate last year, compared to 33% in 2015. The rema ining 44 cas es have either b een res olved since the end of th e yea r or remain un resolved for differen t reason s.

Commentary

The thing that has become consistently clear during the years the DCRS has been in operation is that communication between dentists and patients is the most effective tool available for complaints resolution

Complaints regarding non-display of prices in reception areas and dentists charging higher prices than those shown on the practice’s website have increased substantially It is important that pricing is displayed, consistent everywhere it appears and kept up to date

The Service continues to receive complaints regarding staff in dental practices other than dentists, which are outside its remit Our website, dentalcomplaints ie, contains a lot of useful information about what cases the Service can accept It also contains some helpful information for patients wishing to reach a resolution with their dentists and for dentists on how to best deal with complaints We would like to highlight that just because there is a complaint about a service a dentist provided, doesn’t mean there is anything wrong with the work the dentist does It doesn’t even mean there’s any substance to the complaint, but the Service exists to give the consumer the right to make a complaint and they have that right enshrined in the guidelines from the Dental Council Dentists too are seeing the benefits, as the Service has noticed that more and more dentists are co-operating Not everyone is happy with the outcome when we issue a recommendation on a case, but that is the nature of the Service Sometimes patients feel aggrieved when we tell them that we don’t think that they have a case Just because someone makes a complaint doesn’t mean they will end up getting something

Concerns

The vast majority of people in Ireland will never have a complaint about their dentist, as the standard of work in the country is very high The number of people getting ‘cheap’ dental work done abroad continues to be a problem and this is not recommended by the DCRS Patients are left with absolutely no recourse if something goes wrong and may be left with a hefty bill if remedial

The vast m ajority of p eop le in Irela nd will never have a co mplaint ab out their dentist , a s the sta nda rd of wo rk in the country is very high T he numb er of peo ple g et ting ‘chea p’ d ental w ork done ab road continues to b e a pro blem and this is not recom mended by the DCRS.

work to fix bad dental work needs to be done here

Another worrying development is people attempting orthodontic work themselves at home There are websites which will send people aligners in the post after they use an at-home “evaluation kit” and people can then fit these themselves All without the guidance of a dentist This is quite worrying and the DCRS has seen one case relating to these already

One more problem we are seeing is people buying teeth whitening products online, as they receive no professional advice Dentistry is a complex area and it is not something anyone should ever attempt to do at home themselves

Michael Kilkoyne Dental Complaints Resolution Ser vice Facilitator

ADVICE AND SUMMARY

Advice for dentists

The most impor tant thing you do when a complaint is made is deal with it Sit down and talk to your patient Make the time and if you promise you’re going to call your patient back, call them back Sometimes a complaint ends up with the DCRS because the dentist has failed to deal with it What we mean by that is that the dentist failed to respond to a complaint from their patient No business owner wants to receive a complaint, but an effective and fair complaints management system, operated with a positive attitude towards complaints, can help a person to both maintain and improve their relationships with their customers

Advice for patients

For patients, the most impor tant thing is the same as it is for dentists: go and speak to your dentist and try to sor t it out The Service won’t deal with a complaint from a patient unless they have spoken to their dentist first If the dentist has refused to talk to them, then the Service will listen to what they have to say

When someone is preparing to have dental work done, the best thing to do is to find an Irish-based dentist who is a member of the IDA There is nothing the Service can do about dental work that is done outside the Republic of Ireland Look around for a dentist who you feel you can trust, rather than just looking at prices

Summary

The Service received about the same number of communications from patients that it did in 2015 It was contacted 1,235 times by patients last year, compared to 1,257 times in 2015 Most of these calls, emails and letters did not lead to an accepted complaint After complaints were analysed and the patients tried to speak to their dentists directly, 102 were accepted by the

When someone is preparing to have dental work done, the best thing to do is to find an Irish-based dentist who is a member of the IDA. There is nothing the Service can do about dental work that is done outside the Republic of Ireland. Look around for a dentist who you feel you can trust, rather than just looking at prices

Service As of December 31, 2016, we were notified that 58 complaints had been resolved (although it’s possible that more had been)

The most common resolution was a refund of fees, which was the outcome in 23 of the cases This was followed by re-treatment in 15 cases Nine dentists agreed to pay for remedial treatment elsewhere and two cases were brought to a close by way of an apology Seven cases did not proceed any further after an explanation found there was no substance to the complaints Two cases could not be brought to a resolution by the Service as a dentist withdrew from the process and one patient was referred to another dentist

The type of complaint broke down as follows:

n fees – 23; n clinical – 22; and, n communication – 13

See Tables 1 and 2 for details of each accepted complaint

What did the DCRS learn in 2016?

Ever y year we see the same things coming up Something goes wrong, it is not dealt with either by the patient or the dentist, tempers flare and it ends up with the DCRS The Ser vice has been running for five years now and the

themselves If that doesn’t work, then the DCRS is more than happy to be of assistance, but to save ever yone time and hassle, it’s impor tant that the par ties to a dispute tr y to reach an agreement together We are ver y happy

improvements on both sides, patients and dentists, in how they deal with each other while in the process of resolving a complaint People are more willing now to tr y to sor t things out because they know it benefits them

Table 1: Complaints in relation to treatment received in 2016.

Treatment Number

Table 2: Breakdown of complaints in relation to non-treatment issues in 2016

1 (case over three years old) 1 (query regarding an orthodontist’s qualifications) . . .we k n o w a fter c o un t less co m pla in ts is th a t th e be st th in g fo r p at ien ts a n d d en tis ts to d o is sit d o wn a n d tr y to w or k t h ing s ou t a m on g th em selv es . If th a t

1 (referred to UK dental complaints service as work was done in Northern Ireland)

C ASE STUDIE S

C A S E 1

HUMAN ERROR

In this case, a break in procedure led to an uncomfor table situation for the dentist and the patient The patient attended the practice to have a filling done The work went well and the patient left happy and with another appointment booked in the clinic The next day, the dentist discovered some instruments had not gone through the final stage of sterilisation but had been completely cleaned and thoroughly disinfected One of these was a mouth mirror which was used during the patient’s procedure The dentist promptly contacted the patient to let him know what had happened and that the risk to his health was extremely low However, the patient found the incident extremely disturbing and cancelled his other appointment For his own peace of mind, he went to his GP and had two blood tests, both of which were negative The dentist and the practice manager met with the patient to apologise and as the patient said, went to great pains to explain how the incident had come about However, the patient felt that inadequate consideration was given to the stress and worry that the incident had caused him He stated that neither a refund nor any compensation for costs incurred was offered by the dentist During the meeting the patient said because there was a very low risk, he would have preferred to have never been contacted by the practice because of the stress it caused In a follow-up letter to the patient, the dentist explained that she has a duty to her patients to be open and honest with them, and that she had not meant to cause him any alarm

b e e n re s o l v e d a n d w a s s u r p r i s e d to re ce i v

m a d e to t h e D C R S S h e d i s p u te d t h e c l a i m t h a t n o o f fe r o f

t h a t w a s

co m p e n s a t i o n h a d b e e n m a d e a n d s a i d t h a t s h e h a d o f fe re d to p a y

fo r t h e p a t i e n t ’s b l o o d te s t s , b u t t h a t h e d e c l i n e d a s h e h a d a G P

c a rd

E x p l a i n i n g t h e p ra c t i ce ’s re s p o n s e to t h e i n c i d e n t s h e s a i d t h e y h a d

l o o ke d i n to h o w t h e i s s u e a ro s e a n d t a ke n a l l n e ce s s a r y s te p s to

e n s u re i t w o u l d n o t h a p p e n a g a i n S h e a p o l o g i s e d a g a i n a n d s a i d i f

t h e re w a s a n y t h i n g s h e co u l d d o , t h a t h e s h o u l d n o t h e s i t a te to

co n t a c t h e r H e a l s o re ce i v e d a l e t te r f ro m t h e p ra c t i ce m a n a g e r

e x p l a i n i n g t h e s i t u a t i o n

A f te r re ce i v i n g t h e co m p l a i n t f ro m t h e D C R S , t h e d e n t i s t s e n t

a n o t h e r l e t te r to t h e p a t i e n t e x p re s s i n g h e r re g re t t h a t h e h a d n o t

co m e to h e r f i r s t a s s h e w o u l d h a v e b e e n h a p p y to s p e a k w i t h h i m

f u r t h e r S h e s a i d t h a t s h e h a d s i n ce re l y b e l i e v e d t h a t a f te r t h e i r

m e e t i n g , t h e p a t i e n t w a s s a t i s f i e d a s t h e y h e a rd n o t h i n g m o re f ro m

h i m A s a g e s t u re o f g o o d w i l l , s h e re f u n d e d t h e co s t o f t h e

t re a t m e n t a n d t h e c a s e w a s c l o s e d

C A S E 2

MISUNDERSTANDING

In this case, a woman visited a dental practice with poor oral health and a t re a t m e n t p l a n w a s d ra w n u p fo r h e r T h e re w a s n o i s s u e u n t i l s h e h a d a filling replaced and a couple of days later, the tooth next to the one where the filling had been replaced broke This caused the patient a lot of pain and s h e s a i d w h e n s h e co n t a c te d t h e p ra c t i ce s h e h a d to w a i t to g e t a n appointment When she got an appointment, a dentist who had not given her the filling told her that sometimes giving a filling can cause a nearby tooth to break She had an impression taken for a false tooth and was told the practice would get in touch as soon as it was ready She said the practice never contacted her and that she sent emails to find out what was going on She received no response and her tooth fell out She decided she wanted an implant but was put on a waiting list T h e p a t i e n t m a d e h e r co m p l a i n t to t h e p ra c t i ce I n response, the dentist who had per formed the restoration said that when the patient’s treatment plan was given to her, she was informed that the tooth which fell out required a filling She said she didn’t per form any procedure which caused the woman’s tooth to fall out and explained that sometimes the decay in a tooth is too big and it cannot be saved

The patient said if she had known work being done on a tooth beside one that needed a filling could cause it to break, she would have made a more informed decision The dentist explained that the fact the tooth broke was not because there was work done on one beside it It was because it needed a filling

The patient said that she should have been informed that getting a filling done on that tooth was a priority and that it should have been done before s h e h a d a n y o l d f i l l i n g s replaced At this point, the patient brought her complaint to the DCRS The Service made contact with the dentist and outlined the complaint to her She wrote that she only met the patient once on June 23, 2015 and performed the restoration The dentist said she made a follow-up appointment for the patient for July 7, b u

appointment was made for July 23 but she failed to attend again

On August 17, the patient returned to the clinic after her tooth broke It was determined that the tooth could not be saved The patient agreed that the rest of the tooth should be removed and to have an implant put in its place An impression was taken for a temporary denture and a n

e a g u e s fo r h e r to o t h f ra c t u r i n g S h e p o i n te d o u t t h a t t h e p a t i e n t h a d h e r i n i t i a l a p p o i n t m e n t i n 2 0 1 4 , b u t d i d n ’t h a v e a s e co n d o n e u n t i l m i d 2 0 1 5 , a n d

h o w s h e m i s s e d h e r fo l l o w - u p a p p o i n t m e n t s S h e s a i d s h e a n d h e r

co l l e a g u e s w o u l d b e h a p p y to re s u m e t h e p a t i e n t ’s t re a t m e n t w h e n e v e r s h e

w a n te d a n d a s ke d t h e S e r v i ce to co m m u n i c a te w i t h t h e p a t i e n t to s e e i f s h e

w o u l d b e o p e n to co m i n g i n to t h e p ra c t i ce a n d t a l k i n g w i t h h e r T h e p a t i e n t

agreed to this and af ter the meeting, the two par ties came to an agreement

C ASE STUDIE S

C A S E 3

CLEARING THINGS UP

In this case, a patient attended her dentist to have a sore tooth extracted and she mentioned to him that she would like to have an implant put in its place sometime after the extraction It was a complicated procedure but at the end, the patient was shown the tooth and told it had been fully extracted She went back to the practice a week later to receive her temporary denture and complained that she was still feeling pain in the area where the tooth was extracted The dentist assured her that this would pass Af ter about a month, the practice called her to come in for a follow-up examination An x-ray was taken and she was told that a piece of the root was still in her mouth and that this would probably have to be surgically removed

She was also told that the extraction would be complicated and that she might have to wait up to a year before the site would be healed enough to take an implant This information upset the patient as she had heard that the optimum time to get an implant was between three and six months after an extraction

She was referred to the practice’s oral surgeon who extracted the remaining root at a cost to the patient of ¤350 After the procedure, the surgeon said he hadn’t touched bone but par t of the bone had already been extracted during the first procedure Because of this, she was told that an implant might not be possible and that she would have to see a specialist

The patient contacted the DCRS as she was not happy, especially when she had to pay ¤350 to remove the piece of root She asked the Service if there was

any chance she would be able to get back the money she paid for this She later requested that the dentist pay for a bone graft to facilitate an implant being placed in the spot where the tooth was removed

The dentist responded by explaining how in the first instance, what was meant to be a simple extraction turned into a surgical one

He said that he spoke to the oral surgeon who could not recall telling the patient that she wouldn’t be able to have an implant put into the site in the near future

The surgeon said he informed the patient of socket preservation procedures to enable future implant placement

The dentist and surgeon both told the patient that she should seek the opinion of a specialist that they would refer her to The dentist said he hoped this would clear up any misunderstanding

He also agreed to refund the ¤350 she paid to have the leftover piece of root removed as a gesture of goodwill He asked that if she had any fur ther issues with the extraction site or any other problems, that she contact him and he would be happy to assist her

Engaging with the patient here and clearing up the misunderstanding was instrumental to resolving the situation

C A S E 4

WORKING WITH EACH OTHER

In this case, the patient had an implant procedure and was not very pleased with how it turned out The implant procedure was to replace three top front teeth

The patient said two of the crowns were bonded to each other at the back to compensate for one crown being loose on the abutment of the implant He also stated that the dentist was unable to remove the crown to adjust and refit it

The patient let the dentist know how unhappy he was with the standard of work and he claims the dentist told him he would get used to it

the bonding on the crowns was not up to the standard he expected He said h

T h e d e n t i s t t h e n e n g a g e d w i t h t h e p a t i e n t a n d t r i e d to d o s o m e re p a i r w o r k

o n t h e o r i g i n a l i m p l a n t U n fo r t u n a te l y, t h i s d i d n ’t w o r k T h e d e n t i s t t h e n a g re e d to re d o t h e w o r k e n t i re l y a n d a p re v i o u s l y v e r y a n g r y p a t i e n t w a s

u l t i m a te l y s a t i s f i e d w i t h h i s n e w i m p l a n t

T h i s c a s e s h o w s t h a t o n c e a d e n t i s t e n g a g e s w i t h a p a t i e n t , t h e y o f t e n

discover they don’t need the DCRS and work things out directly themselves